Managing Hospital Waste
By Ed Barr
Editor's note: This column originally appeared in the March 2020 issue of Healthcare Hygiene magazine.
One of the challenges for hospitals is the expense and expertise needed to manage multiple waste streams. These waste streams pose a challenge, as most are governed by multiple governmental agencies.
The average hospital will deal with the following waste streams:
Municipal Solid Waste (MSW): MSW or trash is the largest form of waste by volume and weight. To manage this stream the waste is normally deposited in a compactor and the cost is based on the tonnage generated and the distance transported for disposal. Haulers can range from national companies to local “mom and pop” companies.
Regulated Medical Waste (RMW): RMW is known by several names i.e. Infectious, biohazardous, red bag trash etc. This waste stream poses several challenges as it is heavily regulated and consists of blood saturated items, sharps, trace chemotherapeutic and pathological. RMW is often mis-characterized and can cost a hospital money if placed in the MSW waste stream. Also, since it is normally disposed of by the pound it can be quite costly. Special training must be provided to employees to handle the waste and to sign manifest for shipment.
Recycling: Recycling is a waste stream that poses a challenge for most hospitals to manage. The types of items recycled include: Corrugated or cardboard, office paper, aluminum cans, plastic and glass food and beverage containers, packaging, toner cartridges are among the items commonly recycled. Separate handling and shipment are required and if not done properly can lead to contamination which causes a hospital to pay additional costs for disposal.
Hazardous Waste: Hospitals have several sources of chemicals coming from clinical and research labs as well as waste generated during clinical usage including bulk chemotherapy. Other waste in this category includes industrial grade and phone batteries.
Pharmaceutical Waste: Hospitals are now required to collect and separately dispose of their drugs. This requires separate collection boxes in the main and satellite pharmacies as well as clinical areas.
Electronic Waste: This waste consists of computers, televisions and other devises used in the institution. If the information has patient information covered by HIPAA you need to ensure that information is wiped out and not accessible to any unauthorized individuals.
Bulk Waste: Any waste too large to be disposed of in a compactor must be placed in an open top dumpster. This includes old furniture, hospital beds and other medical equipment
Construction Debris: Hospitals continually upgrade their facilities and the debris from the construction must be removed and disposed of. Some jurisdictions require separate handling of this material.
Radioactive Waste: Any radioactive waste used in the treatment of patients or research must be separately stored and disposed of.
Kitchen Grease: Grease collection from commercial kitchens are quite common and hospitals are no exception.
Each of these items requires time, labor and considerable expense to manage. Most are regulated by local, state and the federal government.
When managing waste streams, it is important to partner with vendors who can provide services for your institution. Some questions you may want to ask are:
- How long have they been in business?
- How many hospitals are they providing service for?
- What is the emergency plan for equipment failure during nights and weekends?
- Do they provide the service directly or do they subcontract the work?
- How does their program comply with local, state and federal regulations?
- How do they provide proof of destruction?
Regardless of the answers you want to make sure that you follow the trail of the waste to endure destruction. For example, if you have a company that removes your electronic waste you want to make sure you can prove destruction not just holding an invoice with the information.
For RMW, the stakes are higher if the waste is not properly disposed of. For example, if RMW is placed in your MSW waste stream and shows up at a landfill or transfer station the hospital is liable for removal and proper disposal. In addition, the waste provider will report the incident to the state department of environmental protection which can result in an investigation or fines for the hospital.
- If you decide to treat your waste onsite there are several things to consider:
- The capital costs associated to purchase onsite treatment frequently must compete with a limited pool capital dollar
- How long has the company been in business? Is this the company’s first install? Do they have a proven list of customers?
- How complicated is the equipment? What type of skills are needed to operate and maintain the equipment?
- What support does the company offer for ongoing preventive maintenance and repair issues?
- How does the equipment disinfect or sterilize the RMW? How do you know the waste has been treated?
Managing waste is a complicated process. However, the good news is there help and information out there to help you protect your institution and our planet.
Ed Barr, CHESP is a director of environmental services for Sodexo. He has been active in the field of waste management and recycling for more than 30 years having run programs for a major academic medical center as well as serving as program manager for hospitals in the Mid-Atlantic region. He has served as president of the Greater Philadelphia Recycling Council and president of Greater Philadelphia AHE.
Contaminated Air and Surgical Infection Associated With Implant Procedures
By Sue Barnes, RN, CIC, FAPIC
Surgical Site Infection (SSI) Risk for Patients Who Have Implant Procedures
Patients undergoing surgical procedures which involve an implant such as prosthetic joint replacement, are at risk of post-operative infection caused by the very smallest bacterial inoculum.1 This is due to the surface of the implant on which biofilm can expediently develop, and also due to the patient’s immune system focusing initially on the implant versus any bacteria that might have adhered to its surface. Consequently, the number of organisms required to cause an infection when an implant is involved is reduced by a factor of 100,000.2
The Impact of Implant-Associated SSI
A common implant procedure in the United States is total hip replacement, of which there are approximately 300,000 performed annually. The average SSI rate for these procedures is 2.18 percent.3 While this is a low rate it still represents 8,400 patients, each experiencing pain, suffering and for some lost wages and impact on family and quality of life.4 For each patient the range of cost for treatment of the infection is between $389,307 and $474,004, and is associated with a mortality rate of between 2 percent and 7 percent.5,6 In addition to prosthetic joint replacement, many other types of surgical procedures now involve implants including, breast, plastics, orthopedic, spine, general (hernia mesh), gynecology (pelvic floor mesh), cardiac (pacemaker, stent, valve, internal atrial defibrillator).
Air Contamination and SSI
The direct correlation of bacteria laden particulates in operating room air to surgical infection risk has been reported for decades in peer reviewed studies.7-9 These particulates can become transiently airborne during a case, settle in the open incision and adhere to the implant.10 These may originate from any one of several sources, including respiratory aerosols of the surgical team which can escape from the surgical mask, especially in the presence of an upper respiratory tract viral infection.11,12 Another potential source of transiently airborne pathogens in operating rooms is the skin of surgical team members and/or patient. Skin scales are constantly shed from the human body, to which bacteria are often attached.13 Illustrating this risk, is a documented outbreak involving eight SSI reported after modified radical mastectomy in a tertiary-care hospital, caused by Group A streptococci (GAS). The source was found to be a surgeon colonized (skin) with GAS.14
A third potential source of transient airborne contamination in operating rooms is equipment which includes a water reservoir. The outbreak of Mycobacterium chimaera SSI after cardiac surgical procedures demonstrates this risk. In this outbreak, the water tanks on the heater-cooler devices used in open heart surgery were found to be the source for the airborne transmission of M. chimaera resulting in more than 100 SSI cases since 2013 in Europe and the U.S.15,16
Current State of Air Quality in U.S. Operating Rooms (OR) versus Compounding Pharmacies
In the OR, surgical procedures involve an incision (sterile space), which remains open to the OR air. In compounding pharmacies sterile solutions are prepared to be introduced into the sterile vascular system. Regulations governing these two spaces are not equivalently protective. On the one hand, U.S. compounding pharmacies must comply with International Standards Organization (ISO) class 5 standards for air quality.17 However, there is no requirement for air quality testing in US operating rooms, where it is assumed to be sufficient as a result of the engineering controls (positive air pressure, increased air changes, temp and humidity control and high efficiency particulate air filter or HEPA).18 However, it has been demonstrated that those controls can be defeated by door openings and room traffic during cases.19-21
Adjunctive Air Decontamination Technology
Technologies designed to improve air quality in operating rooms fall into three primary categories – air filtration, air disinfection and combined filtration plus disinfection. This adjunctive technology is arguably most crucial in the outer area of the OR beyond the OR table, which is protected with directional air flow and HEPA air filtration. In this outer area of the OR, there is typically less effective air flow, increased human activity, door openings and floor contamination. Consequently, the air in this surrounding area can potentially contaminate instrumentation, implants, gloves, surgical team members, surgical drapes, and tables which are in direct communication with the patient. Employing an adjunctive technology for the outer area of operating rooms, which provides air disinfection plus filtration of particulates, would seem prudent. Innovative portable devices which combine ultraviolet (UV) technology and HEPA filtration to eliminate particulates and microorganisms are in use in increasing numbers of ORs. These devices have been reported in peer reviewed studies to reduce transiently air bacteria in operating rooms by 50 percent to 60 percent and reduce overall rates of prosthetic joint infection (p<0.042).22-29
TO VIEW "REDUCED OCCURRENCES OF PJI" TABLE CLICK ON THIS LINK: PJI table
Current standard methods for ensuring adequate OR air quality are limited to positive air pressure, 20 air changes per hour, surgical attire, traffic control (and HEPA filtration in some ORs). These methods alone have been proven insufficient to prevent contaminated air associated SSI as demonstrated by multiple outbreaks including the M. chimera outbreak in cardiac surgery associated with heater cooler devices. Air decontamination technology (UV + HEPA) can serve as an adjunct to standard methods for ensuring safe air quality for ORs, especially where implant procedures are performed.
Sue Barnes, RN, CIC, FAPIC is an independent clinical consultant, Board certified in Infection Control and Prevention, a Fellow of APIC (FAPIC) and co-founder of the National Corporate IP Director Network. She currently provides marketing and clinical consultation to select industry partners who seek to support infection prevention with innovative products. Disclosure: The author provides consulting services for Aerobiotix, Inc.
- Petrova OE and Sauer K, Sticky situations: key components that control bacterial surface attachment. J Bacteriol, 2012. 194(10): p. 2413-25.
- Zimmerli W, Trampuz A, Ochsner P. Prosthetic-Joint Infections. N Engl J Med. Oct. 14, 2004; 351:1645-1654.
- Kurtz SM, Economic burden of periprosthetic joint infection in the United States. J. Arthroplasty 2012.27:61-65.e61.
- Total Hip Replacement - Information from American Academy of Orthopedic Surgeons. Accessed at: https://orthoinfo.aaos.org/en/treatment/total-hip-replacement/.
- Parisi TJ. What is the Long-term Economic Societal Effect of Periprosthetic Infections After THA. Clin Orthop Relat Res. April 7, 2017.
- Tande AJ, Patel R. Prosthetic Joint Infection. Clinical Microbiology Reviews. 2014;27(2):302-345. doi:10.1128/CMR.00111-13.
- Eickhoff, T. C. (1994). Airborne nosocomial infection: a contemporary perspective. Infect Control Hosp Epidemiol. 15(10): 663-672.
- Durmaz G et al. The relationship between airborne colonization and nosocomial infections in intensive care units Mikrobiyol Bul. 2005 Oct;39(4):465-71.
- Kowalski W. Ultraviolet Germicidal Irradiation Handbook. Springer Verlag, Berlin 2009. pp 399-418.
- Owers KL, James E, Bannister GC. Source of bacterial shedding in laminar flow theatres. J Hosp Infect. 2004 Nov;58(3):230-2.
- Stein R. Super-spreaders in infectious diseases. International Journal of Infectious Diseases. Vol 15 (2011) e510-e513.
- Mora M, Mahnert A, Koskinen K, Pausan MR, Oberauner-Wappis L, Krause R, et al. Microorganisms in Confined Habitats: Microbial Monitoring and Control of Intensive Care Units, Operating Rooms, Cleanrooms and the International Space Station. Front Microbiol. 2016;7:1573.
- Hardin W. and Nichols R. (1995). Aseptic Technique in the operating room. Surgical Infections. D.E. Fry, Ed., Little Brown & Company Boston 109-117.
- Qing-Zeng C, Yun-Bo S, Shi-Hai L, et al. Outbreak of Infections Caused by Group A Streptococcus after Modified Radical Mastectomy. Surgical Infections. 2013;14(4):385-388.
