Three New Studies Evaluate the Impact of Environmental Hygiene Strategies on HAI Reduction

By Linda Homan, RN, BSN, CIC

This article originally appeared in the September 2022 issue of Healthcare Hygiene magazine.

In today’s environment of limited budget and staffing resources for environmental hygiene, it is more important than ever to weigh the evidence before investing in a product, process or technology. Evaluating the clinical impact of environmental cleaning and disinfection products, processes and technologies remains challenging.

In 2013, leaders at the Division of Healthcare Quality Promotion of the Centers for Disease Control and Prevention (CDC) published an article that outlined the hierarchy of evidence needed to advance the science of environmental hygiene and improve patient safety.1 The hierarchy of study design for increasing patient safety through healthcare environmental surface cleaning and disinfection, listed from lowest to highest strength of evidence is as follows:
I. Laboratory demonstration of bioburden reduction efficacy (103-106 log reductions depending on the claims).
• Data that must be submitted to the Environmental Protection Agency (EPA) to prove efficacy of a product.
II. Demonstrate in-use bioburden reduction.
• Evidence that use of a product, process or technology reduces bioburden on surfaces in a clinical setting.
III. Demonstrate that in-use bioburden reduction may be clinically relevant.
• Terminal-only use: Reduction of same room transmission
• Terminal and daily use: Reduction of hand contamination
IV. Demonstrate reduced pathogen transmission via admission-discharge active surveillance testing or clinical incidence.
• Evidence that patients do not become colonized with pathogens during their healthcare stay.
V. Demonstrate reduced infections.
• Evidence that the product, process or technology reduces patient infections - the ultimate goal of environmental hygiene.

The authors point out that, for studies to reach the rigor required for levels III-V, careful attention must be paid to baseline infection rates, trends, patient population and sample size. Level III-V studies must also control for other key infection prevention interventions such as hand hygiene, source control/isolation practices, device/procedure-specific interventions and antibiotic use, as these variables can influence the patient outcome.

In the past decade, the body of evidence supporting the role of environmental hygiene in infection prevention has grown significantly. However, the most important evidence (Level V) demonstrating that a product, process or technology decreases healthcare-associated infections (HAI), has been slower in coming. This is at least in part due to the rigor that is required to measure this outcome.

Three recent studies evaluated the efficacy of different environmental hygiene strategies on HAI reduction – 1) monitoring and feedback of environmental cleaning using a made-for-purpose fluorescent marker, 2) implementing a comprehensive environmental hygiene program, and 3) the use of UV-C disinfection upon patient discharge or transfer.

Read on to find out which of these interventions were found to decrease HAIs and which were not.

Optimized Process: Environmental Hygiene Monitoring and Feedback
The CDC, as well as professional associations such as the Association for the Healthcare Environment (AHE), the Association of perioperative Registered Nurses (AORN), and the Association for Professionals in Infection Control and Epidemiology (APIC), recommend the use of an objective environmental hygiene monitoring method, along with direct observation, to ensure that high-touch objects are consistently and thoroughly cleaned.

A new study published in July 2022 reports on 10 years of retrospective data on the impact of a monitoring and feedback program using a made-for-purpose fluorescent marker to improve the thoroughness of cleaning in multiple hospital units.2 The author found that the use of a fluorescent marker improved and ultimately sustained thoroughness of cleaning over the course of a decade. The initiative started with patient room discharge cleaning and expanded into operating room, cardiac cath lab, labor and delivery and endoscopy suites over time. Over time, and with consistent effort, thoroughness of cleaning improved to meet target goals and was sustained over several years. A key strategy was the use of nurse liaisons who, along with other infection prevention initiatives, were trained to conduct environmental hygiene monitoring and provide feedback to environmental services (EVS) staff and leadership. The value of this approach was reinforced as they found that, during periods when EVS was self-monitoring, the cleaning results were falsely higher than cleaning scores as validated by an objective third party.

Most importantly, the author reported that improvements in cleaning and disinfecting performance throughout the hospital over a 10-year period were associated with infection reduction: A 75 percent overall reduction in HAI rates, including a 55 percent reduction in surgical site infection rates and a 70 percent reduction in hospital-acquired C. difficile infection rates. As mentioned above, for a Level V study, controlling for variables that may impact the infection rates is important. This study was conducted retrospectively, measuring real-world implementation of a quality improvement program. It did not control for baseline infection rates, trends, patient population and sample size or variables such as other infection prevention initiatives that may have impacted the results over the 10-year time span. Such is the nature of measuring any infection prevention strategy, especially over a long period of time – it is hard to tease out the independent impact of one initiative when we often implement multiple strategies at the same time to ensure the best patient outcome. In the case of this study, the 10-year length of the study adds strength to the findings.

Optimized Product AND Process
In June, 2022, a multi-center, controlled study measuring the impact of an optimized environmental hygiene program on hospital-onset C. difficile was published.3 In this study, eight hospitals that had implemented a program to improve environmental cleaning measured their C. difficile infection rates before and after implementation of the program. The program consisted of daily cleaning with a hydrogen peroxide/peroxyacetic acid sporicidal disinfectant, training on a standardized, evidence-based process, monitoring and feedback on thoroughness of cleaning with a made-for-purpose fluorescent gel marker, and actionable data to drive improvement via a digital dashboard. Thoroughness of cleaning was improved and sustained over the 18 months following implementation of the program. The result was a sustained 50 percent decrease in HO-CDIs in the hospitals that implemented the program versus control hospitals that had not implemented the program. This study met the rigor needed for a Level V study, thus demonstrating that the intervention reduced infections. To do this, the researchers addressed the following variables and confounders that can impact patient outcomes.
• They addressed baseline infection rates and trends. The intervention site patient acuity was stable over 39 months. The endemic HO-CDI SIRs before the intervention were stable.
• They included hospital controls. They compared the C. difficile infection rates in the intervention hospitals to rates in hospitals in the same hospital system that had not implemented the program and found that CDI rates did not decline as much in the hospitals that had not implemented the program.
• They controlled for other key infection prevention interventions. They surveyed infection preventionists from the eight intervention hospitals and found that other hospital-level factors that could have driven lower C. difficile rates showed no identifiable changes between the pre-intervention and post-intervention periods that would have impacted the outcome.
• Lastly, the researchers utilized a “removed treatment design” to show that a nonequivalent dependent variable of catheter-associated urinary tract infection (an HAI for which the environment does not play a key role in infection transmission) did not change during the intervention period in intervention hospitals whereas the HO-CDI rate declined.

