Are Shiny Floor Enough? Environmental Hygiene Challenges in Hospitals Philip C. Carling, M.D. Boston University School o

1. Are Shiny Floor Enough?Environmental Hygiene Challengesin HospitalsPhilip C. Carling, M.D.Boston University School of Medicine San Francisco Bay Area APIC Spring Meeting Walnut Creek, California May 14, 2008 Grant Support - None Disclosures - None

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

3. Surface Contamination of Near-patient Environment23 Studies

4. Rapid recontamination with MRSA of the environment of an intensive care unit after decontamination with hydrogen peroxide vapour Adapted from - Hardy KJ et.al J Hosp. Infections 66,360 August 2007

5. Survival of Pathogens on Environmental Surfaces C. Difficiele – > 5 months MRSA – 90 to > 236 d. VRE – 7 to 120 d. (Median = 60 d.) A. baumanii – Mean = 9 d. Rhinoviruses – Several hours Hepatitis A – > 4 hours Norovirus - Weeks

6. How well is Environmental Cleaning being done in hospitals ? Is Environmental Cleaning in hospitals important? A. Yes How Effective are the Environmental Disinfectants used in hospitals ? B. C.

7. How Well Does Environmental Disinfecting Work ? • Phenolic Compounds • Quartinary Amonium Compounds • Chloride Disinfectants • Formaldehyde Kill a wide range of microbial pathogens Work Rapidly Work effectively in clinical settings ALL

8. Should the thoroughness of environmental cleaning be evaluated programmatically?

9. CDC Monitor (i.e., supervise and inspect) cleaning performance to ensure consistent cleaning and disinfection of surfaces in close proximity to the patient and likely to be touched by the patient and health care Professionals (e.g. bedrails, carts, bedside commodes, doorknobs, faucet handles). Category 1B. Management of MDROs in Healthcare Settings – October 2006 V.B.8.b.

10. IHI “Hospitals should use immediate feedback mechanisms to assess cleaning and reinforce proper technique” 5 Million Lives Campaign – Guide to Significantly Reducing MRSA Infections December 2006

11. CMS The hospital must provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases…The infection prevention and control program must include appropriate monitoring of housekeeping… activities to ensure that the hospital maintains a sanitary environment. §482.42 Condition of Participation: Infection Control Interpretive Guidelines §482.42 November 21, 2007

12. CMS A hospital with a comprehensive hospital-wide infection control program should have and implement ….provisions to monitor compliance with all policies, procedures and protocols… §482.42 Condition of Participation: Infection Control Interpretive Guidelines §482.42 November 21, 2007

13. How well is Environmental Cleaning being done in hospitals ? Four Methods of evaluation: Direct observation Culture the environment ATP bioluminescence Tool Fluorescent marking tool

14. How well is Environmental Cleaning being done in hospitals ? Four Methods of evaluation: Direct observation Hayden – only study Education and feedback Thoroughness of cleaning 48% 83% Culture the environment ATP bioluminescence Tool Fluorescent marking tool

15. How well is Environmental Cleaning being done in hospitals ? Four Methods of evaluation: Direct observation Culture the environment Many Studies have evaluated environmental contamination in occupied rooms Only two studies have evaluated the impact of routine terminal cleaning on HAI pathogens ATP bioluminescence Tool Fluorescent marking tool

16. A Microbiologic Evaluation of Patient Room Contamination and Disinfection % POSITIVE Bhalla etal. ICHE 2004

17. 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

18. 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 VRE-positive cultures n=17 rooms *Similar results found after ES cleaning following interventions Eckstein et al, BMC Infect Dis. 2007 Jun 21;7:61.

19. 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.

20. How well is Environmental Cleaning being done in hospitals ? Four Methods of evaluation: Direct observation Culture the environment Many Studies have evaluated environmental contamination in occupied rooms Only two studies have evaluated the impact of routine terminal cleaning on HAI pathogens Conclusion: Environmental Culturing as a research tool is very valuable but cost will limit routine use in hospitals

21. How well is Environmental Cleaning being done in hospitals ? Four Methods of evaluation: Direct observation Culture the environment ATP bioluminescence Tool Fluorescent marking tool

22. Surface evaluation using ATP bioluminescence Swab surface luciferace tagging of ATP Hand held luminometer Used in the commercial food preparation industry to evaluate surface cleaning before reuse and as an educational tool for more than 30 years.

23. How well is Environmental Cleaning being done in hospitals ? Four Methods of evaluation: Direct observation Culture the environment ATP bioluminescence Tool Conclusion: May be useful for one on one teaching but does not evaluate programmatic process

24. GOAL OF THE PROJECT To develop a surrogate marking system to evaluate the effectiveness of environmental cleaning/disinfection of the near-patient environment

25. The Targeting Solution A mixture of several glues, soaps and a targeting dye which: Dries rapidly Environmentally stable Readily wetted by spray disinfectants Easily removed with light abrasion Inconspicuous

26. Targeting Patient Rooms Objects were chosen by considering sites A. A patient was most likely to contaminate and B. A care givers may touch with their hands Up to 14 objects marked in each room after terminal cleaning Objects were evaluated after one to two patients had cycled through the room to see if targets had been removed by discharge cleaning activities

27. Environmental Cleaning Evaluation in Three hospitals - A confidential evaluation without Environmental Services awareness was implemented - About 50 patient rooms / Hospital - Up to 14 objects marked when the room was empty - Evaluated after patient had cycled through the room and it had been terminally cleaned

28. Preliminary Results – Three Hospitals Clinical Infectious Diseases – February 2006

29. The Healthcare Environmental Hygiene Study Group On the basis of our preliminary results and presentations at SHEA, APIC and ICAAC conferences we have gathered together a group of hospitals to further evaluate the tool and process improvement programs

30. Goals of the Multi-institutional Terminal Room Cleaning Project To determine if: • The targeting methodology is appropriately user friendly; • The thoroughness of cleaning at other institutions is similar or different from what we had found to date; • Cleaning can be improved using focused educational interventions and feedback to the ES staff using limited resources (time).