- Van Ingen J et al. Global outbreak of severe Mycobacterium chimaera disease after cardiac surgery: a molecular epidemiological study. Lancet Infect Dis. 2017 Oct;17(10):1033-1041.
- Balsam LB et al. Mycobacterium chimaera left ventricular assist device infections. J Card Surg. 2017 Jun;32(6):402-404.
- ISO documents (n.d.) https://www.terrauniversal.com/cleanrooms/iso-classification-cleanroom-standards.php.
- ASHRAE 170: https://www.techstreet.com/ashrae/standards/ashrae-170-2017?gateway_code=ashrae&product_id=1999079
- AORN Recommended Practices for Traffic Patterns in the Perioperative Practice Setting. AORN Journal. March 2006. Vol. 83, No. 3, Pages 681-684, 686.
- HICPAC Guidelines for Environmental Infection Control in Health-Care Facilities. MMWR June 6, 2003 / 52(RR10);1-42.
- Lynch R et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. Am J Medical Quality. Vol. 24, No. 1, Jan/Feb 2009.
- Bischoff W et al. Impact of a novel mobile air purification system on the bacterial air burden during routine care. Oral presentation SHEA Conference. Spring 2018.
- Curtis G et al. Reduction of particles in operating room using UV air disinfection and recirculation units. Journal Arthroplasty. (2017) 1-5.
- Davies GS, Bradford N, Oliver R, Walsh WR. The effects of a novel decontamination-recirculating system in reducing airborne particulate: A laboratory-based study. Oral presentation: The European Bone & Joint Infection Society Conference. Sept 7-9, 2017.
- Gannon C et al. Reduction of total and viable air particles in the OR setting by using ultraviolet in-room air disinfection and recirculation units. American Association of Hip and Knee Surgeons Conference. Nov. 4, 2017.
- Kirschman D, Eachempati S. Airborne bacteria in the operating room can be reduced by HEPA/Ultraviolet air recirculation system (HUAIRS). Presented at the Surgical Infection Society (SIS) 37th annual meeting. May 2-5 2017.
- Messina G et al. A mobile device to reduce airborne particulate and prevent surgical site infections. European Health Association Conference. Nov. 20-23, 2019.
- Parvizi J et al. Environment of care: is it time to reassess microbial contamination of the operating room air as a risk factor for surgical site infection in total joint arthroplasty? Am J Infect Control. 2017 Nov 1;45(11):1267-1272.
- Walsh WR et al. The Effect of a Novel Air Decontamination Recirculation System on Viable Airborne Particulates. Oral Presentation European Bone and Joint Infection Society (EBJIS) 36th annual meeting. September 7-9 2017.
10 Commonly Asked Questions Relating to Environmental Hygiene
By J. Darrel Hicks, MREH, CHESP
This column originally appeared in the February 2020 issue of Healthcare Hygiene magazine.
1: To what extent does the environmental surfaces cleaning affect contamination levels in hospitals?
The role of the hospital environment as a reservoir of infection is poorly understood. But this is certain; one well-trained hygiene specialist (housekeeper or environmental services professional) can prevent more disease transmission than a room full of doctors can cure.
2: Is there a way to measure the efficacy of a cleaning program?
There are four ways to measure the efficacy of a cleaning program. They are: (A) Visual assessment-not a reliable indicator of surface cleanliness. (B) ATP bioluminescence-measures organic debris (each unit has own reading scale) will give you a reading within seconds. (C) Microbiological methods-can be costly and pathogen specific. (D) Fluorescent marker to ensure that cleaning processes have been adequately performed.
3: What is the difference between disinfectants and sanitizers?
Sanitizers can be used in cafeterias, kitchens and food preparation surfaces to keep certain (short list) microorganisms at a safe level. But, if you want those same microorganisms ELIMINATED, you would need to use a disinfectant such as a quaternary ammonium compound (quat), phenolic, accelerated hydrogen peroxide or other the U.S. Environmental Protection Agency (EPA)-registered disinfectant.
4: Knowing that surfaces nearest the patient harbor the greatest number of pathogens, what is the best method to reduce or eliminate those pathogens?
Washing or scrubbing a surface physically removes soil and organic material such as blood and body fluids and takes with it the disease-causing pathogens. The guiding principle is always to remove germs, if possible, rather than kill them, and then when necessary, use the least amount of the mildest chemical that will do the job, because stronger often means more toxic to people.
5: Is microfiber that much better than cotton when it comes to mops and cloth wipers?
Yes. Microfiber helps physically remove the food and moisture necessary for microorganisms to survive, but better grades of microfiber (those with very dense weaving and fiber configuration) can even remove large quantities of microbes, including hard-to-kill spores.
6: Is it necessary to disinfect floors in hospitals?
A: Floors aren’t a high-touch surface, but some cleaning professionals and healthcare experts suggest that they should be included in disinfection processes. The other school of thought is to simply use a neutral floor cleaner since floors are quickly re-contaminated as soon as somebody walks on them or something is dropped on them.
7: How long must a surface, wetted with disinfectant, remain wet?
This question deals with exposure time or contact time. Each disinfectant has a label with directions for contact time. The U.S. Centers for Disease Control (CDC) guideline recommends a contact time of 1 minute at a minimum. If the label states different contact times for different organisms, the highest contact time listed must be used because one doesn’t know the contents of the soil being cleaned.
8: Is it possible to perform ‘green disinfection’?
Disinfectants -- used properly and wisely -- are designed to protect public health. In many situations—and especially in healthcare and other critical facilities—there is no substitute for disinfectant cleaning. That being said, there are some old technologies (i.e., copper or silver impregnated surfaces, steam vapor devices, spray-and-vac technology) and some new, emerging technologies that hold great promise (i.e., UVC (short wave or germicidal light) photons damage DNA and Hydrogen Peroxide (HP). Both UVC and HP technologies are meant to supplement, not replace routine disinfection.
9: What are “superbugs” and why should we be concerned about them?
Some pathogens have gotten the reputation for being “superbugs” because of their ability to survive on environmental surfaces for up to 56 days after contamination on common hospital materials. Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) are two of the most talked about “superbugs” that have been implicated in transferring from hospital surfaces to previously uninfected patients.
10: Is it true that quats (quaternary ammonium disinfectants) are inactivated by cotton mops and cloths?
True, once cotton mops or wipers are introduced into a fresh solution of quat disinfectant, the cotton binds the available, active ingredients of the disinfectant within minutes. To avoid this, use a synthetic microfiber cloth or man-made spun material (no cellulose) in quat disinfectants.
J. Darrel Hicks, BA, MREH, CHESP, is the owner/principal of Darrel Hicks, LLC and the author of the book Infection Prevention for Dummies. He is also a board member of the Healthcare Surfaces Institute.
Moving Out of the Cul-de-sac
J. Darrel Hicks, MREH, CHESP
This column originally appeared in the January 2020 issue of Healthcare Hygiene magazine.
For more than 50 years, I’ve lived in suburbs where cul-de-sacs abound. City designers abandoned dense urban grids for garden communities with meandering streets and cul-de-sacs in the 1930s. These new cul-de-sac neighborhoods were thought to be safer and more private alternatives to the pollution, poverty and overcrowding of traditional cities.
For the past four months I’ve been working as the interim environmental services director in a hospital in California. One of my frustrations has been in getting the infection control committee’s approval of a new EPA-registered disinfectant. In tandem with the new disinfectant, I was seeking approval of a total room disinfection technology.
In the past two years before my arrival, the infection control committee approved a hospital-wide disinfectant with a tuberculocidal claim that meets OSHA’s bloodborne pathogen standard for disinfecting surfaces contaminated by blood or other potentially infectious materials. The product must remain wet for 5 minutes. But, for all contact-isolation rooms, a product that requires 3 minutes of contact on pre-cleaned surfaces is used.
Currently, the infection control committee is living happily on the cul-de-sac where it is safe to the through traffic. The cul-de-sac is where the kids can safely play in the circle and neighbors get to have the occasional “block party.” But the cul-de-sac is not where new and better solutions to the problems the hospital faces lives.
The “cul-de-sac” mentality is not isolated to a hospital in California. This mentality thwarts new and innovative products and processes from improving environmental hygiene. Decision-makers and stakeholders too often hide behind questions such as “Who else is using it?” and “What does it kill?” or make statements such as “We don’t switch disinfectants unless there’s a problem that isn’t being addressed.”
It’s at this juncture that feels like quitting this pursuit for a “better, more efficacious” way of room disinfection. Instead of quitting, entrepreneur Seth Godin says, “One should rededicate or try ‘an invigorated new strategy designed to break the problem apart.’”
Godin goes on to say, “I like to call this the pivot. It's an adjustment, a strategic relocation, a change in direction that you make while keeping your eye on your goal. You're like an airplane making constant course corrections until it reaches its final destination.”
I will continue building a relationship with the infection control nurse and infectious diseases physician to identify areas of common agreement. I will implement new and better cleaning and disinfection tools for the EVS staff to more thoroughly clean the patient’s room. Education and retraining will get done in short order. And, I’ll work with the infection control nurse on doing fluorescent marking of rooms before daily or terminal cleaning. This will allow us to begin building data and confidence in “the program” that will ultimately take us off the cul-de-sac and onto the interstate of better outcomes.
Check your calendar. It’s not only a new year, but it’s a new decade, too.
If you find yourself or your organization comfortably living on the cul-de-sac while infection rates remain stagnant and patient satisfaction scores are slightly above the 50th percentile, perhaps it’s time to move out of the cul-de-sac and onto the interstate.
J. Darrel Hicks, BA, MREH, CHESP, is the owner/principal of Darrel Hicks, LLC and the author of the book Infection Prevention for Dummies. He is also a board member of the Healthcare Surfaces Institute.
Hand Grenades and Horseshoes
By J. Darrel Hicks, BA, MREH, CHESP
This article originally appeared in the December 2019 issue of Healthcare Hygiene magazine.
Few people remember that it was baseball great Frank Robinson who first said, "Close don't count in baseball. Close only counts in horseshoes and hand grenades." The quote appeared in Time magazine (July 31, 1973). But what does that phrase mean? It means that the world is usually binary -- you win/you lose, you hit/you miss. If you lose a baseball game 12–11, you only lost by one run, but you lost. Think of “Close but no cigar.” This phrase gives an example of being close and uses alliteration at the same time.
In order for a chemical to claim disinfection it must attain a 6-log reduction of specific organisms, in a prescribed amount of time. While sterilization means at least a 6+ log reduction while leaving no growth or viable survivors.
It is important to understand what log reduction is and why it is important to the process of surface disinfection, surface sterilization and surface decontamination. Scientists and other professionals who are responsible, or even legally responsible, for preventing illness and contamination are concerned with log reduction or elimination of pathogenic bioburden.
The term “log” is short for logarithm, a mathematical term for a power to which a number can be raised (e.g., using 10 as the given number, a log-2 increase can be shown as 10ˆ2 or 10 x 10=100). Alternatively, a log reduction is taking the power in the opposite direction. For example, a log reduction of 1.0 log is equivalent to a 10-fold reduction. Or, stated another way, moving down one decimal place, a 90 percent reduction.
Healthcare surfaces can be contaminated with pathogenic organisms (bioburden), and only achieving a log reduction below 6-log means dangerous viruses, bacteria, fungi and Clostridium difficile (C. diff) spores can or will survive and repopulate surfaces within the treated area. The literature has shown that bioburden can be spread around to contaminate patients and/or grow new bacterial and fungal colonies on new surfaces.
