HAI Prevention Technology

ICT takes a look at some of the newer and emerging technologies that are being used in the fight against healthcare-acquired infections (HAIs). Designed to be a quick guide to what is available in the marketplace, it is not meant to represent endorsement of any particular product or company; product claims are those of the manufacturer.

ICT asked companies for their input on three points:

-- A description of their technology

-- How the technology facilitates the control/eradication of infection-causing pathogens and the science behind it

-- Advice for the evaluation and purchasing of this technology

Automated Hand Hygiene Technology

HandGiene

The HandGiene system uses RFID, wireless and Zigbee technology, coupled with Web-based data collection and reporting software, to provide real-time monitoring and feedback monitoring for all handwashing activities of healthcare personnel. Unobtrusive and easy to use, the HandGiene system does not add any additional steps for busy employees to take; they just wash or sanitize their hands as usual while the system documents and reports the interaction. HandGiene can be used with a variety of proprietary, FDA-approved soap and sanitizer formulations with industry-accepted, pathogen-destroying additives. Administrators can easily create required documentation for compliance to infection protocols from the intuitive software. HandGiene not only alerts infection control officers when non-compliance occurs, but also can alert maintenance when a dispenser needs to be refilled.

Because of the integrated RFID-enabled system of identification tags, stand-alone sensors in soap or hand-sanitizer dispensers and software, it makes the monitoring, recording and documenting of hand-hygiene protocols that meet handwashing regulations and requirements easy to apply. The system gives infection preventionists the ability to track and meet a compliance rate of up to 100 percent. Most experts agree that more than 50 percent of all HAIs could be eliminated by handwashing. Because the HandGiene system works with soap or hand sanitizers that take 15 seconds to 20 seconds of friction to dissipate, it meets the Joint Commission and CDCs requirement for destroying infection-causing pathogens. Since the RFID tag is read on entering and leaving an areaand logged into a real-time databaseHandGiene technology provides real-time monitoring for instant alerts, feedback and accountability.

Ask the following questions: Is the technology as easy to install? Can it be integrated into current smart-card use? Does the system make it easy to follow handwashing protocols or does it add steps for busy staff? Does the system provide a solution for the problem of soap or hand-cleanser availability? Are you leasing a system or buying one? If leasing, are the ongoing costs greater than the cost of installation? Are there hidden costs such as software fees or maintenance issues such as smaller dispensers? Will the soap or hand-sanitizer be more cost-effective than the brand you already use? What is the estimated ROI? What additional monthly costs are there, if any?

Cognetive Systems, Inc.

The Intelligent Hygiene (iH) utilizes low-cost, battery-powered wireless sensors embedded within soap and/or sanitizer dispensers to automatically acquire handwash event data over distributed areas, and wirelessly forwards the data to a central computer. iHs Web-based software processes handwash data and provides feedback in the form of handwash compliance rate as a percentage, and graphical display of compliance rate trend. Compliance rate trends are displayed on monitors located as desired by management such that healthcare workers are provided with real-time handwash compliance rate feedback throughout their normal work-day activities. iHs software is configurable, allowing handwash compliance rates to be calculated and reported as a ratio of hand hygiene events per actual or average opportunities, hospital bed-days, and/or healthcare worker man-hours. iH is a badgeless system and avoids the singling out of individual healthcare workers in favor of determining and sustainably improving the handwash performance of groups or teams of healthcare workers.

Research shows that it is not only surveillance and monitoring of hand hygiene activity this is necessary to achieve sustainable improvement in compliance rates, but also that healthcare workers must be provided with frequent and unobtrusive feedback regarding measured hand hygiene performance against performance targets. Todays most prevalent method for determining hand hygiene compliance is human observation for determining both hand hygiene events and hand hygiene opportunities. The human observation method is costly, impractical, and non-scalable, and thus can only be performed on occasion. iH provides a reliable, unobtrusive and practical method for measuring and monitoring hand hygiene compliance rates 24/7, and provides continual visual feedback for sustained improvement. Because iH is a badgeless team-based system, it is by nature unobtrusive and lower in cost and complexity, and thus easy to implement.