UV-C disinfection as an adjunct to standard cleaning and disinfection
In the past decade, as hospitals look for ways to further improve environmental hygiene, decrease HAIs and instill confidence in patients that the hospital environment is as clean as possible, ultraviolet light technology has been introduced into the workflow to augment standard cleaning and disinfection practices upon patient discharge or transfer. Although UV-C technologies have shown microbicidal efficacy in laboratory studies, assessment of their effectiveness and ability to augment physical cleaning and disinfection in the clinical setting has been challenging. Well-designed, independent, controlled, comparative studies are needed to objectively quantify the cost and potential added value of such technologies when routine cleaning and disinfection has been optimized.4

A new multi-center study evaluated the effectiveness of ultraviolet-C (UV-C) disinfection as an adjunct to standard chlorine-based disinfection for terminal room cleaning in the reduction of multidrug-resistant organisms -- MRSA, VRE, CRE, ESBL and C. difficile.5 They compared acquisition of these five pathogens between patients exposed to them in rooms that had been terminally cleaned with chlorine-based disinfectant versus patients who had been exposed in rooms that had been terminally cleaned with chlorine-based disinfectant plus UV-C disinfection. The authors found that that adjunct UV-C disinfection did not provide incremental value in reducing transfer of MDRO above and beyond standard cleaning and disinfection. They concluded that “our analysis does not support the use of UV-C in addition to post-discharge cleaning with chlorine-based disinfectant to lower risk of prior occupant pathogen transfer.” This study meets the criteria for a Level IV study. It demonstrates reduced pathogen transmission via admission-discharge active surveillance testing or clinical incidence.

Reduction of HAIs is the goal of all environmental hygiene strategies, and the CDC has outlined the hierarchy of evidence needed to demonstrate the impact of a product, process or technology on HAI reduction. The level of scientific rigor required to demonstrate a clear connection between a strategy and HAI reduction is considerable and there are relatively few studies that have met this criteria to date. In today’s environment of limited resources for environmental hygiene, it is more important than ever to weigh the evidence before investing in a product, process or technology. The three recently published studies discussed here provide important insights into the clinical impact of environmental cleaning and disinfection products, processes and technologies to help EVS leaders make informed decisions on where to focus limited resources.

Linda Homan, RN, BSN, CIC, is director of clinical affairs for Ecolab Healthcare.

References:
1. McDonald LC and Arduino M. Climbing the Evidentiary Hierarchy for Environmental Infection Control. Clin Infect Dis. 2013;56(1):36-9. DOI: 10.1093/cid/cis845
2. Parry MF, et al. (2022). Environmental cleaning and disinfection: Sustaining changed practice and improving quality in the community hospital. Antimicrobial Stewardship & Healthcare Epidemiology. 2022;2(e113):1-7. https://doi.org/10.1017/ash.2022.257
3. Carling PC, et al. (2022). Mitigating hospital-onset Clostridioides difficile: The impact of an optimized environmental hygiene program in eight hospitals. Infect Control & Hosp Epidemiol. 2022 Jun 20:1-7 https://doi.org/10.1017/ice.2022.84
4. Carling PC. Health Care Environmental Hygiene: New Insights and Centers for Disease Control and Prevention Guidance. Infect Dis Clin N Am. 2021;35:609–629. https://doi.org/10.1016/j.idc.2021.04.005
5. Hodges JC, et al. (2022). Assessment of the effectiveness of ultraviolet C disinfection on transmission of hospital-acquired pathogens from prior room occupants. Antimicrobial Stewardship & Healthcare Epidemiology. 2022;2(e110):1-5. https://doi.org/10.1017/ash.2022.254

 

Leverage Principles of Adult Learning, Individual Learning Styles and Online Learning to Optimize Training on Environmental Hygiene in the OR

By Linda Homan, RN, BSN, CIC

This column originally appeared in the March 2022 issue of Healthcare Hygiene magazine.

Training staff on environmental hygiene in the operating room has always been important and challenging. And the staff turnover brought on by COVID-19 makes this challenging task even more difficult. You may be dealing with record-high staffing shortages even as surgical volume increases, creating a constant need for on-boarding and refresher training.
This is a good time to ensure that your training is effective. There is an entire educational discipline dedicated to the principles of adult learning. Regardless of whether you are training clinicians or environmental services staff on environmental hygiene in the operating room, it pays to be aware of these principles, along with individual learning styles.
MS Knowles, a leading expert in adult education, outlined the following principles of adult learning.1

Adult learners want to know why they should learn
We are more likely to put time and energy into learning if we know why it’s important. Make sure those that clean operating rooms understand the critical role they play in preventing patient infections. We also learn better if we understand the costs of not learning. “What’s in it for me?” Be sure to emphasize that learning this information will make their work easier and faster and that they will be recognized for completing the work well.

Adults need to take responsibility
Adults assume they oversee their own behavior and can make their own decisions. We expect to be treated as capable of taking on responsibility. However, once we enter a classroom, we may revert to their experience in school, where we were passive learners. To prevent this from happening, develop training methods that are outside the usual classroom passive learning setting. Online learning is a good example of this. It enables learners to take responsibility for their own learning.

Adults bring life experience to learning
For better or worse, adults come to the table with a wealth of personal experience and knowledge. Respect and value our experience but know how it tempers our learning. On the negative side, experience can lead to bias and presumption -- “I already know how to do this.” On the positive side, information learned earlier can be adapted to new situations. For instance, for a new employee who has experience in environmental services in the hospitality industry, compare the purpose and methods in that setting to those in the operating room.

Adults want to learn when the need arises
Adults learn best when it is their choice. Know that some learners might not want to be there, while others are ready to learn. To the extent possible, allow choice and self-directed learning. Again, this can be accomplished with online, self-directed learning.

Adults are task-oriented
We want our learning to be practical and problem-centered – a means to an end. Keep training focused on the tasks that are needed to do the work.

In addition to the differences between child and adult learners, each individual has a preferred learning style that is either visual, auditory, or kinesthetic. There are different ways of effectively teaching for each of these styles. Think about your own learning style as you read through these!