A disinfectant kills microbes; however, depending on the pathogen, preventing the microbes from getting a foothold by removing food and moisture (two essentials for sustaining living organisms) may, in the long-term, be as effective as a chemical disinfectant. In fact, most chemical disinfectants can’t do their job when greater than 5 percent organic soil is in the way. Soil can absorb the active ingredient, provide more places for the germs to hide, and change the chemical nature of the disinfectant.
The number of bacterial survivors is very important because they can quickly increase their populations exponentially/logarithmically. For example, Staphylococcus aureus (under ideal conditions) doubles in 24-30 minutes. This means 1,000 or 10ˆ3 or Log 3, bacterial survivors would increase to 2,000 after 30 minutes, after 60 minutes they would increase to 4,000, after two hours to 16,000 and then increase to over one million after 5 hours or more if the growing environment is right.
When it comes to disinfection of environmental surfaces, close doesn’t count. Not only do “Survivors” replicate quickly and efficiently, but they can also become resistant to disinfectants. To improve outcomes of room disinfection, disinfectants should only be applied to pre-cleaned surfaces according to the Environmental Protection Agency (EPA) and the Centers for Disease Control and Prevention (CDC). These agencies require that any hospital cleaning process that claims efficacy against C. diff spores must achieve no growth, which means no survivors that can multiply and create new bacterial colonies.
There is nothing about the EPA’s use of the AOAC Use-Dilution Test. The AOAC Use-Dilution Test is far removed from "real-life" use of disinfectants. The most glaring separation from "real life" product usage is that contaminated surfaces are submerged in excess disinfectant for the entire contact time (up to 10 minutes). Add to that the fact that sterile water is used for application of the disinfectant. The role of professional cleaning staff in hospitals is dependent on the best disinfectant products that have been vetted in real world conditions of damaged furniture and finishes, water hardness, and education about the prevention and transmission of disease. That’s the challenge confronting the environmental services department.
In closing, if the healthcare surfaces are to be safe, clean and disinfected, we must have better products, processes and staff education about their role in infection prevention. Being “close” just isn’t good enough.
Darrel Hicks, BA, MREH, CHESP, is the owner/principal of Darrel Hicks, LLC and the author of the book Infection Prevention for Dummies. He is also a board member of the Healthcare Surfaces Institute.
Challenging Variation of Hospital Cleaning with a Simple Four-Step Protocol
By Kelly M. Pyrek
This article originally appeared in the November 2019 issue of Healthcare Hygiene magazine.
Variation in environmental hygiene interventions is compounding the challenge of understanding the potential impact that cleaning and disinfection has on infection rates.
While recommendations exist, mainly in the medical literature as well as from professional organizations, there is not one single, standardized protocol for U.S. hospitals.
“There is no accepted cleaning protocol because there is still insufficient evidence for healthcare cleaning and how it should be done,” says Stephanie J. Dancer, BSc, MB BS, MSc, MD, FRCPath, DTM, a medical microbiologist at NHS Lanarkshire and professor of microbiology at Edinburgh Napier University in the UK. “It is difficult to agree a universal process without a robust evidence base. The current debate is skirting around the edges by arguing over cleaning and/or decontamination methods and risk assessment of specific patient areas.”
Dancer adds, “Cleaning is not sexy; it is underpaid, undervalued and viewed through a prism of social class. There is little commitment to produce standardized guidelines, particularly if implementation is going to cost more. People who could make it happen do not understand the importance of cleaning because they may not have had to do it for themselves.”
Variability in cleaning practices is problematic, Dancer says, because “Different methods, types, application and frequencies of cleaning destroy any chance of collating scientific evidence. In addition, cleaners are people who will clean differently every shift depending on how they feel. Cleaners cannot be standardized. Nor should they be.”
One might think that basic guidance for environmental cleaning and disinfection could be construed as naïve in this age of sophisticated interventions, but as Dancer and Kramer (2018) emphasize, “repeated application of a sequential cleaning system would offer a time-efficient and effective method for decontaminating a bed space in the healthcare environment.”
They add further, “It is already known that surfaces are regularly missed during cleaning, and that time spent cleaning does not correlate with thoroughness of cleaning. Cleaning an area in a methodical pattern establishes a routine so that items or areas are not missed during the cleaning process. A practical guideline would improve cleaning of high-risk near-patient sites and could impact on HAI risk. Secondly, an explanatory guide would help cleaning staff to understand what they should do, when they should do it, and why they should do it. The principles focus on the occupied bed space because a vacant bed space receives so-called ‘terminal’ or ‘discharge’ cleaning, for which there is already comprehensive guidance. An unoccupied bed space is easier to clean as it lacks patient, visitors, clinical equipment and personal belongings. However, while there remains a small HAI risk for cleaning staff from the terminally cleaned bed space, the risk is arguably greater with a patient in situ. Patients themselves continually touch high-risk sites, without hand hygiene reminders or opportunities.”
Lack of compliance with infection prevention practices in hospitals is well documented in the literature and can be explained away by everything from deficits in resources, to time pressure and gaps in healthcare personnel knowledge about the imperatives of environmental hygiene. Barriers to optimal practice must be overcome, Dancer says, but consensus is lacking as to how precisely that can be achieved.
“The most intractable barrier to implementing a standardized protocol (other than lack of evidence) is usually due to lack of managerial commitment and support,” she says. “In addition, cleaning staff require a salary and more resources might be needed for a new cleaning process. Plus, no agreement on methods means that consumable costs could terminate any willingness to restructure the cleaning service. How do hospitals in low income countries afford expensive disinfectants or automated devices?
Dancer continues, “Another barrier is the fact that it is difficult to measure both the cleaning process and surface cleanliness. Even monitoring the impact of a cleaning intervention by using patient parameters such as hospital-acquired infection (HAI) is challenging. This is because there are multi-factorial reasons for HAI occurrence outside the outbreak situation. So, hospital authorities cannot easily audit the benefits from their newly implemented universal cleaning protocol.”
To help address the lack of standardization, Dancer and Kramer (2018) outlined a systematic process by which each component of environmental hygiene is placed within an evidence-based and ordered protocol. But when conducting their literature search, the authors hit a barrier of their own – they could not identify any papers providing an evidence-based practical approach to systematic cleaning in hospitals, and therefore proposed their own, simple four-step guide for daily cleaning of the occupied bed space.
Their schematic is as follows: Step 1 (LOOK) describes a visual assessment of the area to be cleaned; Step 2 (PLAN) argues why the bed space needs preparation before cleaning; Step 3 (CLEAN) covers surface cleaning/decontamination; and Step 4 (DRY) is the final stage whereby surfaces are allowed to dry.
That the protocol has only four steps is by design, Dancer says, to help overcome challenges relating to the overall complexity of cleaning disinfection tasks, the skill and comprehension levels of environmental services professionals, and the immense pressure of room-turnover times.
“Why not keep it simple,” Dancer emphasizes. “Domestic workers clean because they need a job; and/or may not have the qualifications to do anything else. So, a four-step protocol is more easily assailable; easier to teach; easier to monitor; easier to understand. Cleaners might not speak the language of the country in whose hospitals they are working, and a practical four-step process could be transmuted into a visual guideline with pictures, diagrams and photographs to explain each step.”
She continues, “People need to know exactly what they have to do; how they should do it; where and when they should do it; how often they should do it; and what the risks are, for themselves as well as patients. They also need to know the value of what they do, even if this does not translate into a generous pay packet. In addition, standardization of the process lends itself to monitoring and feedback, both of which guarantee a better outcome.”
As Dancer and Kramer (2018) observe, “Cleaners themselves receive little or no training for what they do, and any teaching initiatives may be compounded by time, language and literacy problems. Universally poorly paid, they are expected to perform a physically arduous and repetitive job with additional personal risks from cleaning materials as well as exposure to infected patients. Cleaning staff would likely welcome a systematic aid to good practice with in-built risk assessment for themselves, as well as staff and patients.”
The four-step guide proposed by Dancer and Kramer (2018) targets primarily environmental services personnel rather than nursing staff, and as such prioritizes bed-space items and furniture and not clinical equipment.
Let’s examine each of the four steps:
Step 1: LOOK
The process begins with a visual assessment. As Dancer and Kramer (2018) advise, “Every cleaner should inspect the area to be cleaned and consider overall conditions and degree of visual contamination before beginning a cleaning task.”
Step 2: PLAN
This step explains why and how the area to be cleaned needs to be prepared for cleaning. Healthcare environmental services staff should survey the area to be cleaned, ascertaining the most appropriate level of cleaning, what should be cleaned and how, and being sure to use the proper tools and cleaning/disinfection chemistries.
Step 3: CLEAN
As Dancer and Kramer (2018) explain, “Cleaning refers to the removal of soil from surfaces by use of physical wiping or scrubbing; the chemical action of a surfactant or detergent; and water to wet, emulsify or reduce surface tension. The process removes both dirt and microorganisms from surfaces, thereby reducing the amount of organic bioburden. Cleaning should always precede disinfection because the presence of soil will impede disinfectant activity. Some hospitals use detergents for routine cleaning, while others choose products that either inactivate or kill living microorganisms. This is termed ‘disinfection’ or ‘hygienic’ cleaning … Cleaning and disinfection become inextricably intertwined when wipes are impregnated with disinfectant as the overall effect is a combination of disinfectant activity and physical removal of soil.”
They emphasize some of the best practices relating to cleaning and disinfection:
- Clean from high to low, then clean sites nearest to the patient first, then sites furthest from the patient (e.g. door handle, sink, bathroom.
- Make high-touch/ hand-touch sites a priority.
- Clean a site from least visually dirty to obviously dirty.
- Wipes should be used according to manufacturers' instructions. Use one wipe for each site; some sites may require several wipes (e.g. bed frame). Unfolding the wipe and using it flat on the surface maximizes the area cleaned and minimizes the amount of hand contact. Wipe in one direction without retracing the area already cleaned; apply the ‘one wipe; one site; one direction’ principle.
- Be aware that microbes may be transferred between surfaces (via gloved hands, cloths, etc.)
- Always remove visible soil with detergent and water before the use of disinfectant.
- The physical removal of soil and microbiocidal activity from disinfectant may be achieved by use of a disinfectant-containing wipe.
-The researchers emphasize, “Sites such as bed rails, bed control (if electric-bed), nurse call bell, bedside locker and bed table constitute the highest priority for cleaning because they are frequently touched and readily provide a reservoir for hospital pathogens. There is a two-way direction of transmission between these surfaces and hands, which can only be disrupted by targeted cleaning and hand hygiene. Given that cleaning usually occurs just once per day, and hand hygiene depends on a multitude of factors, it comes as no surprise that infections are readily acquired from bed-space sites.
Step 4: DRY
The final stage encompasses physical drying of surfaces. As Dancer and Kramer (2018) note, “The cleaning process is not complete until all surfaces are completely dry. Contact time is usually considered critical to disinfection, but it can be difficult to fulfill in a time-pressured healthcare environment.” They add, “This fourth stage should also include the cleaner's own assessment as to overall cleanliness of the bed space or room. If they are satisfied that the process is complete, the area can be signed off verbally or by written notification, labeling or use of a checklist. Further monitoring helps to maintain, and improve, the quality of cleaning but it is not necessarily mandatory and will depend upon available resources …When leaving the patient area, the gloved hand should be subjected to hand disinfection if the cleaner has to fulfill further duties before the next cleaning objective. Otherwise, gloves and any other protective apparel may be removed, and hands washed and dried before further duties.”
Reference: Dancer SJ and Kramer A. Four steps to clean hospitals: LOOK, PLAN, CLEAN and DRY. J Hosp Infect. December 2018.
From Wheels Up, To Wheels Down
By J. Darrel Hicks, BA, MREH, CHESP
This column originally appeared in the November 2019 issue of Healthcare Hygiene magazine.