When evaluating state-of-the-art technologies for improving hand hygiene performance, it is easy to become overwhelmed when imagining the amount of surveillance technology necessary to determine the hand hygiene compliance rate of every healthcare worker on staff. Its been said that anything that is important is worth measuring, and those things that are not measured will never improve. Look for hand hygiene performance improvement systems which provide simple, low-cost methods of collecting and analyzing hand hygiene performance data; and continual, easy to interpret visual feedback. And perhaps most importantly, look for unobtrusive technology that measures group performance and avoids singling out individuals as this is where system cost and complexity lies. Simple measurement against a goal is the right first step toward sustainable improvement.

Touchless Technology

Kimberly-Clark Professional

Touchless dispensing systems, such as electronic bath tissue dispensers, electronic towel dispensers and electronic skin care dispensers, are one way to help reduce the spread of germs, particularly in a restroom environment. The electronic revolution that has taken place in the washroom in recent years has greatly enhanced restroom hygiene by eliminating the need to touch dispensers, levers and handles during use. These systems can help make the task of using as well as maintaining the restroom easier, more efficient and more cost-effective, while providing improved hygiene and sanitation features. Touchless skin care dispensers can also be used to promote hand hygiene outside the restroom via wall-mounted systems that dispense instant hand sanitizers or on stands that can be moved around and used where the need is greatest.

One area where microorganisms can flourish is the restroom. Lavatory surfaces such as dispensers for bathroom tissue, paper towels or soap that are touched frequently may serve as reservoirs of microbial contamination. When hands come into contact with these surfaces, microbial agents can then be transferred to the nose, mouth, eyes or environmental surfaces via indirect contact transmission. With touchless dispensing systems, users dont have to touch dispensers, faucets and other surfaces during use. By eliminating the need to touch a potential source of germs, touchless systems can help reduce their spread.

Its important to note that touchless systems do not have to be electronic. There are also mechanical no-touch dispensers with no levers to pull, that provide the same hygienic benefits as sensor-activated dispensers. Consider purchasing manual dispensing systems for some products, such as hard roll towels, and electronic, battery-powered dispensing systems for other products, such as soap. Both types of touchless systems provide ease-of-use and hygienic dispensing. Touchless systems are especially crucial for hand towel dispensers, since hand towels are typically used once hands are clean, after having been washed and rinsed. When purchasing electronic touchless dispensers, look for systems that are quiet and offer a long batterylife. Also look for programmable systems that offer controlled dispensing, which can result in a reduction in the amount of product used.

Adenosine Triphosphate (ATP)

Ecolab, Inc.

DAZO® is a fluorescent marking gel that can be applied to high-touch surfaces to evaluate patient room cleaning. DAZO leaves a consistent circular mark which is invisible in natural light but fluoresces under a black light. To objectively evaluate cleaning, high-touch objects such as bed rails, call buttons, light switches, toilet seats and other objects are marked with DAZO before the room is cleaned. After cleaning, each of the high-touch areas is inspected with a black light to determine if the marks were cleaned. If the mark is removed, the surface has been wiped with a wet cloth. If the mark is still intact, the surface has not been wiped.

Healthcare facilities can use DAZO® to get quantitative feedback on surface cleaning. DAZO is a part of the EnCompass Environmental Hygiene Program, which combines highly accurate dispensing, clinically tested microfiber cloths and tools, standardized procedures and effective training programs to help facilities improve cleaning outcomes. The EnCompass program integrates the DAZO marking gel to objectively measure process outcomes, collect data and help drive continuous cleaning improvement. This method allows immediate feedback on cleaning results and provides opportunities for data driven, ongoing training for environmental services staff. Used together, the tools and cleaning chemistries of the EnCompass program and the DAZO marking gel help ensure that the surfaces where DAZO marks are removed were properly cleaned.

To properly address environmental hygiene, there are several key components that must be in place to deliver improved cleaning outcomes. These include such critical process inputs as consistent delivery of the correct disinfectant concentration, compensation for the interaction between disinfectant and cleaning textiles, infection control practices to prevent cross contamination, standardized processes to consistently disinfect high-touch surfaces, objective metrics to measure program effectiveness and training on best practices. DAZO is an important tool to provide healthcare facilities with quantitative feedback on surface cleaning. However, to improve cleaning outcomes, healthcare facilities must consider a holistic, programmatic approach that incorporates dispensing accuracy, standardized processes, outcomes measurement and ongoing training.