Visual learners learn by seeing. They like visual stimuli and picture themselves doing the task in their “mind’s eye.” In a classroom setting this may look like they are into staring off into the distance. They may drift away when extensive listening is required. These learners need something to watch. Use visual aids like video clips and graphics to supplement text in online learning. For in person learning use demonstrations, slides, and flipcharts.

Auditory learners learn by listening. They learn by listening to audio and can repeat and follow verbal instructions. They also like to talk so they enjoy dialogues and music. To teach auditory learners, tell them what they are going to learn, teach them, then tell them what they have learned. Include auditory activities such as listening to stories or playing verbal games. In online learning, include voice-over as an option.

Kinesthetic learners learn by doing. They learn better when they can move and manipulate things. They will learn best from hands on experience. In a classroom setting, keep them engaged by using activities like return demonstration (see one, do one, teach one) and role play. In online learning, use gamification.

Everyone uses all three styles of learning, so try to incorporate variety in your training methods to keep people engaged.
Leveraging the principles of adult learning and individual learning styles will make your training more effective. Effective training provides a huge return on investment through increased patient safety, staff engagement and retention, regulatory compliance, and sustainable performance improvement.

You don’t need to do this alone. Good vendor partners will provide training that incorporates the principles of adult learning and individual learning styles, are delivered digitally, in multiple languages, and on any connected device. Look for vendor training modules that have built-in mechanisms to assess knowledge and document competence. Now more than ever, we need ways to provide quality training and education that can be delivered “just in time, just in place, just enough, and just for me.”

Linda Homan, RN, BSN, CIC, is senior manager of clinical affairs for Ecolab.

Reference:
1. Craig RL, ed. The ASTD Training and Development Handbook: a Guide to Human Resource Development. New York: McGraw-Hill, 1996.

 

COVID-19 is Driving Practice Changes: Seize the Opportunity to Evaluate Which Changes Keep and Which to Toss Post-Pandemic

By Linda Homan, RN, BSN, CIC

This column originally appeared in the December 2021 issue of Healthcare Hygiene magazine.

A disastrous event like a pandemic causes practice changes, some based on evidence, and some based on ignorance or fear of the unknown. In our personal lives, some of us started carrying personal-sized hand sanitizer and practicing physical distancing. These evidence-based practices would be good to continue post-pandemic, as they can help prevent transmission of a host of infections, including colds and influenza. Some folks started washing their groceries and leaving packages outside for days to kill SARS-CoV-2. These are examples of practices borne out of ignorance. Now that we know more about the virus that causes COVID and how unlikely it is to be transmitted on our groceries or packages, these are practices that should be tossed. As we continue to manage through the pandemic, there is an opportunity to critically evaluate changes we’ve made in environmental hygiene practice. Here are some learnings and practices that we should consider keeping, as their value extends beyond the pandemic.

Environmental hygiene is infection prevention
In an article published in the Annals of Internal Medicine, environmental services workers were described as “unsung heroes, the critical first line of defense against infection” and “the unnoticed sinew of a well-functioning hospital.”1 If nothing else good comes of the pandemic, it has demonstrated the importance of environmental hygiene and the environmental services (EVS) team in infection prevention. Suddenly, in addition to being an integral part of day-to-day infection prevention by disinfecting patient rooms and procedure areas, EVS has been asked to disinfect more spaces, in more ways than ever before. Other departments such as physical therapy and nutrition may have requested increased environmental hygiene. It requires critical thinking and evaluation of the evidence to decide what really needs to be done, and how best to accomplish it.

There is reason to believe that increased cleaning and disinfection in areas outside of patient rooms is a practice worth keeping. A recent study demonstrated that high-touch objects in areas such as procedure rooms, waiting rooms, and clinics are contaminated with pathogens that can cause HAIs.2 The researchers cultured high-touch surfaces in radiology, physical therapy, emergency departments, waiting rooms, clinics, and endoscopy centers across four hospitals, four outpatient clinics, and one surgery center and found that 9.4 percent of cultured surfaces were positive for at least one bacterial pathogen.
Key Learnings: As the pandemic shines a light on the importance of environmental hygiene and environmental services, it’s time to recognize and embrace the critical role they play in infection prevention and incorporate EVS into the safety culture of the hospital. We should continue or perhaps even increase our focus on cleaning and disinfection in areas beyond patient rooms and procedure areas.

Be a healthy skeptic
As COVID spread, suddenly everyone thought they were environmental hygiene experts and had an opinion on how cleaning and disinfection should be done. New technology was suggested for you to use, and sometimes there was minimal data available to evaluate the technology. The drive to clean larger surface areas caused some to look at technology that hadn’t been considered before. You may have been asked about fogging, misting, spraying, or pesticidal devices such as UV lights, ozone generators, or air purifiers. Perhaps you developed a new appreciation for EPA’s Emerging Viral Pathogen Claims and List N. In these situations, it’s important to be a healthy skeptic. Carefully evaluate new chemistry or new ways of applying familiar chemistry and technology to make sure you are using it in a way that is supported by its claims. Refer to EPA’s Antimicrobial Products Registered with EPA Claims Against Common Pathogens https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants
Key Learning: Evaluate new chemistry and technology based on its safety, effectiveness and fit into the workflow before incorporating it into your day-to-day operations post-pandemic.

Expect to be flexible
This is a new-to-the-world virus, so new guidelines were developed to address it, and then the guidelines evolved quickly as our knowledge of the virus grew. This required frequent practice changes and was a source of frustration for many. But the truth is, science is defined as “knowledge about or study of the natural world based on facts learned through experiments and observation.”3 As we learned more about COVID through experiments and observation, we quickly adjusted practice accordingly. Change in practice based on new information is good! For example, if we hadn’t adapted our practice based on new information, we would still be “double-dipping” our cloths and mops in disinfectants.
Key Learning: For environmental hygiene practice to be evidence-based, we must adapt quickly once new, credible information is available.