As I sat buckled into my seat ready for takeoff, one of the cockpit officers was making his usual announcements, and then said, “It’ll be three hours and five minutes from wheels up to wheels down in St. Louis.”
One can’t help but wonder, “How can he be so precise? How does he know exactly how long it’ll take?”
In the business of cleaning and disinfecting the patient-care environment, the environmental services (EVS) department is asked to perform processes that change a “soiled” room into a “patient-ready” room.
Perhaps the soiled room was a Trauma Room in the Emergency Department that just treated a victim of a car accident. Or, the 500 sq. ft. surgical suite that was used to do a quadruple bypass on person who suffered a heart attack.
The process has different names depending on where the soiled room is. Names such as “turnover,” “between-case-cleaning,” “terminal cleaning,” or “end-of-day cleaning.” But the most important thing to know about the “process” is, this is the best opportunity to break the chain of infection from one patient to the next.
An EVS worker who is educated about infection prevention, equipped with the right products and processes, and given enough time for the task, will prevent more infections than a room full of doctors can cure.
The process involves using a clean, micro-denier cloth and the hospital-approved disinfectant to remove the bioburden and disinfect the surfaces that are wiped. Do you know how long the process will take?
The co-pilot seemed to know how long it would take to travel from San Jose to St. Louis. To process a patient’s room where the occupant with Clostridium difficile stayed for 24 days, does it take 35, 45 or 55 minutes? Is the process the same for an isolation room as the trauma room or the operating room? Are these processes defined? Are they the same in every hospital? Are there benchmarks for how much time to allow for each situation?
Let’s assume for the moment that the national benchmark states that the terminal process for the isolation room should take 55 minutes. Is the national benchmark 55 minutes still in play when the charge nurse says, “This room is a STAT! Hurry up, the ER patient is on the way”? Would you put your mother in a STAT room that was improperly processed by an EVS technician who spent 30 minutes in the room.
When time is placed above patient safety in turnovers, terminal cleanings, and between-case cleanings, the chain of infection may remain unbroken. As leaders in environmental services, risk management and infection prevention, we need to speak with one voice for the safety of patients who are undeserving of a healthcare-acquired infection (HAI).
To be sure, we should use the tools at our disposal to ensure that we are working efficiently. Some of those tools include:
- Checklists (there are some good ones available, but some are so long they are unrealistic)
- Team cleaning (identify what needs to be processed, use color coding so each team member knows what their responsibility is)
- Observations by leaders (environmental services or nursing)
- Competency assessments
- Measuring the effectiveness of people, products and processes
By the way…the co-pilot was right. We landed three hours and five minutes from wheels up to wheels down.
- Darrel Hicks, BA, MREH, CHESP, is the owner/principal of Darrel Hicks, LLC and the author of the book Infection Prevention for Dummies.
A Carrier Platform to Test Microbial Decontamination of High-Touch Environmental Surfaces by Wiping
By Syed A. Sattar, PhD; Bahram Zargar, PhD; and Saeideh Naderi, PhD
This article originally appeared in the October 2019 issue of Healthcare Hygiene magazine.
High-touch environmental surfaces (HITES) can spread pathogens in healthcare and other settings (Carling 2016, Weber et al., 2013), and wiping is crucial for HITES decontamination except with no-touch technologies. However, routine decontamination by wiping remains suboptimal (Carling 2016; Sattar and Maillard 2013) and may spread pathogens over a wider area (Ramm et al. 2015). In addition, methods for pre-market testing of environmental surface disinfectants are either qualitative or devoid of any wiping action (Sattar 2010). We report here a quantitative and ‘dynamic’ (combining the physical and chemical action of wipes) test protocol to better reflect the field use of disinfecting wipes.
Materials and Methods
Acinetobacter baumannii (ATCC 19606), a common healthcare-associated pathogen (Howard et al., 2012), was used for the testing. Trypticase soy broth (TSB) and Trypticase soy agar (TSA) were used, respectively, to grow (20±2 h) and recover (48±2 h) it from the test and control samples at 36±1°C.
A Teflon-based platform with perforations (Figure 1; 30.0 cm x 60.0 cm x 0.5 cm) held nine sterile disks (1 cm in diam.) of brushed stainless steel (AISI 430) as archetypical hard, non-porous HITES. The platform was sterilized by autoclaving. Each sterile disk on one platform received 10 µL of the microbial suspension in a soil load (Sattar et al. 2007) and the inoculum dried. To maintain a uniform pressure during wiping, the operator first practiced the wiping with the platform placed on a digital read-out scale. The platform was then wiped with either Product A (2,600 ppm quaternary ammonium compound; (QAC) or Product B (250 ppm sodium hypochlorite (SH) at neutral pH; Product C, the control, was a microbicide-free fabric (J-Cloth; E.D. Smith Foods, Ltd.) dampened with normal saline with a detergent (0.1% polysorbate-80). The used wipe was immediately applied on another platform with clean disks to assess transfer of any viable organisms.
A custom-built retriever simultaneous collected the disks from a given platform into separate vials with 10 mL of an eluent/neutralizer in each. The eluates were individually membrane-filtered (0.22 µm pore diam.) and each filter placed on a TSA plate to recover colony-forming units (CFU) and calculate log10 reductions. Each type of wipe was tested three times under ambient conditions (RH at 45±5%; air temp. 22±2°C). After wiping, the platforms were left undisturbed for 5 minutes.
As shown in Table 1, Product A reduced the contamination by >4 log10 (>99.99%) with virtually no detectable transfer of CFU to clean disks. This suggested that the contamination was either inactivated or sequestered in the applicator itself. Product B achieved a >2 log10 (>99.00%) reduction in the viability of the test microbe while transferring a higher level of CFUs as compared to Product A. Product C (J-Cloth) achieved <1 log10 (<86.2%) reduction in the test microbe’s viability while transferring >1% of the contamination. In this instance, the reduction in the level of viability was entirely due to mechanical removal of the contamination. The level of transfer from the control fabric was also higher due to the absence of any microbicidal activity.
The concentration of SH (neutral pH) in this study was kept deliberately low to enhance workplace safety while also reducing the chemical loading of the environment. Higher levels of SH would most likely perform as well as the QAC-based wipe.
QACs and SH continue to be among the most common microbicides in HITES wipes. However, their respective concentrations in prewetted wipes can vary widely along with the nature of the applicator itself. In the case of the SH-based wipe tested in this study, the fabric was a microfiber cloth as supplied by the wipe manufacturer.
The results showed the ability of the platform to assess HITES decontamination as well as the ability of the used wipes to transfer contamination to clean surfaces. Predictably, such microbial transfer was the highest with the control wipe wetted with a buffer.
The platform and the disk retrieval system are simple, generic in design, and capable of handling most types of HITES as well as all major classes of human pathogens known to spread via HITES.
The findings reported here further reinforce the applicability of the platform in assessing disinfecting wipes in a field-relevant manner. The platform can not only test prewetted wipes but also spray-and-wipe systems. Teflon was chosen to make the platform for its high heat- and chemical-resistance as well as easy cleanability between uses.
With additional experimentation using a wider variety of pathogens and wipe technologies, the system has the potential to become an international standard, such as that for ASTM International (www.astm.org).
This study was supported in part with funding from the Healthcare Surfaces Institute (www.healthcaresurfacesinstititute.org).
ASTM International (2011). Standard quantitative disk carrier test method for determining the bactericidal, virucidal, fungicidal, mycobactericidal & sporicidal activities of liquid chemicals (E-2197-11). ASTM, West Conshohocken, Penn.
Carling PC. (2016). Optimizing Health Care Environmental Hygiene, Infect Dis Clin North Am. Sept; 30(3):639-660.
Howard A, O’Donoghue M, Feeney A and Sleator RD. (2012). Acinetobacter baumannii, an emerging opportunistic pathogen. Virulence. 3(3): 243-250.
Ramm L, Siani H, Wesgate R, Maillard J-Y. (2015). Pathogen transfer and high variability in pathogen removal by detergent wipes. Am J Infect Control. 43(7):724-728.
Sattar SA and Maillard J.-Y. (2013). The crucial role of wiping in decontamination of high-touch environmental surfaces: review of current status and directions for the future, Am J Infect Control. May; 41(5 Suppl):S97-104.
Sattar SA. (2010). Promises & pitfalls of recent advances in chemical means of preventing the spread of nosocomial infections by environmental surfaces. Am J Infect Control 38: S34-S40.
Springthorpe VS and Sattar SA. (2007). Application of a quantitative carrier test to evaluate microbicides against mycobacteria. J. AOAC Int. 90:817-824.
Weber DJ, Anderson D, Rutala WA. (2013). The role of the surface environment in healthcare-associated infections. Curr Opin Infect Dis. 26(4):338-344.
Table 1. Summary of data on the quantitative assessments of CFU reductions and transfer of Acinetobacter baumannii by three types of wipes using a platform developed at CREM Co Labs.
Test # % Reduction % Transfer Mean Percent ±
1 99.9994 0.00058 99.994± 0.0085 0.0095± 0.0083
2 99.9844 0.011
3 99.998 0.017
1 98.78 0.086 99.318± 0.5038 0.0490± 0.0317
2 99.39 0.032
3 99.78 0.030
Product C (control)
1 92.65 1.350 86.242±12.1884 1.075±0.5313
2 93.88 1.410
3 72.19 0.460
Stainless steel disks embedded in the contaminated and transfer Teflon platforms being wiped.
Syed A. Sattar, PhD, is professor emeritus of microbiology at the University of Ottawa, Ottawa, ON, Canada, and affiliated with CREM Co Labs of Mississauga, ON, Canada. Bahram Zargar, PhD, and Saeideh Naderi, PhD, are affiliated with CREM Co Labs.
Is It Time to Rethink Air Quality in the OR?
By Kathy Warye
Over the last decade, U.S. healthcare institutions have made significant strides in reducing healthcare-associated infection (HAI) through a combination of vertical strategies, targeted toward the reduction of device or organism specific infection and horizontal strategies aimed at mitigating infection risk across the continuum of care. Strong financial incentives established as part of the Affordable Care Act continue to pressure hospitals to find new ways of reducing HAIs. Despite these measures, HAIs continue to be among the most prevalent and costly adverse events in US healthcare institutions.1
In 2010, Weber, et al. found that in the case of several of the more critical organisms present in hospitals, that patient-to-patient transmission was directly proportional to the level of environmental contamination.2 The emergence of MDROs that persist in the environment, combined with a growing body of evidence correlating contaminated surfaces to HAI, heightened awareness of the environment as a transmission risk in institutions.
As a result, cleaning and disinfection of the patient environment became a core, horizontal infection prevention strategy. The Joint Commission and CMS require hospitals to have rigorous environmental cleaning policies and procedures in place which are subject to routine audit for accreditation. And with this new standard of care, a virtual tsunami of products and services emerged to support these efforts.
Today, the hospital surface disinfectant market alone is projected to be worth $1.2 billion by 2024.
Up to this point, however, infection prevention efforts and investment aimed at reducing the risk of environmental transmission have focused almost exclusively on hard surfaces. With the exception of isolation of patients with serious respiratory infection, hospital air quality has received comparatively little attention. This can be explained, in part, by several factors: Sampling and measurement of viable aerosolized bacteria has been both costly and burdensome. And until recently, there has been an absence of innovation in technology for hospital air quality management. With limited evidence and no new solutions on the horizon, it is understandable that other infection prevention concerns took priority over air.
In the U.S., the importance of airborne transmission to HAI generally is a matter of considerable debate. However, in the case of SSI, there are many reasons why healthcare institutions should consider air quality the next frontier for reduction.
