1. Is Your Facility Clean? DAZO Knows Sandra Von Behren 03/26/20101TSICP

2. Objectives Discuss the role of the environment in the transmission of healthcare-associated infections (HAIs) and multi-drug resistant organisms (MDROs) Identify available methods to evaluate environmental cleanliness Discuss strategies to improve environmental cleaning and decrease the risk of MDRO and HAI transmission 03/26/2010TSICP2

3. Philip C. Carling, MD Boston University School of Medicine Department of Epidemiology, Carney Hospital Boston, MA 03/26/2010TSICP3

4. The Environment as a Source of Pathogens S. aureus – Dancer et al; JHI 2006; 62: 200-206 MRSA – Boyce et al, ICHE 1997; 18:622-627 VRE – Bhalla et al, ICHE 2004; 25: 164-167 – Hayden, et al, ICHE 2008; 29: 149-154 03/26/2010TSICP4

5. Environmental Contamination: Is There A Link to HAI Acqusition? Patients admitted to rooms previously occupied by patients with MRSA, VRE, Acinetobacter baumanii are at risk of acquiring organisms from the environment 03/26/2010TSICP5 Huang, et al; Arch Intern Med 2006; 166: 1945-1951 Hardy, et al; ICHE 2006; 27: 127-132 Sexton et al; JHI 2006; 62: 187-194 Martinez, et al; Arch Intern Med 2003; 163: 1905-1912

6. Environmental Contamination with Antimicrobial Resistant Organisms (MDROs) Adopted from – Speck SHEA Abstract 167, Baltimore, April 2007

7. Environmental Contamination with Antimicrobial Resistant Organisms (MDROs) Adopted from – Speck SHEA Abstract 167, Baltimore, April 2007 39 % of positive cultures from staff only touched objects were different from those for which the patient was being isolated

8. 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

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

10. Survival of Pathogens on Environmental Surfaces C. difficile > 5 months Staphylococci 7 months VRE 4 months Acinetobacter 5 months Norovirus 3 weeks Adenovirus 3 months Rotavirus 3 months SARS, HIV etc. days to week

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

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

14. ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS HCW HANDS SUSCEPTABLE PATIENTS

15. ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS HCW HANDS SUSCEPTABLE PATIENTS ISOLATION

16. ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS HCW HANDS SUSCEPTABLE PATIENTS ISOLATION HAND HYGENE

17. ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS ENVIRONMENTAL SURFACES HCW HANDS SUSCEPTABLE PATIENTS ISOLATION HAND HYGENE

18. ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS ENVIRONMENTAL SURFACES HCW HANDS SUSCEPTABLE PATIENTS ISOLATION HAND HYGENE

19. ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS ENVIRONMENTAL SURFACES HCW HANDS SUSCEPTABLE PATIENTS ISOLATION HAND HYGENE DISINFECTION CLEANING

20. Prevent Transmission: Hand Hygiene Many facilities have had significant improvements Microbial resurgence is rapid following HH Logistical limitations in a complex environment 03/26/2010TSICP20

21. HH in Complex Intense Environments is Very Difficult 30 to 40 HH “Moments” per Hour during direct patient care

22. Isolation Difficult to implement and maintain When to Begin—When to stop Unintended consequences 03/26/2010TSICP22

23. Isolation is Difficult

24. Our review of the literature demonstrates that contact precautions have unintended consequences that are potentially deleterious to the patient. Measures to ameliorate these deleterious consequences of contact precautions are urgently needed. Am J Infect Control. 2009 (May); 37: 85-91

25. What can we do?? Improve effectiveness of environmental cleaning/ disinfection patient environment

26. How Can We Evaluate Environmental Cleaning Direct observation Culture the environment ATP bioluminescence Tool Fluorescent marking tool 03/26/2010TSICP26

27. ATP bioluminescence Swab surface luciferase 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.

28. ATP Bioluminescence Testing in Healthcare Settings Potential usefulness: Has been used as a surrogate for environmental culturing Provides an estimate of cleanliness Can rapidly define how clean an object is…. but non-microbial ATP is also evaluated Standards to optimize predictive values are still being evaluated Can be used to do one-on-one education of ES staff

29. ATP Bioluminescence Testing in Healthcare Settings Potential limitations: Secondary cleaning of the site is required to remove disinfectant induced signal decay or enhancement. Involvement of the ES staff is implicit since evaluation must be done within minutes of cleaning. Pre-intervention evaluation of disinfection cleaning is difficult without inducing a Hawthorne effect Results are individual ES staff / time specific. Many manufacturers of luminometers and ATP swabs makes interinstitutional standardization difficult