Ensure adequate supply for the next disaster
As Maya Angelou said, “When someone shows you who they are, believe them the first time.” Were your vendors good partners during the pandemic? This was an opportunity for vendors to demonstrate their true value to you. A good vendor partner ensured that existing customers kept receiving products and only took on additional customers as supply allowed. Now is a good time to ask your vendors if they are taking key learnings from the pandemic and applying them to prevent future product shortages when the next disaster strikes.
Key Learning: There are two questions you can ask your vendor partner to ensure that they are applying lessons learned from the pandemic to ensure adequate future supply.
1. How are vendors ensuring adequate supply, production capabilities, raw material availability, and distribution capacity?
For example:
• By staying close to their customers to know and understand any changes in demand
• By ensuring responsive supply chains, and, where possible, planning with max lead time
2. How are vendors applying the learnings from this pandemic to develop and communicate response plans for the next pandemic or disaster?
For example:
• By sourcing and supplying customers from manufacturing operations close to the customer.
• By identifying potential bottlenecks in situations and reducing dependency on single sources or multi-source suppliers of raw materials.

Linda Homan, RN, BSN, CIC, is senior manager of clinical affairs for Ecolab.

References:
1. Tyan K and Cohen PA. Investing in our first line of defense: Environmental services workers. Annals of Internal Medicine. 2020;173(4):306-7. doi: 10.7326/M20-2237
2. Cadnum JL, Pearlmutter BS, Jencson AL, et al. Microbial burden of inpatient and outpatient areas beyond patient hospital rooms. Infect Control Hosp Epidemiol. 2021 Jul 23;1-5. doi: 10.1017/ice.2021.309
3. Merriam Webster Online Dictionary (2021). Merriam Webster, Inc. https://www.merriam-webster.com/dictionary/science

 

The Critical Role of Environmental Hygiene in the Prevention and Control of Candida auris

By Linda Homan, RN, BSN, CIC

This column originally appeared in the September 2021 issue of Healthcare Hygiene magazine.

Candida auris is an emerging, multidrug- resistant fungi that is highly transmissible. The word “auris” is derived from the Latin word for ear, because this was the first body site in which the fungi was identified.1 As with other Candida species, C. auris colonizes the skin, mucous membranes, gastrointestinal tract and the female genital tract. Five percent to 10 percent of susceptible patients develop invasive infections, such as bloodstream infections, with high mortality rates. Infections caused by this organism have been tracked carefully and, until recently, were thought to occur due to exposure to antifungal drugs rather than via person-to-person transmission. However, in July 2021, the Centers for Disease Control and Prevention (CDC) released a report confirming transmission from patient-to-patient.2

In the wake of this new understanding that C. auris can be transmitted from person-to-person, the Association for Professionals in Infection Control and Epidemiology (APIC) released a statement urging healthcare facilities to adopt aggressive infection prevention and control measures to stop the spread of C. auris in healthcare settings.3 The most important prevention and control measures, as described by the CDC and reinforced by APIC, include:4
• Adherence to hand hygiene: Alcohol-based hand sanitizers are effective against C. auris, and are the preferred method for hand hygiene when hands are not visibly soiled.
• Transmission-based precautions are applied based on the setting, as with other multi-drug resistant organisms.
• Early identification and susceptibility testing, followed by coordinated communication between laboratory and clinical staff and between facilities is critical when C. auris is identified.
• Meticulous cleaning and disinfection of the patient-care environment that is confirmed by increased environmental monitoring in patient care areas.

As we have seen with other pathogens of concern such as C. difficile, these guidelines reinforce the critical role that the environment plays in the transmission of C. auris. Studies have determined that this organism can survive on moist and dry surfaces for up to one month.3,5 Even more challenging, there is evidence that it can survive in both wet and dry biofilms, making it harder to eradicate from the environment once it has been introduced.6.

In 2020, the CDC created Core Components for Environmental Cleaning and Disinfection in Hospitals.7 These core components outline an effective environmental hygiene program, and are more important than ever when faced with an emerging pathogen such as C. auris. Let’s look at these Core Components and how relate to management of C. auris:
Integrate EVS into the hospital safety culture.

Providing a clean patient environment is a cornerstone of a hospital’s safety culture. To prevent transmission of C. auris, frequent communication and collaboration between departments is critical. When patients are diagnosed or admitted with C. auris, the environmental services (EVS) department must be promptly notified so that C. auris protocols can be activated.

Educate and train.

When novel pathogens such as C. auris arise, all staff must be educated on the organism, its transmission, transmission-based precautions needed, and specific practices and products that must be incorporated to prevent transmission. Reinforce concepts with ongoing education with new healthcare personnel and as new guidance becomes available.

Select products that are effective against the organisms of concern.

There have been several studies that evaluate the efficacy of disinfectants against C. auris.8 The Environmental Protection Agency (EPA) maintains List P, which includes all EPA-registered antimicrobial products with claims against Candida auris, along with their contact times.9 Among the active ingredients that are effective are hydrogen peroxide/peracetic acid, dodecylbenzenesulfonic acid (DDBSA), hydrogen peroxide and sodium hypochlorite. If products on List P are not accessible or are otherwise unsuitable, interim CDC guidance permits the use of an EPA-registered, hospital- grade disinfectant that is effective against C. difficile. Quaternary ammonium compounds (QACs) are widely used as disinfectants in healthcare; however, data from recently published studies indicates that products whose only active ingredient is QAC are not effective against C. auris.4,10 Regardless of the product selected, it is important to read label claims and follow all manufacturer’s instructions for use, including applying the product for the correct contact time.

No-touch technologies such as vaporized hydrogen peroxide or germicidal UV irradiation are increasingly integrated into terminal cleaning processes.11 While there is limited research about the efficacy of these technologies specifically against C. auris, they may be an adjunct to routine cleaning and disinfection processes. Decontamination with 35 percent hydrogen peroxide vapor was deployed as part of a range of measures to successfully control a C. auris outbreak in a European hospital.12 In laboratory testing, Candida auris and two other Candida species were significantly less susceptible to killing by UV-C than MRSA.13

Standardize protocols.

The CDC C. auris guidelines recommend meticulous attention to daily and terminal cleaning/disinfection of all patient rooms, all areas where they receive care, and all shared equipment. C. auris has been cultured from many locations in patient rooms, including high touch surfaces and general environmental surfaces such as windowsills. Shared equipment such as glucometers, blood pressure cuffs and nursing carts have also been found to be contaminated with C. auris.4

Monitor Adherence and Provide Feedback.