SSIs are complex and multifactorial, yet 30 years of studies demonstrate the contribution of aerosolized bioburden to SSI. As far back as the 1980s, Lidwell found that most bacteria contaminating surgical wounds are likely to have reached it by the airborne route. Whyte found that 98 percent of bacteria in patients' wounds after surgery in a conventionally-ventilated operating room came directly or indirectly from the air.3-4 The recent outbreak of M. chimaera found to be epidemiologically linked to aerosolized bacteria from contaminated heater-cooler units used in cardiac surgery is a more recent reinforcement of the airborne route in SSI.5
While progress has been made in SS reduction, the Agency for Healthcare Research and Quality (AHRQ) reported no decrease, between 2014 and 2017, in a core group of SSIs subject to reporting to NHSN.1 SCIP, SIP and other initiatives aimed at standardization of best practice yielded improvement and new evidence may lead to identification of additional process improvement opportunities, however, the low-hanging fruit in process and practice has likely been harvested.
So, where do we go from here? Rethinking air quality in the OR may be the place to start. Sweden and the Netherlands have promulgated standards in the last two years which limit bacterial colony forming units (CFUs) in key areas of the hospital based on patient risk.6 In the OR, air quality must be maintained at no greater than 10 CFUs per cubic meter (<10CFU/m3). Additional European nations and Australia are considering similar requirements, and the WHO recently issued a conditional recommendation that laminar airflow ventilation systems should not be used to reduce SSI risk for patients undergoing total arthroplasty surgery.7
Requirements for air quality management date to the 1970s and focus on the mechanism of air management not the efficacy of those controls. This is understandable given the absence of innovation in air quality management technology. Since the 1970s, architectural controls have been the only viable approach; however, there is a steady flow of research which calls the efficacy of these controls into question. For example, studies have demonstrated that air exchanges and positive air pressure are easily thwarted by door openings and traffic.9-11
Rethinking OR air quality may be particularly important as the population ages and demand for surgery with implants increases. A recent study predicted exponential growth in total hip and knee arthroplasty (THA/TKA) procedural volume between 2020 and 2030. With no abatement in the rate of infection, by TKA/THA prosthetic joint infections will increase by 14 percent.12
A postoperative infection in a clean surgical wound requires a microbial burden of 105 CFUs, whereas when a foreign body, such as an implant, is present an infection can occur with as few as 10 to 50 CFUs.13-14 A prospective randomized multicenter study showed that joint replacements in rooms with over 50 CFU bacteria were 2.6 times as likely to have postoperative infection than those with 10-20 CFU.15
Infection prevention strategy begins with a risk assessment. Bacterial levels as high as 150 (CFU)/m3 have been documented in U.S. ORs, yet despite the known risk of infection, there is no requirement for bacterial testing or particulate counts in the nation’s operating rooms.16 We have little understanding of the risk or the extent to which air may be undermining our efforts to reduce SSI. New, less costly and easier to use air quality measurement technology is entering the market which will help make routine assessment of aerosolized bioburden viable.
Is it time for the US to consider more rigorous standards of care for air quality in the operating room? While there are considerable open research questions, aerosolized bacteria is a known contributor to SSI. And with process and practice measures exhausted, infection prevention stakeholders must look to other ways of mitigating risk. Ten years ago, environmental disinfection was the new frontier in infection prevention, but air was absent from the scope of that effort. In light of new evidence, new technology and the challenge of achieving further reductions in SSI, infection prevention stakeholders may want to consider broadening the scope of environmental disinfection strategy to OR air quality, gain a better understanding of the level of contamination and relative risk their ORs and embrace the potential of enhanced air management strategies to further protect patients from SSI.
1- 2016 National & State Healthcare-Associated Infections Progress Report, Agency for Healthcare Quality and Research
2- Weber, D., & Rutala, W. (2011). The Role of the Environment in Transmission of Clostridium difficile Infection in Healthcare Facilities. Infection Control & Hospital Epidemiology, 32(3), 207-209. doi:10.1086/658670
3-Lidwell, O.M., Lowbury, E.J.L., Whyte, W., Blowers, R., Stanley, S.J. & Lowe, D.(1983). Airborne contamination of wounds in joint replacement operations: the relationship to sepsis rates. Journal
of Hospital Infection, 4(2),111-131.
4 -Whyte, W., Hodgson, R. & Tinkler, J. (1982). The importance of airbornebacterial contamination of wounds. Journal of Hospital Infection, 3(2),123-135.
5-Sax H, et al, Prolonged Outbreak of Mycobacterium chimaera Infection After Open-Chest Heart Surgery Clin Infect Dis. 2015: 61 (1); 67-75.
6- Swedish Standards Inst., Teknisk specification SIS-TS 39:2015
7- WHO. Global guidelines on the prevention of surgical site infection. Available from: http://www.who.int/gpsc/ssi-guidelines/en/. Accessed February 13, 2017.
8- 31-WHO. Global guidelines on the prevention of surgical site infection. Available from: http://www.who.int/gpsc/ssi-guidelines/en/.
9- Perez, et al, Door openings in the operating room are associated with increased environmental contamination, Am J Infect Control, Volume 46, Issue 8, Pages 954–956
10-Teter, et al, Assessment of operating room airflow using air particle counts and direct observation of door openings, Am J Infect Cont., Volume 45, Issue 5, Pages 477–482
11- Birgand, G., Azevedo, C., Rukly, S., Pissard-Gibollet, R., Toupet, G., Timsit, J., & Lucet, J. (2019). Motion-capture system to assess intraoperative staff movements and door openings: Impact on surrogates of the infectious risk in surgery. Infection Control & Hospital Epidemiology, 40(5), 566-573. doi:10.1017/ice.2019.35
12- Wolford H et al, The projected burden of complex surgical site infections following hip and knee arthroplasties in adults in the United States, 2020 through 2030. Infect Cont Hosp Epi (2018), 39, 1189–1195 doi:10.1017/ice.2018.184
13-Edmiston CE. Prosthetic device infections in surgery. In: Nichols RL, Nyhus LM, editors. Update surgical sepsis. Philadelphia (PA): J.B. Lippincott Co.; 1993.pp. 196-222.
14-Parvisi et al, Environment of care: Is it time to reassess microbial contamination of the operating room air as a risk factor for surgical site infection in total joint arthroplasty? Am J Infect Cont, Vol 45, Issue 11, 1267 – 1272.
The following article is from the Environmental Hygiene column published in the October 2019 issue of Healthcare Hygiene magazine.
Cleaning and Disinfection in the 21st Century
By J. Darrel Hicks
Although cleanliness may be next to Godliness, it's also very closely related to disinfection. In fact, cleaning may avert the need to disinfect in some situations because clean and dry surfaces can't harbor microbial growth for very long.
In view of the evidence that transmission of many healthcare-acquired pathogens (HAPs) is related to contamination of near-patient surfaces and equipment, all hospitals are encouraged to develop programs to optimize the thoroughness of high-touch surface cleaning as part of terminal room cleaning at the time of discharge or transfer of patients. In view of this fact, isn't it time to get rid of Spaulding's classification of those near patient surfaces and equipment as "non-critical"?
Numerous studies have demonstrated the role of the environment as a reservoir and in the transmission of human pathogens. However, the precise role of environmental cleaning and disinfection in preventing acquisition of healthcare-acquired infections (HAIs) is uncertain in part, because of variations in assessment methodology and lack of randomized control studies. This standard relies on the available scientific evidence for effective cleaning and disinfection practices in order to minimize the risk of pathogen transmission to patients and protect patient health.
How do we define "clean" or "cleaning," "disinfection" or "disinfecting" for the environmental services (ES) technician to insure a safe, clean and disinfected environment?
Personally, I prefer the definition that Michael Berry, PhD, promotes for "clean" and "cleaning." Clean is a condition free of unwanted matter that has the potential to cause an adverse or undesirable effect.
Cleaning is the fundamental management process of putting unwanted matter in its proper place to achieve a clean condition. Cleaning professionals will understand these definitions and be able to deliver the desired outcomes.
In my professional opinion, along with "Spaulding's non-critical" classification for near patient surfaces, we need to get rid of the term "visibly soiled." There are more than enough C. difficile spores in the size of a pinhead to transmit the pathogen. When the ES technician is given the instruction to clean "visibly soiled" surfaces, are they looking for soil the size of a pinhead? No, they don't have time...they have eight more patient rooms to clean in the next two hours before they clock out.
Cleaning and disinfection have shown benefits in infection prevention and control, and as the research continues to evolve, more clarity emerges. The challenge to research in this area is the lack of clinical trials. This is further compounded by the difficulty in conducting cleaning and disinfection research clinical trials in healthcare facilities.
The following are the more traditional, time-worn definitions for consideration:
- Cleaning agent — a substance, or mixture of substances, that physically removes foreign material (e.g., dust, soil, food) and patient-derived material (e.g., blood, secretions, excretions, microorganisms) from environmental surfaces and inanimate objects due to the detergent or enzymatic properties of the formulation. See One-Step Cleaning Agent Disinfectant, Detergent.
- Cleaning — the physical removal of foreign material (e.g., dust, soil, food) and patient-derived material (e.g., blood, secretions, excretions, microorganisms). Cleaning physically removes rather than kills microorganisms. It is accomplished with water, detergents and mechanical action.
1. The terms decontamination” and “sanitation” may be used for this process in certain settings, e.g., central service or dietetics.
2. Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms. Cleaning agents are the most common chemicals used in housekeeping activity”.
3. Organic material present on objects that are being disinfected can hinder the action of some disinfectants. Gross (visible) contamination on any surface needs to be removed (cleaned) even if using a one-step cleaning agent/disinfectant.
- Contamination — the presence of an infectious agent on hands or on a surface such as clothes, gowns, gloves, bedding, toys, surgical instruments, patient care equipment, dressings or other inanimate objects.
- Decontamination — the process of cleaning, by use of physical and chemical means, to remove, inactivate, or destroy, followed by the inactivation of pathogenic micro-organisms, in order to render an object safe for handling.
- Disinfectant — a substance, or mixture of substances, capable of destroying or irreversibly inactivating pathogenic (disease-causing) and potentially pathogenic (opportunistic) microorganisms, but not necessarily bacterial spores, present on environmental surfaces and inanimate objects due to the antimicrobial action of the active ingredient(s). A disinfectant shall have an EPA registration number.
- Disinfection — the inactivation of disease-producing microorganisms to a level previously specified as being appropriate for a defined purpose on the equipment or surface after the cleaning process has been properly completed. Disinfection does not destroy all bacterial spores. Note: Disinfection typically involves chemicals, heat, ultraviolet light, ozonated water or self-disinfecting materials.
- Environmental services (ES) — the department primarily responsible for the development and implementation of the environmental cleaning and disinfection programs, policies and SOPs for the healthcare facility including but not limited to: environmental surfaces; furniture; mobile shared non-invasive equipment; portable electronic devices; waste management; and the development and applications/inspections of its program operations;
1. In general, the healthcare facility ES department has this responsibility -- although other departments and services (e.g., nursing, physiotherapy, dental) -- can also be accountable for following the cleaning and disinfection standards.
2. Environmental services and housekeeping services are often used interchangeably.
- Fomites — inanimate objects in the environment that may become contaminated with microorganisms and serve as vehicles of transmission.
The fact is, surfaces appearing to be clean might not necessarily be clean when scientifically quantified or qualified. Remember, what you can't see, can hurt you. The ES technician should be educated and trained to strive for health-based or hygienic cleaning (cleaning for a healthier environment and not just for appearances). That means cleaning AND disinfecting
A hospital-approved disinfectant kills microbe of importance to a facility. ES leaders should choose disinfectants in concert with infection preventionists, pharmacy leaders and infectious disease physicians.