31. Altru Hospital Grand Forks, ND Avera McKennan MC Sioux Falls, SD B I Deaconess MC Boston, MA Bay Park Hospital Oregon, OH Boston MC Boston, MA Brigham & Women’s Boston, MA Carney Hospital Boston, MA Defiance Reg. MC Defiance, OH Flower Hospital Sylvania, OH Fostoria Hospital Fostoria, OH Kaiser Med C Sacramento, CA Kaiser Santa Rosa Santa Rosa, CA Kaiser Sunnyside Clackamas, OR Lahey Clinic Burlington, MA Memorial Hosp of RI Pawtucket. RI Mercy Med Center Merced, CA Miriam Hospital Providence, RI Methodist Hospital Henderson, KY L. Morse Hosp Natick, MA Nebraska Medical Center Omaha, NE Oregon HS Center Portland, OR Provident ST Vincent Portland, OR Pullman Regional Hosp. Pullman, WA Quincy Medical Center Quincy, MA Rhode Island Hosp. Providence, RI Saint Luke’s Hospital Bethlehem, PA St Vincent Healthcare Billings, MT Shands – AGH Gainesville, FL Sharp Memorial H San Diego, CA Somerville Hospital Somerville, MA South County Hosp. Wakefield, RI Stamford Hospital Stamford, CT Toledo Hospital Toledo, OH U. Iowa Hospitals Iowa City, IA Union Memorial Hosp Baltimore, MD Washington H Center Washington, DC Westerly Hospital Westerly, RI Whidden Mem. Hosp. Everett, MA Healthcare Environmental Hygiene Study Group

32. RESULTS

33. Hospital Demographics All Acute Care Hospitals Size – 25 to 754 Beds (Mean = 243) Medicare Case Mix Index – 1.41 (Average) Rooms evaluated – 28 – 69 (Mean = 43) All high touch objects evaluated by ICP volunteers

34. The Program Phase I Covert Baseline Environmental Cleaning Evaluation (The same as Previously described)

35. Baseline Environmental Evaluation of 3 Acute Care Hospitals Mean = 47.7 % Hospitals % of Objects Cleaned

36. Baseline Environmental Evaluation of 20 Acute Care Hospitals Mean = 48.3 % Hospitals % of Objects Cleaned ICHE January 2008

37. PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS %

38. PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS %

39. The Program Phase I – Covert Baseline Environmental Evaluation Phase II A. Educational Interventions – ES Staff B. Feedback to the ES – Staff

40. The Program Phase I – Covert Baseline Environmental Evaluation Phase II A. Educational Interventions – ES Staff B. Feedback to the ES – Staff (repeated as needed)

41. Basis for Sub-optimal Improvement • Manpower / Staffing Issues: Unequal distribution of work loads Unrealistic ES staff expectations Shorter LOS – Same ES manpower Escalating “Isolation Cleaning” • ES Management Issues Resistance to new ideas “If the floors shine…What’s the problem” “Who died and left the ICPs in charge of ES” • Systems Problems – Previously Hidden Identifying Opportunities to Enhance Environmental Cleaning in Twenty-three Acute Care HospitalsCarling P, Parry MF, Von Beheren S, for the HCEHSG ICHE 2008; 29:1-7

42. Implementation Challenges • >30 Additional hospitals wanted to participate but the ICPs were too overwhelmed with other responsibilities • 7 Hospitals withdrew: 4 Administrative reprioritization of ICP 3 Fear the hospital would be identified • ASHES Conference – September 2006

43. Were The Goals Realized ? To determine if: • The targeting methodology is appropriately user friendly; YES – Easy on – Easy off • The thoroughness of cleaning at other institutions is similar or different from what we had found to date; Overall quite similar • Cleaning can be improved using focused educational interventions and feedback to the ES staff using limited resources (time). YES….but in some hospitals it takes more work

44. Fluorescent marking toolConclusions Advantages: Simple to use highly objective process improvement tool Applicable to many healthcare settings / processes Disadvantages: Evaluates process alone Does notevaluate how well an individual object is cleaned

45. Does it make a difference?

46. Studies in which have evaluated the relevance and epidemiology of environmental HAPs

47. Healthcare Environmental Hygiene Study GroupCurrent Projects • Hospital Post Discharge Cleaning Project – Beta sites • OR Terminal Cleaning Project – 16 sites • NICU Discharge Cleaning Project – 15 sites • ICU daily Cleaning Project – 12 sites • Skilled Nursing Facility Daily Cleaning Project – 5 Sites • Iowa Statewide MRSA Control Project – About 100 sites • Chemotherapy Suite Daily Cleaning Project – 10 sites • Canadian Consortium – 6 Major Medical Centers

48. Thanks for inviting me to your meeting!! Philip C. Carling, M.D. pcarling@cchcs.org