Disinfectants are only effective when consistently and correctly applied. Objective monitoring and feedback on the thoroughness of cleaning using objective methods such as fluorescent markers are essential to ensure that critical surfaces and equipment have been disinfected. The CDC C. auris guidelines recommend increased environmental hygiene monitoring when there is a patient with known/suspected C. auris in the facility.4 Environmental hygiene monitoring data must be shared with staff and leadership to drive continuous improvement. For more information on evaluating environmental cleaning, review the CDC Toolkit: Options for Evaluating Environmental Cleaning.14

We now understand that Candida auris, a very dangerous emerging pathogen, can be transmitted easily from patient-to-patient, with the healthcare environment as a key vector. Once again, environmental hygiene plays a central role in preventing transmission of this emerging infection. The CDC has published recommendations for infection prevention for Candida auris, including the use of disinfectants that are effective against C. auris and increased environmental hygiene monitoring to ensure cleanliness. These pathogen-specific recommendations dovetail into previously published Core Components of Environmental Cleaning and Disinfection in Hospitals.

Linda Homan, RN, BSN, CIC, is senior manager of clinical affairs for Ecolab.

References:
1. Satoh K, Makimura K, Hasumi Y, Nishiyama Y, Uchida K and Yamaguchi H. (2009). Candida auris sp. nov., a novel ascomycetous yeast isoated from the external ear canal of an inpatient in a Japanese hospital. Microbiology and Immunology, 41-44.
2. Lyman M. (2021). Notes from the Field: Transmission of Pan-resistant and Echinocandin-resistant Candida auris in healthcare facilities - Texas and the District of Columbia, January-April 2021. Morbidity and Mortality Weekly Report, 1022-1023.
3. Association for Professionals in Infection Control and Epidemiology. July 28, 2021. APIC Statement: With resistant C. auris spreading, healthcare facilities must adopt aggressive infection prevention and control measures. Retrieved from Association for Professionals in Infection Control and Epidemiology: https://apic.org/apic-statement-with-resistant-c-auris-spreading-healthcare-facilities-must-adopt-aggressive-infection-prevention-and-control-measures/
4. Centers for Disease Control and Prevention. July 19, 2021. Infection Prevention and Control for Candida auris. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html
5. Piedrahita C, Cadnum J, Jencson A, Saikh A, Ghannoum M and Donskey C. July 28, 2017. Environmental surfaces in healthcare facilities are a potential source for transmission of Candida auris and other Candida species. Infection Control and Hospital Epidemiology, 1107-1109. Retrieved from Association for Professionals in Infection Control and Epidemiology: https://apic.org/apic-statement-with-resistant-c-auris-spreading-healthcare-facilities-must-adopt-aggressive-infection-prevention-and-control-measures/
6. Ahmad S and Alfouzan W. (2021). Candida auris: Epidemiology, diagnosis, pathgenesis, antifungal susceptibility, and infection control measures to combat the spread of infections in healthcare facilities. Microorganisms, 807-832.
7. Centers for Disease Control and Prevention. Oct. 13, 2020. Reduce Risk from Surfaces: Core Components of Environmental Cleaning and Disinfection in Hospitals. Retrieved from Centers for Diease Control and Prevention: https://www.cdc.gov/hai/prevent/environment/surfaces.html
8. Ku T, Walraven C and Lee S. (2018). Candida auris: Disinfectants and Implications for Infection Control. Frontiers in Microbiology, 1-12.
9. United States Environmental Protection Agency. July 21, 2021. List P: Antimicrobial products registered with EPA for claims against Candida auris. Retrieved from EPA: https://www.epa.gov/pesticide-registration/list-p-antimicrobial-products-registered-epa-claims-against-candida-auris
10. Cadnum J, Shaikh A, Piedrahita C, et al. (2017). Effectiveness of disinfectants against Candida auris and other Candida species. Infect Control Hosp Epidemiol. 1240-1243.
11. Weber D, Kanamori H and Rutala W. (2016). No Touch technologies for environmental decontamination. Focus on ultraviolet devices and hydrogen peroxide systems. Current Opinion in Infectious Diseases, 424-31.
12. Schelenz S, Hagen F, Rhodes J, Abdolrasouli A, Chowdhary A, Hall A, et al. (2016). First hospital outbreak of the globally emerging Candida auris in a European hospital. Antimicrobial Resistance and Infection Control, 1-7.
13. Cadhum J, Shaikh A, Piedrahita C, Jencson A, Larkin E, Ghannoum M and Donskey, C. (2017). Relative resistance of emerging fungal pathogen Candida auris and other Candida species to killing by ultraviolet light. Infect Control Hosp Epidemiol. 94-96.
14. Centers for Disease Control and Prevention. Oct. 15, 2010. Healthcare-associated Infections: Options for Evaluating Environmental Cleaning. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html

 

The Business Case for UV-C Disinfection

By Jim Gauthier

This column originally appeared in the July 2021 issue of Healthcare Hygiene magazine.

Contaminated surfaces play a significant role in the transmission of pathogens. A paper by Jon Otter of the National Center for Biotechnology Information summarized studies that demonstrated different healthcare pathogens that are found in the environment that are shed by patients that can be moved to other patients. Organisms included Clostridioides difficile, antibiotic resistant organisms, and viruses.

Frequently touched surfaces are more heavily contaminated and represent greater risk. In a hospital environment, surfaces near patients are often contaminated. Those contaminated surfaces increase the risk of transmission, either directly or through hands of patients and staff. Crowded rooms with lots of activities and poor ventilation can help spread respiratory viruses. Manual cleaning and disinfection is often inadequate, creating increased risk for transmission.

Carling, et al. (2008) studied cleaning compliance across 23 acute-care facilities and found that overall compliance with key surfaces was 49 percent (range of 35 percent to 81 percent), indicating half of high-touch surfaces were not being routinely cleaned during discharge (terminal) cleaning of patient rooms. Cleaning compliance varied significantly by surface (the bathroom light switch was 20 percent and the sink was 82 percent). Carling’s study found a high variability between hospitals, with the cleaning compliance by surface in a different order for each hospital.

Due to time pressures, manual cleaning and disinfection are not being consistently performed to achieve safe environments. A study by the Association for the Healthcare Environment (AHE) of environmental services (EVS) cleaning in hospitals in the U.S. found that on average staff spent 15 minutes performing a daily clean of a patient’s room and 44 minutes performing terminal cleaning procedures in a recently vacated patient room. Because of time pressures, staff may resort to shortcut cleaning practices, which reduces cleaning compliance. Also, individuals will clean a room slightly differently than their peers, regardless of training received.