However, depending on the pathogen, preventing the microbes from getting a foothold by removing food and moisture (two essentials for sustaining living organisms) may, in the long-term, be as effective as a chemical disinfectant. In fact, chemical disinfectants can't do their job when high levels (greater than 5 percent which is required for EPA-registration) are in the way. Soil can absorb the active ingredient, provide more places for the germs to hide, and change the chemical nature of the disinfectant.
Cleaning and disinfection are NOT interchangeable terms, but many treat them as if they were. Cleaning and disinfection are two distinct operations that those doing the daily processing of patient care areas must understand. That's why both the EPA and the CDC guidance calls for the application of disinfectants to pre-cleaned surfaces. A surface that has not been cleaned effectively cannot be said to be properly disinfected.
I'd like to leave you with this truth: One engaged ES technician given the right tools, education and enough time to perform the process of cleaning and disinfection, can prevent more infections than a room full of doctors can cure.
J. Darrel Hicks, BA, Master REH, CHESP, Certificate of Mastery in Infection Prevention, and a Certified Expert Trainer -- is the owner/principal of Darrel Hicks, LLC. His enterprise specializes in B2B consulting, webinar presentations, seminars and facility consulting services related to cleaning and disinfection. Hicks authored Infection Prevention for Dummies, a 43-page, pocket-size book that deals with the role that proper cleaning and disinfection plays in saving lives.
“I’m an EVS Technician and I Save Lives…What’s Your Super-Power?”
By J. Darrel Hicks
Environmental Services Week, Sept. 8-14, 2019, is a week to join all national and international healthcare environmental services (EVS) professionals to celebrate the outstanding work of these specialists and teams. Every year this week represents a special opportunity to acknowledge the outstanding efforts of your housekeeping team and thank them for a job well done.
Simple cleaning of the environmental surfaces may be one of the key defenses in the future battle against infectious disease. With antibiotic-resistant organisms proliferating on common touchpoints for up to 56 or more days, the study of cleaning and measuring cleanliness is becoming all-important.
“Compliant cleaning and disinfection of environmental surfaces and medical equipment is a critical first line of defense against all pathogens in the healthcare environment, and especially those that are resistant to antibiotics,” says Sarah Bell-West, PhD, senior scientist at Clorox Healthcare.
EVS workers play an essential role in prevention of healthcare-acquired infections (HAIs). Studies have demonstrated significant improvements in cleaning through interventions directed at environmental services workers. For optimal effectiveness, such interventions require that environmental service workers be knowledgeable about the prevention and transmission of disease and well trained with the best practices that keep patients safe.
When it comes to keeping pathogenic organisms at a safe level on environmental surfaces, the least educated and lowest paid people in the hospital must eliminate those dangerous bacteria.
“This is the level in the hospital hierarchy where you have the least investment, the least status and the least respect,” says Jan Patterson, MD, past-president of the Society for Healthcare Epidemiology of America (SHEA).
It’s time to certify Environmental Service Workers
When hospitals want to compete in their market, leaders often look to the latest 128-slice, 3-D CT scanner, a Divinci robot to perform surgeries, recruit the best surgeon, or begin a new service line with the best return on investment (ROI). While these capital expenditures and improvements might attract publicity for a fleeting moment, the board of directors needs to consider a different, low cost option that provides the best chance to improve patient satisfaction, reduce HAIs and improve the bottom line: The Environmental Services Department.
The literature is replete with articles and studies in infection prevention annals extolling the virtues of various environmental hygiene Products, Processes and Programs to reduce HAIs in healthcare. The one missing “P” is the People who work hard, do a dirty (sometimes disgusting) and repetitive job, and make $10 an hour while providing a safe, clean and disinfected environment for patients and staff; the people of the EVS department.
In an article titled, “Clean Sweep: Hospitals Bring Janitors to the Front Lines of Infection Control” (Aug. 15, 2012 Scientific American), Maryn McKenna wrote, “It hasn’t been that long ago the poster bug for nasty bacteria that attack patients in hospitals was MRSA. Because MRSA clings to the skin, the chief strategy for limiting its spread was thorough hand washing. Now, however, the most dangerous bacteria are the ones that survive on inorganic surfaces such as keyboards, bed rails and privacy curtains. To get rid of these germs, hospitals must rely on the staff members who know every nook and cranny in each room, as well as which cleaning products contain which chemical compounds.”
Having been a leader in several different hospital EVS departments over a period of 33 years, I interviewed candidates for front-line positions. When I asked, “Why do you want to work here?” the common reply was, “Because, you pay more than I make now.” The EVS tech job would pay her 25 cents more an hour than she made stuffing hamburgers in bags at Burger King.
This young lady went from working the window at the corner fast food restaurant to cleaning the operating room in two weeks for a quarter more an hour. The comparison of job roles and responsibilities is obviously not close to being similar. It’s time to educate and certify environmental services workers so, in this case, the young lady understands that better, more thorough cleaning and disinfection, saves lives. It’s time to turn that young lady into a Certified Environmental Services Technician (CEST).
Why don’t hospitals value the EVS technician? Too often, housekeepers or environmental service workers are thought to be expendable (anyone knows how to clean a toilet and mop a floor, right?) and difficult to educate because English may not be their first language. The thought is, “What if I educate and certify them and they leave?” But, worse than that, what if you don’t educate and certify them and they stay?
The Learning Objectives for the CEST
• Define Environmental Services #1 job as Infection Prevention
• Equip the frontline cleaning professional with knowledge of infection prevention as it relates to their daily tasks
• Analyze the cleaning professional’s role in patient satisfaction
• Support the cleaning professional with practical “how to” tips for cleaning and disinfection
• Introduce cleaning and disinfection strategies that effectively break the chain of infection (i.e., 7 Steps of Cleaning, daily duty lists, daily checklists, florescent marking of high touch surfaces, employee engagement, etc.)
• Convert the cleaning professional into a Certified Environmental Services Technician
The stakes are too high to allow the rooms of residents or patients to be cleaned by a person who is not a CEST. The CEST must be properly compensated, regarded as a part of the facility’s multi-modal infection prevention program, be well trained in the nuances of cleaning and disinfection, allotted the time to do the necessary tasks, equipped with the “Best in Class” tools to clean and disinfect surfaces and educated about the prevention and transmission of disease.
In closing, an educated and Certified E.S. Tech will be viewed as a knowledgeable professional working amongst other healthcare professionals who are certified or registered in their field. Knowledge leads the environmental services worker to be proud of the profession they have chosen and respected by those they work alongside of.
A closing thought: One well-trained, well-equipped, conscientious Certified Environmental Services Technician, given the proper tools AND an adequate amount of time to clean and disinfect a room patient’s room can PREVENT more infections than a room full of doctors can CURE.
I encourage you to keep the recognition going and celebrate your EVS superstars 365 days a year, this special week is a great excuse to focus on your team and reward them for doing an excellent job!
I am a Certified Environmental Services Technician and I save lives… what’s your super-power?
J. Darrel Hicks, BA, Master REH, CHESP, Certificate of Mastery in Infection Prevention, and a Certified Expert Trainer -- is the owner/principal of Darrel Hicks, LLC. His enterprise specializes in B2B consulting, webinar presentations, seminars and facility consulting services related to cleaning and disinfection. Hicks authored Infection Prevention for Dummies, a 43-page, pocket-size book that deals with the role that proper cleaning and disinfection plays in saving lives.
By George Clarke
A fundamental problem in the healthcare industry is the opinion that environmental services (ES) staff serves as “just the cleaner, the janitor or the housekeeper.” This couldn’t be further from the truth. In fact, the healthcare ES staff – we prefer the designation Environmental Hygiene Specialist – are a crucial, yet all too often unheralded, factor in preventing drug-resistant infections.
According to the Centers for Disease Control (CDC), on any given day, one in 31 hospital patients has at least one healthcare associated infection (HAI). A recent study in the American Journal of Infection Control shows that Clostridium difficile infection (CDI), just one of many types of superbug infections, can result from the bacteria found on hospital environmental surfaces. Without proper cleaning of such surfaces, cross-contamination can occur, resulting in a preventable HAI (pHAI). The study showed that, with the proper ES protocols in place, CDI rates fell to zero over the course of 1,000 patient days. This is just the latest in a growing body of research highlighting the role played by ES staff in reducing HAIs.
Moreover, new standards and regulations from the Center for Disease Control and Prevention (CDC) and Association for the Healthcare Environment encourage hospitals to agree to and implement ES cleaning programs and total facility cleaning standards to clean and disinfect all high-touch surfaces.
In response to such research and recommendations, leading healthcare organizations are starting to recognize the importance of ES staff as part of an enterprise-wide multimodal intervention plan to combat such infections. As a result, all types of healthcare facilities – from acute-care hospitals to assisted living facilities – are elevating the role of cleaning and disinfecting processes to ensure the health and safety of patients, caregivers and their staff.
Below are the crucial factors in any ES program.
ES Staff Training and Recognition
Texas State University clinical microbiologist Rodney E. Rohde, PhD, says that distinguished ES Hygiene Specialists as among one of the most important “behind-the-scenes” professions in combatting HAIs and superbugs in healthcare systems and the community at large. In A Secret Weapon for Preventing HAIs, Rohde wrote that ES comprises the “first-line-of-defense specialists whose training has included learning best practices for effective infection prevention.”
Training programs recognize the science of cleaning and disinfecting that ES performs – both the clinical function of removing and inactivating/killing HAI-producing microbes, and the practical function of cleaning. ES staff training should include:
• Proper use of high-performance, reusable textile products and ergonomic tools
• Color-coded, one-per-room methodologies that simplify training, help reduce chemical usage, and – most important – offer a straightforward and elegant way to eliminate the risk of cross-contamination
• Improved cleaning thoroughness and enhanced cleaning methods of high-touch surfaces
More and more, healthcare management is acknowledging and rewarding ES staff that have undergone extensive in-service training in which participants learn best practices for infection prevention and hygiene management in the patient room, OR and throughout the healthcare facility. Such recognition serves as a significant employee morale boost. Once ES staff complete training, senior management supported and attended events offer an opportunity to present a certificate, pin or other designation, recognizing the ES staff members efforts and commitment to providing safe patient environments.
High-Performance, Reusable Products
High-performance, reusable textiles benefit from ongoing research and development of innovative fibers and materials. They deliver unrivaled performance, including absorbency, extremely high wet strength and far more versatility. The uncontested benefit of high-performance, reusable micro-denier fiber products is their ability to remove everything that can be physically removed from an environmental surface – some have the proven ability to remove the endotoxins released by bacteria when killed with disinfectant.
Such reusable micro-denier textiles usually are processed by experienced hospital linen processors, either on-premises or outsourced – following ARTA, CDC, OSHA, Healthcare Laundry Accreditation Council (HLAC) or TRSA recommended laundry processes. To counter a fictitious claim frequently made by disposable manufacturers, if recontamination were an issue with reusables, then hospitals would be overwhelmed with contaminated sheets, scrubs, incontinence pads, sheets, etc., that often are grossly contaminated with human excrement, vomit and BBP’s (blood borne pathogens). The fact is, according to the CDC, contamination of the patient environment from laundered textiles rarely, if ever, happens.
Disposable mops and wipers, on the other hand, provide limited performance in removing pathogens from an environmental surface. The majority are made from 100 percent polyester fiber imported from China and are primarily used as a vehicle to get the disinfectant/chemical onto a surface.
Moreover, depending on the disposable product selected, the increase in cost ranges from three to more than twelve times that of using a reusable wiper.
Disinfectants to Support the Healthcare Wiper Cycle
An oft-overlooked topic is the disinfectants being used and how they are incorporated throughout the healthcare cleaning cycle. The mop or wiper cycle is repeated every day in every healthcare facility. This is the typical scenario:
• The standard practice for a reusable mop or wiper is the “dip and wring” method. Clean products are folded and stacked in a pail and immersed in an EPA registered disinfectant. The wiper is then used in the patient room – ideally, following a color-coded methodology.