30. Evaluating Patient Zone Environmental Hygiene

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

35. Dazo Solution (Initially called “GOO”)

36. Target After Marking

37. Target Enhanced

38. The Targeting Solution A mixture of several glues, soaps and a targeting dye which: – Dries rapidly – Remains stable – Easily removed with light abrasion and damp cloth – Inconspicuous

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

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

41. 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 The Healthcare Environmental Hygiene Study Group

42. Healthcare Environmental Hygiene Study Group – Acute Hospitals (90) MA = 12 RI = 5

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

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

46. 17 HOSPITALS 10 HOSPITALS 8 HOSPITALS Terminal Room Cleaning Project – Three Programmatic Responses

47. Hospitals Environmental Hygiene Study Group 36 Hospital Results % of Objects Cleaned PRE INTERVENTION POST INTERVENTION P = <.0001Resource Neutral

48. TERMINAL ROOM CLEANING INFECTION PREVENTION TARGETS Sink and Faucets Toilet Surfaces Toilet Flush Handle Bedpan Cleaner Toilet Area Handholds Toilet Area Door Knobs or Push Plates Bedside Table Tray Table Patient Chair Side Rails Room Door Knobs Call Box Telephone Bathroom Light Switches Specific Opportunities for Improvement

49. Focus Group Held 4 meetings with Environmental Services (EVS) staff on different shifts – 5-6 staff members in each session – Met for 4 hours – No EVS supervisors present – Meal provided 03/26/2010TSICP49

50. Focus Group Questions What recommendations do you have to improve cleaning outcomes? What barriers do you see that would prevent implementation of these recommendations? 03/26/2010TSICP50

51. Problems Identified Staffing not always adjusted to busiest times Pressure from nursing staff to “get it done” Supervisors not visible Staff on evening shift “on call” from one end of hospital to the other 03/26/2010TSICP51

52. Recommendations More “on the spot” feedback from supervisors Help from supervisors to prioritize work Better communication with nursing Consistency unit to unit Maintain level of cleaning done when TJC is expected Have a quality control officer Use Dazo as follow-up to classroom orientation Evaluation of work efficiencies (Organizational Improvement) 03/26/2010TSICP52

53. ICU Project Daily Clean of Isolation Rooms Marked room and read in or 2 days 03/26/2010TSICP53

54. Possible Interventions? How can we improve on daily disinfection cleanings? Who is responsible for each item? -Siderail bed control-Table/counter/workspace -Call button-Computer keyboard -Tray table-Storage drawer handle -Monitor control-Room light switch -Vent control- Room door handles -Commode-IV pump -Sink

55. Item Responsibility Environmental Services: – Tray table – Light switch – Room door handles – Sink – Work surface – Cabinet handles – Call button – In-room commode ICU Nursing: – Keyboards – Side rails – IV pumps – Monitor control panel Respiratory Therapists: – Ventilator Control Panel Re-evaluation will take place in 3-4 weeks Re-evaluation will take place in 3-4 weeks

56. Brigham & Woman’s ICU Study

57. Impact of an Environmental Cleaning Intervention on the Risk of Acquiring MRSA and VRE from Prior Room Occupants (SHEA Abstract 273) 2009 Datta R, Platt R, Kleinman K, Huang SS

58. Brigham & Woman’s ICU Study Impact of an Environmental Cleaning Intervention on the Risk of Acquiring MRSA and VRE from Prior Room Occupants (SHEA Abstract 273) 2009 Datta R, Platt R, Kleinman K, Huang SS “For both MRSA and VRE, absolute risk appeared diminished during the intervention regardless of prior occupant status”

59. Conclusions It is likely that surfaces in the Patient Zone are of relevance in the transmission of Healthcare Associated Pathogens. While optimizing hand hygiene and isolation practice is clearly important there is no reason why the effectiveness and thoroughness of environmental hygienic cleaning should not also be optimized, particularly since such an intervention can be essentially resource neutral.

60. References 1.Hayden MK, Bonten JM, Blom DW, Lyle EA. Reduction in acquisition of Vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis 2006; 42:1552-1560. 2.Eckstein BC, Adams DA, et al. Reduction of Clostridium Difficile and vancomycin- resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infect Dis. 2007 Jun 21;7:61 3.Dancer SJ, White L, Robertson C. Monitoring environmental cleanliness on two surgical wards. Int J Env Health Res 2008; 18: 357-364 4.195.92.246.148/knowledge_network/documents/Bioluminescence_20070620104 921.pdf 5.Carling PC, Parry M, Rupp, M, Po JL,DickB, Von Beheren S. for the Healthcare Environmental Hygiene Study Group. Improving Cleaning of the Environment Surrounding Patients in 36 Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:11,035-1041