In their study, Bernstein, et al. (2016) found that 30 percent of EVS staff say they don’t have enough time to do daily cleaning and 20 percent state they don’t have enough time for discharge cleaning. This type of oversights can present serious risk to patients admitted into a room previously occupied by colonized or infected patient.

The Centers for Disease Control and Prevention (CDC) recommends “…a multi-barrier strategy to prevent healthcare-associated infections.” In their Hierarchy of Controls (see figure 1), rather than focusing only on improving cleaning compliance (an administrative control), adding an engineering control may be more effective, and could help reduce some of the variability seen between different EVS staff.

“No-touch” disinfection solutions such as UV-C devices work without user involvement to protect from any gaps in current cleaning practices. What’s more, UV-C devices have been robustly tested and found effective through more than 40 studies measuring either the biocidal effect of UV-C light on microorganisms or the impact on healthcare-associated infection (HAI) rates. UV-C has been proven to kill vegetative bacteria, fungi, viruses and bacterial spores.

Wong, et al. (2016) evaluated 61 rooms and 360 surfaces for contamination before and after regular hospital disinfection. The authors found that prior to cleaning, 30 percent to 35 percent of rooms tested positive for MRSA, VRE, or C. difficile. Standard patient room cleaning and disinfection had a modest effect as some surfaces were routinely missed, and other surfaces appeared to have been contaminated during the cleaning process. However, the use of UV-C reduced contamination in those rooms to less than 5 percent. Floor bacterial levels were similarly reduced due to UV-C.

Ultraviolet (UV) light is a component of the electromagnetic spectrum that falls in the region between visible light and X-rays. It is invisible to the human eye, has been used for decades to disinfect air and water. Killing of microorganisms is most effective at light wavelengths of 254 nanometers. UV light can be divided into UV-A (black light), UV-B (tanning beds), or UV-C (disinfection). UV-C can deactivate DNA (dimerization). The physical process does not kill organisms directly, but it will prevent them from reproducing. While UV-C can be used as an effective, environmentally friendly, non-chemical approach to disinfection, it is most effective if surfaces are properly cleaned prior to its application, as UV-C has poor penetration through soils or fabric.

UV light, as electromagnetic radiation, behaves according to set rules of physics. It should be noted that UV light intensity decreases with the square of the distance from the bulb. This mean, if 100 arbitrary units of energy were delivered at one foot from the bulb and the distance was doubled to 2 feet, only 25 percent of the energy would be detected (2 squared is four, ¼ of 100 is 25). And that efficacy number goes down to 11 percent when the bulb is 3 feet away from a surface (3 squared is 9, 1/9 of 100 is ~11). This is physics and not a device issue, as light energy (photons) collides with molecules in the air and lose energy.

UV-C effectiveness is also impacted by the angle of incidence. UV-C light intensity decreases when the light strikes surfaces at flatter angles. Full energy is delivered when a device is perpendicular to the surface (90 degrees). At a 45-degree angle, the effectiveness of the energy drops to 70 percent. And a 22-degree angle cuts efficiency to 38 percent. Anything that reduces the dose delivered reduces efficacy, which, as shown, includes distance to surface and angle of incidence. Efficacy is measured by the total dose of UV-C delivered to a surface, and hence, is a function of bulb intensity, distance of a surface to the bulb, angle to the surface and time of exposure.

UV-C device makers address these factors by:
• Moving the unit on a robotic base; however, these types of these units typically do no stay in one place long enough to provide significant efficacy
• Adding more and more bulbs to the device, trying to shorten the overall exposure time within the area
• Implementing longer cycle times. While this can increase the dose delivered, it can also cause surface damage over time, especially to objects closer to the bulb system, and the longer cycle time can add to delays in reusing the room.
Ideally, the UV-C device under evaluation should feature actuating arms, which can overcome these issues.

Additional issues to factor in concerning the use of UV-C devices include:
• Shadowing: This is when UV light cannot strike a surface directly, so it receives less energy, reducing efficacy. UV light does not reflect (bounce) very efficiently (as the distance issue above becomes more pronounced). UV-C reflective paints have been suggested, but the distance the light has to travel, and the corresponding reduction in power is still a factor.
• Overexposure: High amounts of UV-C for extended periods on certain plastics, such as ABS, may yellow these materials over time.
• Soil residue: Soil on surfaces reduces efficacy of UV light. Cleaning surfaces before UV-C disinfection is highly recommended.

At a recent Association for Professionals in Infection Control and Epidemiology (APIC) conference, a focus panel with infection preventionists around UV-C selection criteria found that turnaround time of the room was the most important consideration for a UV-C device (26 percent of participants). This was followed by cost (18 percent), efficacy (18 percent), ease of use (9 percent) and portability (9 percent). Other criteria included prep time (6 percent), cycle reporting capabilities (6 percent), evidence/studies of effectiveness (5 percent) and user safety (3 percent).

Assuming a hospital wants to move forward with a UV-C device for their facility, questions about funding sources will likely arise. The first thing to do is create an awareness around the need for UV-C. Be sure to identify the problem(s) to be solved. Funds for these types of devices can typically be found in capital equipment budgets, the government, foundations, community interest groups, private funding (i.e., families and others), online campaigns and lobbying in local news and radio.

To justify funding, follow the rules of the SBAR format:
• Situation: Describe the circumstances; bring something unique to the funding source, talk about the need for a non-chemical insurance plan.
• Background: Tell a story; draw a picture, use data from articles to show that cleaning and disinfection may not be 100 percent.
• Assessment: Bring data to the story. Everyone has needs, illustrate why UV-C is so important and will ultimately make the community better.
• Recommendation/request: Do not be shy; ask for what you need.