• Products are put damp (or still wet) in a closed soiled laundry bag with other damp wipers and transported to the laundry. Often, they wait many hours, if not days, to be laundered — thus far exceeding any recommended dwell time for any disinfectant.
• Then, the reusables are laundered by an experienced healthcare laundry, typically processing to CDC and/or OSHA recommendations for blood borne pathogens, then dried at recommended temperatures.
• Before going back into any patient room, the flat mops and wipers are again immersed in an EPA-registered disinfectant.
Given this process, how is it possible that any viable organism survived this entire cycle and re-contaminated a patient room? The only conclusions possible are, either the disinfectant is not living up to its efficacy claims or, most likely, the disposable manufacturers have intentionally neglected to take the disinfectant into consideration.
Currently, bleach-free, EPA-registered sporicidal disinfectants are available that achieve CDI sporicidal disinfection in four minutes or less. As they are not bleach products, they do not corrode hard surfaces and are safer for workers due to their low Hazardous Materials Identification System (HMIS) health rating of one. Such solutions — effective against a broad range of microorganisms including CDI spores, hepatitis B, TB and norovirus — are easier for ES staff to use, more sustainable with packaging, a longer shelf life, and very economical.
A Final Thought: Key Considerations to Support ES Staff
In the best healthcare settings, C-suites are beginning to grasp the difference a highly trained ES staff member can make not only in the lives of patients, but also in the facility’s reputation, goodwill and financial health.
ES staff serves as the first line of defense in ensuring safe environments in hospitals and long-term care facilities, thereby helping protect the broader community. Those who recognize this by investing in these unsung heroes will improve patient outcomes, boost financial health, increase satisfaction rankings and support the community at large. Some key points to keep in mind:
• Adopt an enterprise wide multi-modal approach to reducing pHAIs
• Invest in proper training of ES staff
• Engage with and recognize ES staff for their critical role in infection prevention
• Leverage high-performance, proven textiles and disinfectants for cleaning and infection prevention
Overcoming the lack of knowledge of the unheralded ES professional is critical in the battle against antibiotic resistant superbugs. The next time you’re in a healthcare facility, take a moment to recognize those who are keeping the environment safe via proper cleaning and disinfection protocols. They are as important as doctors and nurses in maintaining your public health and safety.
George Clarke is CEO of UMF Corporation.
Self-Sterilizing Polymer Proves Effective Against Drug-Resistant Pathogens
Researchers from North Carolina State University have found that an elastic polymer possesses broad-spectrum antimicrobial properties, allowing it to kill a range of viruses and drug-resistant bacteria in just minutes -- including methicillin-resistant Staphylococcus aureus (MRSA).
"We were exploring a different approach for creating antimicrobial materials when we observed some interesting behavior from this polymer and decided to explore its potential in greater depth," says Rich Spontak, co-corresponding author of a paper on the work and Distinguished Professor of Chemical and Biomolecular Engineering at NC State. "And what we found is extremely promising as an alternate weapon to existing materials-related approaches in the fight against drug-resistant pathogens. This could be particularly useful in clinical settings -- such as hospitals or doctor's offices -- as well as senior-living facilities, where pathogen transmission can have dire consequences."
The polymer's antimicrobial properties stem from its unique molecular architecture, which attracts water to a sequence of repeat units that are chemically modified (or functionalized) with sulfonic acid groups.
"When microbes come into contact with the polymer, water on the surface of the microbes interacts with the sulfonic acid functional groups in the polymer -- creating an acidic solution that quickly kills the bacteria," says Reza Ghiladi, an associate professor of chemistry at NC State and co-corresponding author of the paper. "These acidic solutions can be made more or less powerful by controlling the number of sulfonic acid functional groups in the polymer."
The researchers tested the polymer against six types of bacteria, including three antibiotic-resistant strains: MRSA, vancomycin-resistant Enterococcus faecium, and carbapenem-resistant Acinetobacter baumannii. When 40 percent or more of the relevant polymer units contain sulfonic acid groups, the polymer killed 99.9999% of each strain of bacteria within five minutes.
The researchers also tested the polymer against three viruses: an analog virus for rabies, a strain of influenza and a strain of human adenovirus.
"The polymer was able to fully destroy the influenza and the rabies analog within five minutes," says Frank Scholle, an associate professor of biological sciences at NC State and co-author of the paper. "While the polymer with lower concentrations of the sulfonic acid groups had no practical effect against human adenovirus, it could destroy 99.997 percent of that virus at higher sulfonic acid levels."
One concern of the researchers was that the polymer's antimicrobial effect could progressively worsen over time, as sulfonic acid groups were neutralized when they interacted with positively charged ions (cations) in water. However, they found that the polymer could be fully "recharged" by exposing it to an acid solution.
"In laboratory settings, you could do this by dipping the polymer into a strong acid," Ghiladi says. "But in other settings - such as a hospital room - you could simply spray the polymer surface with vinegar."
This "recharging" process works because every time one of the negatively charged sulfonic acid groups combines with a cation in water - which can happen when the polymer comes into contact with microbes - the sulfonic acid group becomes electrically neutral. That makes the acid group ineffective against microbes. But when the neutralized polymer is subjected to acid, those functional groups can exchange bound cations with protons from the acid, making the sulfonic acid groups active again - and ready to kill microbial pathogens.
"The work we've done here highlights a promising new approach to creating antimicrobial surfaces for use in the fight against drug-resistant pathogens - and hospital-acquired infections in particular," Ghiladi says.
"Functional block polymers like this are highly versatile - usable as water-treatment media, soft actuators, solar cells and gas-separation membranes - and environmentally benign since they can be readily recycled and re-used," Spontak adds. "These features make them particularly attractive for widespread use.
"And this work focused on only one polymer series manufactured by Kraton Polymers," Spontak says. "We are very eager to see how we can further modify this and other polymers to retain such effective and fast-acting antimicrobial properties while improving other attributes that would be attractive for other applications."
The paper, "Inherently self-sterilizing charged multiblock polymers that kill drug-resistant microbes in minutes," appears in the journal Materials Horizons. First author of the paper is Bharadwaja S. T. Peddinti, a PhD student at NC State. The paper was co-authored by Mariana Vargas, an undergraduate at NC State; and Steven Smith of The Procter & Gamble Company.
The work was supported by The Nonwovens Institute at NC State. The researchers also received imaging assistance from the NC State Cellular and Molecular Imaging Facility, which is supported by the National Science Foundation under grant number DBI-1624613.
Source: NC State
Twice-Daily Disinfection Can Substantially Reduce Bacterial Colonization of In-Hospital Tablet Computers
Tablet computers are increasingly being used in hospital patient care and are often colonized with important human pathogens, while the impact of disinfection interventions remains controversial.
In a prospective hygiene intervention study, Frey, et al. (2019) consecutively sampled tablet computers exclusively used in a high-resource general internal medicine tertiary-care setting with high routine hygiene measures. The researchers sought to examine the change in colonizing bacteria on tablet computers before and after the introduction of a mandatory twice-daily tablet disinfection intervention. Microbial identification was performed by conventional culture, and the association of bacterial colonization with the intervention was investigated using logistic regression.
In a total of 168 samples they identified colonizing bacteria in 149 (89%) of samples. While the most commonly identified species were normal skin bacteria, Staphylococcus aureus found in 18 (11%) of samples was the most frequent potential pathogen. They did not detect any Enterococci or Enterobacteriaceae. The disinfection intervention was associated with substantially less overall bacterial colonization (odds ratio 0.16; 95%-CI 0.04–0.56), while specific colonization with Staphylococcus aureus was only slightly decreased (odds ratio 0.46; 95%-CI 0.16–1.29).
The researchers say their results indicate that a twice daily disinfection can still substantially reduce bacterial colonization of in-hospital tablet computers used in a high-resource and high hygiene setting.
Reference: Frey PM, et al. Bacterial colonization of handheld devices in a tertiary care setting: a hygiene intervention study. Antimicrobial Resistance & Infection Control. 2019; 8:97
Perceptions of Patients, Healthcare Workers, and Environmental Services Staff Regarding Ultraviolet Light Room Decontamination Devices
Mobile ultraviolet C (UV-C) room decontamination devices are widely used in healthcare facilities; however, there is limited information on the perceptions of patients, healthcare workers (HCWs), and environmental services (EVS) staff regarding their use for environmental decontamination.
Dunn, et al. (2019) administered an anonymous questionnaire to participants in four medical/surgical units of a tertiary-care hospital where UV-C devices were deployed for a six-month period. Survey questions assessed perceptions regarding the importance of environmental disinfection, effectiveness of UV-C decontamination, willingness to delay hospital admission in order to use UV-C, and safety of UV-C devices.
Questionnaires were completed by 102 patients, 130 HCWs, and 47 EVS-staff. All of the HCWs and EVS-staff and 99% of the patients agreed that environmental disinfection is important to reduce the risk of exposure from contaminated surfaces. Ninety-eight percent of the EVS-staff, 89% of the HCWs, and 96% of the patients felt that the use of UV-C as an adjunct to routine cleaning increased confidence that rooms are clean. Ninety-four percent of the EVS-staff, 85% of the HCWs, and 90% of the patients expressed a willingness to delay being admitted to a room in order to have UV-C decontamination completed. Seventy-nine percent of the EVS-staff, 76% of the HCWs, and 86% of the patients had no concerns about the safety of UV-C devices.
The researchers conclude that patients, HCWs, and EVS staff agreed that environmental disinfection is important and that UV-C devices are efficacious and safe. Educational tools are needed to allay safety concerns expressed by a minority of HCWs and EVS staff.
Reference: Dunn AN, et al. Perceptions of Patients, Health Care Workers, and Environmental Services Staff Regarding Ultraviolet Light Room Decontamination Devices. Am J Infect Control. June 26, 2019
‘Off the rails’: hospital bed rail design, contamination, and the evaluation of their microbial ecology
Microbial contamination of the near-patient environment is an acknowledged reservoir for nosocomial pathogens. The hospital bed and specifically bed rails have been shown to be frequently and heavily contaminated in observational and interventional studies. Whereas the complexity of bed rail design has evolved over the years, the microbial contamination of these surfaces has been incompletely evaluated. In many published studies, key design variables are not described, compromising the extrapolation of results to other settings. This report reviews the evolving structure of hospital beds and bed rails, the possible impact of different design elements on microbial contamination and their role in pathogen transmission. The findings of Boyle, et al. (2019) support the need for clearly defined standardized assessment protocols to accurately assess bed rail and similar patient zone surface levels of contamination, as part of environmental hygiene investigations.
Healthcare-associated infections (HAIs) are responsible for considerable burdens of morbidity and mortality globally. The magnitude of this problem is especially remarkable in critical care units, with a recent European point prevalence survey observing that 8.3% of patients in such units require treatment for at least one HAI. The hospital environment is a recognized reservoir and vector of nosocomial pathogens, and plays an established role in pathogen transmission in critical care areas. In research studies and in decontamination guidelines, considerable attention has been given to surfaces nearest to patients. Within this near-patient environment, bed rails have been shown to be the most highly contaminated surface, and the most frequently touched by the hands of healthcare workers. Bed rails are required for the majority of patients admitted in critical care, and these must be integrated to the hospital bed, making their presence almost inevitable within the critical care environment.
Nosocomial pathogens have been isolated from bed rails in active critical care units. These include meticillin-resistant Staphylococcus aureus (MRSA), Acinetobacter spp., vancomycin-resistant enterococci (VRE), Clostridium difficileand carbapenem-resistant Klebsiella pneumoniae (CRKP). C. difficile spores have been found on bed rails after routine cleaning. A number of outbreak reports have also documented the involvement of bed rails in transmission clusters of the causative outbreak organism, although the degree of involvement is difficult to quantify given the dynamic nature of the critical care environment.
