High-touch objects -- known as fomites -- and surfaces in the healthcare setting quickly become contaminated and require proper, efficacious cleaning and disinfection.
Here's a look at the latest news and features related to environmental hygiene:
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: 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.