Another funding avenue is through creating a purchase/procurement policy to leverage grant funding. To assure no bias in the process, several key policy items need to be considered:
• Ensure procurement procedures are well documented
• Adopt a clear conflict-of-interest policy
• Avoid the purchase of unnecessary or duplicative items
• Provide full and open competition
• Establish micro and simple acquisition thresholds that are in line with federal rules and reflect internal operations
• Plan for formal procurement
• Non-competitive procurement would be a last resort

Also worth looking into:
• The government’s Emergency Grants for Rural Health Care' program. As part of President Biden’s COVID-19 relief package announced in March, $500 million is set aside for grants that will help rural hospitals’ efforts around COVID-19
• In April HHS announced $1 billion from the American Rescue Plan for construction and renovation projects at health centers
• In May, the U.S. Department of the Treasury announced the American Rescue Plan will deliver $350 billion for eligible state, local, territorial, and Tribal governments to respond to the COVID-19 emergency and bring back jobs

In summary, contaminated surfaces play a significant role in the spread of pathogens, and manual cleaning and disinfection may not always be optimal or consistent. UV-C is a proven and effective chemical-free technology to reduce contamination, risk and process variance. Evaluation of key criteria can help determine the UV-C device that best fits a facility’s needs and workflows. Staff and patients appreciate the investment in technology to keep them safe and resources are available to help with purchase and funding.

Jim Gauthier is senior clinical advisor for infection prevention at Diversey. Funding information provided by Reagan Lynch.

References:
Bernstein DA , Salsgiver E, Simon MS, Greendyke W, Eiras DP, Ito M, Caruso DA, Woodward TM, Perriel OT, Saiman L, Furuya EY and Calfee DP. Understanding Barriers to Optimal Cleaning and Disinfection in Hospitals: A Knowledge, Attitudes, and Practices Survey of Environmental Services Workers. Infect Control Hosp Epidemiol. 2016 Dec;37(12):1492-1495. DOI: 10.1017/ice.2016.206. Epub 2016 Sep 13. DOI: 10.1017/ice.2016.206
Carling PC, Parry MF, Von Beheren SM. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Cont Hosp Epidemiol 2008;29(1):1-7. DOI: 10.1086/524329
Wong T, Woznow T, Petrie M, Murzello E, et al. Postdischarge decontamination of MRSA, VRE, and Clostridium difficile isolation rooms using 2 commercially available automated ultraviolet-C-emitting devices. Am J Infect Control. 2016;44:416-20. http://dx.doi.org/10.1016/j.ajic.2015.10.016

 

Healthcare Drains as a Hidden HAI Reservoir: Challenges and Prevention Strategies

By Linda Homan, RN, BSN, CIC

This column originally appeared in the June 2021 issue of Healthcare Hygiene magazine.

Published literature reviews provide evidence that sink, shower and other wastewater drains in healthcare settings have been associated with outbreaks, particularly among the most vulnerable patient populations in neonatal and adult intensive care units, burn units, transplant units and hematology/oncology units. These outbreaks are difficult to recognize and manage because long intervals of time may pass between cases, and the number of cases at any given time is low. Once an outbreak is identified, it can be challenging to eliminate the source – bacteria growing in biofilms in drains. Previously identified methods to disinfect drains have had very limited success.1,2

Waterborne bacteria are the predominant organisms found in sink-related outbreaks with the most common organism being Pseudomonas aeruginosa. Other pathogens include Enterobacteriaceae, such as Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, Serratia marcescens, Enterobacter species, and Citrobacter species. Multidrug-resistant strains of these organisms are commonly found, with carbapenemases most frequently identified. Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBLs) as well as multidrug-resistant P. aeruginosa and A. baumanii are also commonly identified. The true burden of sink-related infections is likely underestimated as there is currently no widespread systematic strategy to identify and track this type of healthcare-associated infection.3

Immunocompromised patients are most susceptible to infections with these organisms.1 In a review of four studies, Kizny-Gordon, et al. found that risk factors for wastewater drain-associated colonization or infection are: preceding surgery, patient location, prolonged mechanical ventilation, older age, burns, longer hospital stay, and drinking tea from a contaminated dispenser.2 Almost all identified outbreaks have occurred in ICUs and hematology-oncology units.

Parkes, et al. reviewed the risk mitigation strategies for sink related outbreaks between 2012-2018, discussed here.3
• Sink and faucet configurations may contribute to the transmission. Faucets flowing directly into drains and shallow sink basins have been shown to cause splash-back. This can contaminate the hands of healthcare workers or patient care items that are stored adjacent to the sink. In addition, sinks are often used to dispose of fluids and materials other than water. These non-water substances can provide nutrients to encourage bacterial biofilm growth.
• Hospitals often have aging and modified water systems with uneven temperature control and dead-end pipes. Temperature fluctuations and stagnant water can contribute to bacterial growth in hospital tap water.
• Below the drain, plumbing issues may also exist, such as scale build up or p-traps and piping made of materials that encourage biofilm growth.
• Most methods to disinfect drains are not effective at killing bacteria in drains. Efforts to disinfect drains have included complete replacement of the sink or its components, installing self-cleaning traps, disinfection with processed steam, enhanced manual cleaning, descaling of pipes, and disinfection with chlorine-based solutions or other liquid disinfectants. Liquid disinfectants do not contact the surface of the drain long enough to meet the contact time needed to kill the bacteria.4
Existing methods to react to drain-associated outbreaks have been “woefully ineffective” at eliminating sink colonization.3

Parkes, et al. suggest a more proactive approach including optimizing best practices in sink design and placement and changing healthcare worker behavior to prevent transmission:
• Correct defective conditions in water systems such as dead ends, low water-use areas, and temperature/pressure fluctuations
• Ensure that faucets don’t flow directly into the drain to minimize splashing/aerosolizing
• Consider changing to deeper sink basins to prevent cross-contamination of hands and adjacent surfaces
• Eliminate misuse of sinks to dispose of fluids and materials that can provide nutrition for bacterial biofilm growth
• Ensure that patient care items are not stored adjacent to sinks to avoid cross-contamination
• Ensure that p-traps and piping are made of materials that minimize biofilm growth
• Consider replacing sinks or affected components to remove the source of transmission. (Replacing sinks may solve the problem temporarily, but eventually biofilm will grow in the new sink if other prevention measures aren’t taken.)
• Various methods of cleaning and disinfecting drains have been tried with mixed results. They sometimes end the outbreak but do not provide sustained decolonization of sinks.

If you have concerns about drains as a vector for pathogens, a drain disinfection program with a product that kills biofilm and can be easily applied on a routine schedule may provide sustained decolonization of the sink drain, thereby preventing transmission of potentially dangerous pathogens from sinks. However, it’s important that the product used to disinfect drains stays in contact with the drain surface above the p-trap for the required contact time in order to be effective. When compared to liquid or chlorine-based disinfectants, recent studies conducted using hydrogen peroxide/peracetic acid/octanoic acid foaming disinfectant have demonstrated efficacy in drains, have been effective in suppressing proximal sink drain colonization for at least three days, and are easy to use.4-5

Linda Homan, RN, BSN, CIC, is senior manager of clinical affairs for Ecolab.