Although the hospital bed emerged from a single standard design, its development as a medical device as well as increasing competition between manufacturers has resulted in an assortment of configurations and compositions being available. The humble bed rail, once comprised of detachable metal bars, has evolved to be more complex as well as integrated and may be composed of metal or plastic. There is no universally accepted standard design and healthcare facilities may use a variety of them in multiple departments.
Reference: Boyle MA, et al. ‘Off the rails’: hospital bed rail design, contamination, and the evaluation of their microbial ecology. Journal of Hospital Infection. June 21, 2019.
The healthcare environment and infection
Currently two subject areas dominate the pages of the Journal of Hospital Infection, multidrug-resistant Gram-negative bacteria (MDRGNB) and the role of the environment in the spread of healthcare associated infections. These two subject areas are inextricably linked as more evidence emerges of the role of the environment in the spread of MDRGNB in healthcare facilities. It has become increasingly clear that investment in control measures such as rapid molecular laboratory technology, and even increased capacity to isolate patients, is futile unless environmental reservoirs of MDRGNB are also dealt with.
Antifungal resistance too has been described as a global emergency, with recent outbreaks of multi-resistant Candida auris reported globally. In England this year anti-fungal stewardship has been added to the Commissioning for Quality and Innovation (CQUIN) scheme. This scheme makes a proportion of healthcare providers' income conditional on demonstrating improvements in quality and innovation in specified areas of care. However, whilst anti-fungal stewardship is important, again it is important to recognise that C. auris can successfully persist in the hospital environment. Moreover, this species can selectively tolerate clinically relevant concentrations of commonly used hospital disinfectants such as sodium hypochlorite.
Effective cleaning of the healthcare environment is therefore an essential component of our fight against antimicrobial resistance. National standards of cleanliness were first published in England in 2001, and have since been updated on several occasions. However, the general tenet of the various iterations of this guidance has remained largely unchanged. Standards of cleanliness for different items are described, but not the methods required to achieve those standards. For information on methods, healthcare staff must refer to the Revised Healthcare Cleaning Manual, published ten years ago, which contains 83 technical methods statements for tasks performed by cleaning staff alone. However, despite the comprehensiveness of this document, individual methods statements do not necessarily help cleaning staff plan how to clean clinical areas that present varying challenges for effective cleaning from day to day. In this regard, the article in this issue by Dancer and Kramer that advocates a four-step (LOOK, PLAN, CLEAN and DRY) guide for daily cleaning would seem to offer promise as a practical overall guide to cleaning.
The national standards of cleanliness are currently under review, and it is anticipated that the next version will incorporate method statements to support the standards. However, it is intriguing as to whether the revised standards will address some of the key issues around environmental cleanliness that have been the focus of recent publications in the Journal of Hospital Infection.
Reference: Gray J and Orton P. The healthcare environment and infection. Journal of Hospital Infection. June 21, 2019.
Improving and sustaining environmental cleaning compliance in a large academic hospital using fluorescent targeting audits, education, and feedback
A contaminated patient environment contributes to pathogen transmission and plays a significant role in healthcare-associated infections (HAIs). Studies have shown that reducing environmental contamination through improved cleaning practices reduces the risk of acquiring an HAI, but sustaining a hospital-wide culture of cleanliness over time can be challenging. McGarity and Salgado (2019)sought to improve and sustain environmental cleaning compliance long-term for both environmental services (EVS) and the clinical staff using fluorescent audits and a feedback program.
From Oct. 1, 2016 to Sept. 30, 2018, interventions directed towards improving environmental cleaning included: fluorescent marker audits, monthly meetings with EVS and hospital leaders, attending EVS and clinical staff meetings, modification of hospital cleaning policies, 1-on-1 audit walk-throughs with staff, testing additional surfaces over time, and a data feedback program. Each inpatient unit was audited every other month by Infection Prevention and Control (IPC). Compliance data (% surfaces with fluorescent marker removed) was grouped by quarter (3 months) to show the impact of the interventions over time.
The first quarter of audits revealed a compliance rate of 49% for EVS (455 surfaces cleaned of 923 observations) and 15% for clinical staff (26 surfaces cleaned of 173 observations). At the end of two years, the final quarter compliance rate for EVS was 85% (2004 surfaces cleaned of 2366 observations; p<0.05) and clinical compliance was 56% (288 surfaces cleaned of 511 observations; p<0.05). Cleaning compliance for EVS was maintained above 80% for five of the last six quarters and above 50% for clinical staff for the last three quarters.
This study found that significant and sustained improvements in environmental cleaning performance can be achieved through education, audit feedback, and the support of hospital and EVS leadership in conjunction with IPC.
Reference: McGarity AL and Salgado C. Improving and sustaining environmental cleaning compliance in a large academic hospital using fluorescent targeting audits, education, and feedback. American Journal of Infection Control. Vol. 47, No. 6. Page S20. June 2019.
Research News Archives
Barriers and perceptions of environmental cleaning: An environmental services perspective
Pedersen, et al. (2018) examined the barriers and perceptions of using a one-step daily disinfectant and ultraviolet light for environmental cleaning using an anonymous Likert scale survey. Results indicated that environmental services workers believe that cleaning is important for infection prevention and that ultraviolet light and one-step daily disinfectant cleaner are effective sporicides.
During 2011, approximately 722,000 healthcare-associated infections occurred in U.S. acute-care hospitals; 1 in 25 hospitalized individuals acquired a healthcare-associated infection. Environmental contamination increases the risk of cross-transmission of infection and colonization of healthcare-associated pathogens such as Clostridium difficile, methicillin-resistant Staphyloccocus aureus, and vancomycin-resistant Enterococcus. Improved terminal cleaning with nontouch methods, including ultraviolet light (UVC) robots may decrease both individual and facility patient colonization and infection. Because all 1-step cleaners may not be sporicidal, the researchers deliberately chose a one-step sporicidal disinfectant. The one-step daily peracetic acid/hydrogen peroxide-based sporicidal disinfectant has been shown to be as effective as bleach in killing C difficile, methicillin-resistant Staphyloccocus aureus, and vancomycin-resistant Enterococcus on high-touch surfaces and patient room floors. The researchers examined environmental services (EVS) staff members' perceptions and knowledge of environmental cleaning.
The investigators utilized a voluntary, anonymous survey with 18 Likert scale questions, two yes-or-no questions, and two multiple-choice questions.
A total of 118 (response rate, 47% [n = 250]) surveys were collected. Forty-one percent of respondents were aged <40 years, 48% had been employed ≤2 years, and 8% were supervisors. The researchers compared responses based on age and years of experience and observed no significant statistical differences. Supervisors had more experience using UVC disinfecting robots than nonsupervisors (100% vs 29%; P ≤ .05) and were more comfortable using OxyCide (100% vs 64%; P = .05). The biggest barriers to using the one-step product and a UV-C robot were “Other” (59% and 39%, respectively) with “Irritates my skin” and “Not sure how to use” as the most commonly offered responses (20% and 32%, respectively).
Reference: Pedersen L, Masroor N, et al. Barriers and perceptions of environmental cleaning: An environmental services perspective. American Journal of Infection Control. Vol. 46, No. 12. Pages 1406-1407. December 2018
Environmental cleaning and disinfection of patient areas
The healthcare setting is predisposed to harbor potential pathogens, which in turn can pose a great risk to patients. Routine cleaning of the patient environment is critical to reduce the risk of hospital-acquired infections. While many approaches to environmental cleaning exist, manual cleaning supplemented with ongoing assessment and feedback may be the most feasible for healthcare facilities with limited resources.
Cleanliness of the patient environment is an important factor in promoting recovery from illness. The hospital environment is predisposed to harbor potential pathogens given the volume of sick patients, the pace and acuity of patient care activities performed by healthcare workers, and the complexity of hospital surfaces and medical equipment requiring routine cleaning. Recent attention to the quality of environmental cleaning in hospitals has revealed that cleaning efforts are often insufficient, leaving microbial contamination present on surfaces (Carling et al., 2008, Dharan et al., 1999, Carling et al., 2010).
The ability of potential pathogens to persist for long periods of time on inanimate surfaces has been reviewed previously (Kramer et al., 2006); some organisms are able to survive weeks to months in the hospital environment (Kramer et al., 2006). It has also been well documented that patients are at increased risk of acquiring a multidrug-resistant organism (MDRO) if the previous room occupant was infected, suggesting transmission via the contaminated environment despite routine cleaning efforts (Huang et al., 2006, Shaughnessy et al., 2011, Nseir et al., 2011).
Outbreak reports have provided additional evidence that patients are infected by organisms acquired from the inanimate environment. Furthermore, these reports offer clues to which organisms are associated with specific surfaces and areas within healthcare settings (Weber and Rutala, 1997). Nevertheless, the extent to which the hospital environment contributes to hospital-acquired infections (HAIs) continues to be controversial. Many infections appear to be attributable to the endogenous flora of the patients and/or direct transmission via hands of healthcare providers, rather than to inanimate objects. It is difficult to trace the etiologies of transmission events outside the intensive epidemiological investigations that characterize the reported outbreaks.
Despite evidence of the transmission of infectious organisms from environment to patient, the role of a clean environment in hospital prevention remains controversial. The extent to which environmental contamination contributes to healthcare-associated infections is unclear. Surface cleaning is certainly not a substitute for other infection control practices such as hand washing, limiting medical device usage, and gowning or gloving when indicated. However, routine efforts to decrease the overall bioburden of the hospital environment via cleaning is likely foundational to other efforts; lower levels of infectious organisms on surfaces translates to less contamination of healthcare worker hands and patient care objects as they make contact with the hospital environment.
Doll, et al. (2018) conducted a narrative review of the literature regarding environmental cleaning in the healthcare setting. PubMed was searched using the following terms related to each section of this review: (UV-C OR UVC OR pulsed xenon OR UV light OR hydrogen peroxide) AND (cleaning OR disinfection OR infection OR decontamination), (enhanced cleaning) or (improved cleaning) and (hospital infection), and (Copper) and (cleaning or disinfection) and (hospital infection). These searches returned more than 7000 articles, which were screened for relevance by title. Original research articles were further reviewed by abstract; bibliographies were also considered. Preference was given to studies published after 2012, although articles published prior to 2012 were selectively included in order to provide context to this review of the recent literature (for example, existing expert guidelines on hospital cleaning and disinfection). Studies that were non-clinical were excluded. The vast majority of the studies included in this review were observational or of quasi-experimental ‘before-and-after’ design. Furthermore, many of the studies using technologies were sponsored by the manufacturer of the technology under investigation. Taken together, this indicates that there is a risk of bias in the included studies.
The contamination of frequently touched hospital surfaces with drug-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) (Knelson et al., 2014, Lin et al., 2016), vancomycin-resistant Enterococcus (VRE) (Knelson et al., 2014, Bonton et al., 1996), carbapenem-resistant Enterobacteriaceae (CRE) (Lerner et al., 2013, Weber et al., 2015), Acinetobacter species (Weber et al., 2010), and Clostridium difficile (Weber et al., 2010, Sitzlar et al., 2013) has been well documented. It has been estimated that 30–40% of HAIs are caused by the contamination of healthcare worker hands; hands are contaminated either from contact with infected or colonized patients, or with their environment (Weber et al., 2010).
Reference: Doll M, Stevens M and Bearman G. Environmental cleaning and disinfection of patient areas. International Journal of Infectious Diseases. Vol. 67. Pages 52-57. February 2018.