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Massachusetts CDI Preventative Collaboration June 24, 2010

Optimizing Environmental Hygiene: The Key to C. Difficile Control Philip C. Carling, M.D. Carney Hospital and Boston University School of Medicine. Massachusetts CDI Preventative Collaboration June 24, 2010. Consultant – Ecolab, Steris, ASHES Pending Patent License - Ecolab.

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Massachusetts CDI Preventative Collaboration June 24, 2010

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  1. Optimizing Environmental Hygiene: The Key to C. Difficile ControlPhilip C. Carling, M.D.Carney Hospital andBoston University School of Medicine Massachusetts CDI Preventative Collaboration June 24, 2010 Consultant – Ecolab, Steris, ASHES Pending Patent License - Ecolab Pcarling@cchcs.org

  2. Presentation Objectives • Understand current issues related to the roe of the environment in CDI transmission • Understand the basis for suboptimal healthcare environmental cleaning • Appreciate the complexity of making practice recommendations without modern evidenced based studies

  3. Background: EpidemiologyRisk Factors Antimicrobial exposure Acquisition of C. difficile Advanced age Underlying illness Immunosuppression Tube feeds ? Gastric acid suppression Main modifiable risk factors

  4. How contaminated is the hospital environment?

  5. Contaminated Surfaces VRE MRSA C. difficile Bed Rails +++++++ + +++ Bed Table ++++++ + Door Knobs ++ ++ + Doors +++ + Call Button +++ + ++ Chair ++ + ++ Tray Table +++ ++ Toilet Surface + ++++ Sink Surface + + +++ Bedpan Cleaner +

  6. Surface Contamination of Near-patient Environment23 Studies

  7. How does it get there? Riggs M,etal. CID 2007;45:592

  8. C. Difficile Environmental Contamination Mutters R, etal. J Hosp Infect. 2009; 71: 43-48

  9. Can C. diff be transmitted from the environment to patients?

  10. Increased acquisition risk from prior room occupant 7 studies as of July 2010 Two additional studies showed very significant risk without quantification – Martinez (VRE) and Wilks (Acinetobacter)

  11. C. difficile Transmission to Prior Room Occupants Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

  12. C. difficile Transmission to Prior Room Occupants 110% Increased risk Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

  13. Can better cleaning favorably impact environmental contamination with C. diff ?

  14. Studies reporting a favorable impact of enhanced environmental hygiene during a CDAD outbreak

  15. June 2007 Methods: Culture based evaluation - Pre-intervention; - after routine terminal cleaning; - after terminal cleaning by the research staff; - following education of the ES staff and administrative interventions

  16. Bedrail Bedside table Phone Call button Toilet Door handle 80 70 60 50 40 Percent positive 30 20 10 0 After housekeeping cleaning After disinfection by research team* Before cleaning Percentage of C. difficile-positive cultures n=9 rooms *Similar results found after ES cleaning following interventions Eckstein et al, BMC Infect Dis. 2007 Jun 21;7:61.

  17. The impact of HP vapor on C. difficile Boyce J etal. ICHE 2008

  18. The impact of HP vapor on C. difficile Boyce J etal. ICHE 2008

  19. Does improving environmental hygiene have a measurable Impact on environmental contamination with C. difficile? Eckstein – 2007 Boyce – 2008 Impact on Transmission? Quasi-experimental support – Substantial but limited by study design and evaluation in outbreak settings

  20. Why is C. being transmitted to susceptible patients in our hospitals ?

  21. Don’t forget the Rutala Equation Product + Practice

  22. Don’t forget the Rutala Equation Product + Practice The other name for Hygienic Practice ?

  23. The other name for Hygienic Practice The Missing Link

  24. The other name for Hygienic Practice The Missing Link Why?

  25. Thoroughness of Environmental Cleaning

  26. Thoroughness of Environmental Cleaning >65,000 Objects Mean = 34%

  27. 74% MRSA, VRE, CD,AB 8 Reports 40% 10 Studies

  28. Why is environmental cleaning not being done thoroughly ?

  29. “Environmental Rounds” to search for problems in cleaning performanceor….

  30. The search fro the Nefarious Dust Bunny What does this finding say about disinfection cleaning at this hospital???

  31. Finding the “Brown Spot” ES Director IP ES Supervisor What does this finding say about disinfection cleaning at this hospital???

  32. Finding the “Brown Spot” How long has this been here? ES Director The nurses are right. ES at this hospital is terrible IP ES Supervisor What does this finding say about disinfection cleaning at this hospital???

  33. Finding the “Brown Spot” Who can I blame? How long has this been here? ES Director The nurses are right. ES at this hospital is terrible IP ES Supervisor What does this finding say about disinfection cleaning at this hospital???

  34. Finding the “Brown Spot” Who can I blame? I hate Environmental Rounds…. Why doesn’t this IP get a life? How long has this been here? ES Director The nurses are right. ES at this hospital is terrible IP ES Supervisor What does this finding say about disinfection cleaning at this hospital???

  35. “Environmental Rounds” Subjective visual assessment “If something looks dirty, it means housekeeping has failed” Deficiency oriented Episodic evaluation Problem detection feedback Open definition of correctable intervention Conventional monitoring of health care environmental cleaning

  36. Can the thoroughness of Hygienic Cleaning be improved?

  37. RESULTS

  38. Targeting Solution (AKA – Goo)

  39. Terminal cleaning after 1 or 2 patient cycles Cleaned, empty room identified Room marked Room evaluated Phase I: Covert Baseline Environmental Cleaning Evaluation Terminal cleaning after 1 or 2 patient cycles Cleaned, empty room identified Room marked Room evaluated Phase II: A. Programmatic Analysis B. Educational Interventions – ES staff Phase III: Re-evaluation of Cleaning and feedback to ES

  40. Baseline Environmental Evaluation of 36 Acute Care Hospitals Mean = 48.5 % Hospitals (20,056 Objects) % of Objects Cleaned

  41. Hospitals Environmental Hygiene Study Group36 Hospital Results % of Objects Cleaned PRE INTERVENTION POST INTERVENTION Resource Neutral P = <.0001

  42. 74% 40% 11 Studies 82%

  43. Are such results sustainable?

  44. Thoroughness of Terminal Room Environmental Cleaning

  45. Was it a lot of work? Chow S, Shao J, Wang H. Sample size calculations in clinical research. 2ND ed. Chapman & Hall; 2007.

  46. Leadership Enid K. Eck, RN, MPH Regional Director, Infection Prevention and Control Kaiser Permanente, Dedicated, Energetic, Supportive and Optimistic! Programmatic Approach Senior leadership support ES buy in Transparency Blameless Benchmarking Problems Solutions open cooperation Recognition of success at all levels These results suggest that substantial improvements in environmental cleaning are achievable and sustainable

  47. Improved Thoroughness of hygienic cleaning is a worthy goal given the billions of dollars involved…but will it impact transmission of HAPs ?

  48. 74% 40% 11 Studies 82% MRSA, VRE, CD, AB 68% 8 Reports

  49. 74% 40% 11 Studies 82% 68% MRSA, VRE, CD, AB 8 Reports MRSA, VRE 4 Studies

  50. Given these results and in the context of the economic issues involved we need to seriously consider moving beyond Conventional Monitoring of health care environmental cleaning

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