References:

1. Carling PC. Wastewater drains: Epidemiology and interventions in 23 carbapenem-resistant organism outbreaks. Infect Control Hosp Epidemiol. 2018;39(8):972-979.
2. Kizny Gordon AE, Mathers AJ, Cheong EYL et al. Carbapenem-resistant organisms causing hospital-acquired infections: A systematic review of the literature. Clin Infect Dis. 2017;64:1435-1444.
3. Parkes LO, Hota SS. Sink-related outbreaks and mitigation strategies in healthcare facilities. Current Infectious Disease Reports. 2018;20:42.
4. Jones LD, Mana TSC, Cadnum JL, Jencson AL, Silva SY, Wilson BM, Donskey CJ. Effectiveness of foam disinfectants in reducing sink-drain gram-negative bacterial colonization. Infect Control Hosp Epidemiol. 2020;41:280-285.
5. Ramos-Castaneda JA, Faron ML, Hyke J et al. How frequently should sink drains be disinfected? Infect Control Hosp Epidemiol. 2020:1-3.

 

Do Surfaces Contribute to the Spread of COVID-19 and What is the Risk of Contamination?

By Linda Lybert

This column originally appeared in the June 2020 issue of Healthcare Hygiene magazine.

The Centers for Disease Control and Prevention (CDC) last week came out with new guidelines for how to safely reopen and further informed the public that coronavirus does not easily spread via surfaces. Please don’t be confused -- surfaces matter and there is not enough evidence to say it does not spread via surfaces.

It is important to remember this is a novel virus, and there is significant ongoing research happening to try to understand the virus and protect the health and welfare of everyone as we navigate through this serious pandemic. Information is changing, and confusion occurs.

SARS-COv-2 is a novel respiratory virus that causes COVID-19; the primary mode of transmission is aerosolized droplets and human contact. The scientific evidence of this is apparent.

Early research that endeavors to understand the way this virus is transmitted revealed that the pathogen on various surfaces, including walls. Just because the virus was found does not mean that the virus can be acquired from the surface, transmitted to a human host, and they become sick. More research is needed; there is, however, enough research to warn people of a potential area of concern.

The new CDC guidelines clearly outline intensified cleaning and disinfection and state that surfaces are not a primary mode of transmission. There are many recent articles written that minimize the need to clean and disinfect surfaces. What it actually means is that we no longer need to clean all of our groceries, packages, and money. It does call attention to frequently touched surfaces. See the excerpt from the CDC guidelines below.

Intensify cleaning, disinfection, and ventilation (Steps 1–3)
• Clean and disinfect frequently touched surfaces at least daily and shared objects between use
• Avoid use or sharing of items that are not easily cleaned, sanitized, or disinfected
• Ensure safe and correct application of disinfectants
• Ensure that ventilation systems operate properly and increase circulation of outdoor air as much as possible such as by opening windows and doors. Do not open windows and doors if doing so poses a safety risk to individuals and employees using the workspace
• Take steps to ensure that all water systems and features (for example, drinking fountains, decorative fountains) are safe to use after a prolonged facility shutdown to minimize the risk of Legionnaires’ disease and other diseases associated with water

SARS-CoV-2 is a virus, and viruses require a host to survive. While it may live on a surface, what is unknown is how much bioburden it takes for transmission of the virus from the surface to a host and the host to become infected. More research is needed.

As businesses begin to reopen, and infection prevention and cleaning and disinfection strategies and protocols are developed, an assessment of "high-touch" surfaces must be completed. There are many different surface materials and textiles in any given setting, and most people evaluate environmental surfaces. Unfortunately, that leaves out many highly touched surfaces. Consider soft surfaces such as clothing that become highly contaminated throughout the day from many different locations, ultimately supporting the transmission of pathogens wherever people go. What about medical equipment such as blood pressure cuffs, gait belts, wheelchairs, IV poles? It is surprising how highly touched these surfaces are but would not be considered high-touch. The list is long, and it gets complicated very quickly.

Humans shed approximately 1 million microbes a day (Gan, 2015). What amount of viral shedding from a COVID-19 patient does it take before the surfaces surrounding that patient have enough bioburden for easy cross-contamination to then occur? A sick patient with symptoms who is at home will remain in a relatively small area such as a bedroom, identification of surfaces that must be regularly disinfected can be easily identified.

We now know that about 40 percent of the people who are COVID-19 positive are asymptomatic. The identification of high touch and highly touched surfaces must come following observation of the human interaction with surfaces is observed. Sinks, doorknobs, faucets are a great start. What about the family car, with high-touch surfaces including the steering wheel, door handle (both inside and out), seat belt, center console, turn signal, information display, radio, and the keys -- the list of high-touch surfaces in a vehicle is endless.

An immediate and easy solution is to be diligent with hand hygiene. Also, a surface, hands will come in contact with your face and transmit any pathogens that have been acquired. It is easy to take a few minutes to wash your hands using soap and water or hand sanitizer.

Since the release of the new guidelines, there have been numerous articles written, and much misinformation shared. Surfaces are not the primary mode of transmission, but the CDC recommends "intensifying cleaning, disinfection and ventilation." Additional facts include:
• Scientific evidence has shown that the virus spreads via aerosolized spray and droplets and human contact
• We are dealing with a novel virus, and what we know today may change as more research is done.

Looking beyond COVID-19, it is a fact that there are many different types of microbes that effectively live and, in some cases, thrive on surfaces for days weeks and even months. Surfaces have a significant impact in microbial acquisition and transmission. More research is essential. While a virus needs a host to survive for very long other pathogens do not, and you are always at risk. A good cleaning and disinfection strategy, process and protocols are critical.

Linda Lybert is founder and executive director of the Healthcare Surfaces Institute.

References:
Centers for Disease Control and Prevention. Accessible at: https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/CDC-Activities-Initiatives-for-COVID-19-Response.pdf#page=49

Gan V. Our Bodies, Our Microbial Clouds. Sept. 22, 2015.