1. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ The Questions: Automated room disinfection 1 Sarah Simmons, MPH CIC Xenex Disinfection Technologies Research Agenda

2. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Does the environment matter? 2 Manual cleaning is insufficient Prior room occupancy risk Interaction with hand hygiene Known benefit from enhanced cleaning Research Agenda

3. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Types of No-Touch Disinfection 3 Hydrogen Peroxide Vapor Mercury-based Ultraviolet Light Xenon-based Ultraviolet Light Research Agenda

4. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Hydrogen Peroxide Vapor 4 Produces and disperses a vapor of hydrogen peroxide (H 2 O 2 ) Creates Oxygen radicals that react with cell walls Room must be sealed during the process Research Agenda -OH O2-O2- HO 2 O2-O2- O2-O2- -OH O2-O2- HO 2

5. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Ultraviolet Systems 5 Research Agenda Mercury UV (Hg UV)Pulsed Xenon (PX-UV) Continuous LightPulsed Light 253.7 nm200-280 nm Photodimerization Photohydration Photosplitting Photocrosslinking

6. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Photodimerization 6 Research Agenda Bonds DNA/RNA together, preventing cell replication

7. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Photosplitting 7 Research Agenda Breaks the phosphate backbone of the DNA

8. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Photohydration 8 Research Agenda Inserts water molecules into DNA bases, causing functional damage

9. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Photohydration 9 Research Agenda Creates bonds between protein molecules, resulting in structural damage, including the lysing of the cell wall

10. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Does it work? 10 What does it kill? Where does it kill? How long to kill? Research Agenda

11. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Target Organisms C. difficile spores (NAP1) Acinetobacter baumannii Methicillin-resistant S. aureus (MRSA) Feline calicivirus (norovirus surrogate) Vancomycin-resistant Enterocci (VRE) 11

12. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Is it better than/dependent on housekeeping? 12 End game: what does the next patient experience? Is there an improvement over housekeeping? Is there a dependence on housekeeping? Research Agenda

13. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ How should it be used? 13 How? Where? When? How often? Research Agenda

14. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ UV Mapping – One Position 14

15. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ UV Mapping – Two Positions 15

16. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ UV Mapping – Three Positions 16

17. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ UV Mapping - conclusion Multiple positions is the correct way to use UV for room disinfection. 17

18. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Hydrogen Peroxide 18

19. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Do I have to disinfect the same way if I use it? 19 Clean as long? Still use bleach? Changes in inspection? Research Agenda

20. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ What about ORs? 20 Consequences of SSIs Doubles the risk of death after surgery Five fold increased risk for readmission 60% more likely to require ICU care LOS increases 6 days Research Agenda

21. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ What about ORs? 21 Overall Cleaning Compliance 47% Anesthesia Medication Cart 38% Anesthesia Knobs 25% IV Poles 55% Bed Controls 64% Floor 93% Research Agenda

22. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ What about ORs? 22 Additional assurance? Quick clean? Between cases? Terminal Cleaning? Research Agenda

23. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Does it matter to patient outcomes? 23 HAI reductions? Research Agenda

24. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Where should I use it? 24 Select isolation? All isolation? Select units? All discharges? Central processing? Research Agenda

25. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ What about RME, unused supplies and curtains? 25 RME Validating Tracking Unused supplies Assurance Labor billing Curtains Disinfection goal? Curtain types Research Agenda

26. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Do patients like it? 26 Complaints? Compliments? Research Agenda

27. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ What data do you need? 27 What level of disinfection? What level of proof? Research Agenda

28. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Could clonal typing help? 28 Need for outcome measure ID sources of infection ID clusters Proof of effectiveness? Research Agenda

29. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ What’s my goal anyway? 29 Reduce rates? Additional protection for high-risk units? Outbreak response? Bio-preparedness? Research Agenda

30. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ What else should I think about? 30 How are the technologies different? Decontamination effectiveness Cost per room Cycle time Operators Access to rooms Environmental friendliness Infection rate impact Research Agenda

31. © 2012. Confidential. Xenex Healthcare Services LLC. EVERY ROOM. EVERY TIME.™ Carling P, Parry M, Rupp M, Po J, Dick B, Von Beheren S. Improving Cleaning of the Environment Surrounding Patients in 36 Acute Care hospitals. Shaughnessy M, Micielli R, DePestel D, Arndt J, Strachan C, Welch K, Chenoweth C. Evaluation of Hospital Room assignment and acquisition of Clostridium difficile infection. Infection Control and Hospital Epidemiology. Vol.32, No. 3, March 2011 Datta R, Platt R, Yokoe D, Huang S. Environmental Cleaning Intervention and Risk of Acquiring Multidrug-Resistant Organisms From Prior Room Occupants. Arch Intern Med. 2011;171(6):491-494 Drees M, Snydman D, Schmid C, Barfoot L, Hansjosten K, Vue P, Cronin M, Nasrway S, Golan Y. Prior Environmental Contaminaiton Increases the Risk of Acquisition of Vancomycin-Resistant Enterococci. Clin Infect Dis.2008;46(5):678-685 Huang S, Datta R, Platt R. Risk of Acquiring Antibiotic-Resistant Bacteria From Prior Room Occupants. Arch Intern Med. 2006;166(18):1945-1951. Nseir S, Blazejewski C, Lubret R, Walet F, Courcol R, Dorocher A. Risk of acquiring multidrug-resistant Gram-negative bacilli from prior room occupants in the intensive care unit. Clin Microbiol Infect. 2011 Aug;17(8):1201-8 Dubberke E, Reske K, Noble-Wang J, Thomson A, Killgore G, Mayfield J, Camins B, Woeltje K, McDonald J, McDonald L, Fraser V. Prevalence of Clostridium difficile environmental contamination and strain variability in multiple healthcare facilities. Am J Infect Control. 2007 Jun: 35(5):315-8. C Edminston, et al. Molecular Epidemiology of Microbial Contamination in the Operating Room Environment: Is there a risk of infection? Surgery. 2005;138(4):573-582. R Loftus, et al. Transmission of Pathogenic Bacterial Organisms in the Anesthesia Work Area. Anesthesiology 2008; 109(3):399-407. Kowalski, W. (2009). Ultraviolet Germicidal Irradiation Handbook. New York: Springer. 31 References