Neogen

The AccuPoint HC system measures the amount of adenosine triphosphate (ATP) that remains on a surface after it has been cleaned to determine the efficacy of that cleaning. Results are compared to established thresholds and tracked in the DataManager-HC software for further analysis. The system features a hand-held, electronic instrument, single-use sampling devices and software. The user simply swabs a cleaned surface with the AccuPoint Sampler, inserts it into the AccuPoint HC instrument and receives a reading within 25 seconds. The result is recorded for the particular test site, like the bedrails, within a particular room and area of the facility along with the date, time and housekeeper who cleaned the room. After downloading the results to the software, the infection preventionist and EVS manager can review the data by area, room, test site, housekeeper, range of dates and other variables to better understand the cleaning effectiveness in the facility.

The AccuPoint HC system measures ATP, which is an indicator of total organic material on a surface. As such, it is not a direct indicator of environmental pathogens, only of the potential for them to be present on the surface. The system provides the infection preventionist and EVS manager with a tool to work toward more effective and consistent cleaning. The objective is to get to a cleaner and healthier facility which should relate to a reduction in environmental HAIs. Using the AccuPoint HC system, the user can better understand the results of efforts to find and spread best cleaning practices throughout the facility. And when an outbreak occurs in the facility, they can see the results of intervention efforts immediately.

This is a new application for the healthcare industry but one that has been proven in the food production industry for almost 20 years. It does require a change in perspective as well as behavior. It does not measure bacterial presence; it measures cleaning. While it cant help with all HAI-related issues in healthcare facilities, it can directly improve those that can be attributed to environmental contact and, therefore, impacted by better cleaning. With CMS and some insurance companies changing their posture on reimbursements for HAIs, its not hard to build a cost justification for this system. But the benefits can extend to other important areas like HCAHP scores, improved patient experiences, fewer lawsuits and a more positive community perception.

Ruhof Corporation

The Ruhof ATP Complete® Contamination Monitoring System is a quick, simple and reliable method for verifying the cleanliness of all hospital surfaces in just 15 seconds. The ATP Complete® can be used to test for microbial contamination on all surgical instruments, scopes and medical equipment to verify the effectiveness of cleaning protocols. This enables healthcare workers to take immediate corrective action if needed. The ATP Complete® can be used to help lower cross-contamination and reduce HAIs in the workplace by verifying cleaning, identify problem areas and provide evidence of due diligence. The hand-held unit can be synced to a PC where the results are down-loaded for tracking. The data can then be used to run comparison charts and produce color trend analysis graphics and reports.

Being able to monitor cleaning protocols and improve cleaning procedures throughout healthcare facilities where patients, staff and visitors come into direct contact will help significantly lower the risk of infections. The ATP Complete® detects adenosine triphosphate (ATP), the universal energy molecule found in all animal, plant, bacterial, yeast, and mold cells. Product residues, particularly blood and bioburden, contain large amounts of ATP. Microbial contamination contains ATP, but in smaller amounts. After cleaning, all sources of ATP should be significantly reduced. When ATP is picked up by the tip of the Test® Swab and brought into contact with the unique, liquid stable luciferase/luciferin reagent in the Test® Swab tube, light is emitted in direct proportion to the amount of ATP present. The Test® Swab is then placed in the ATP Complete® hand held unit where it measures the amount of light generated and displays the level of contamination present in just 15 seconds.

The ATP Complete® is a tool for monitoring the cleanliness of all surgical instruments and scopes where cleaning is critical. Scopes especially pose a great risk of cross-contamination because of the difficulty in cleaning the internal channels. The ATP Complete® is the only product, that when used in conjunction with Ruhofs Test® InstruSponge, can accurately measure the level of contaminants present inside the channels of scopes and cannulated instruments. The ATP Complete® can be instituted into current hand hygiene programs to measure compliance and can also be used to troubleshoot areas in a hospital where frequent outbreaks occur. The test results are displayed in 15 seconds and can be downloaded to a computer for tracking.

Germicidal Light

American Ultraviolet

UVC, or UVGI as referred to from years past, has been used for more than 70 years as a means to reduce or eliminate DNA-based contaminants (bacteria, viruses and mold) from surfaces and in HVAC systems. We recommend the addition of the lights to the existing filter systems that are in place, not instead of them. The filters capture particulate and the lights target the organisms that we want to eliminate from the system altogether.

UVC breaks the cell chain of the DNA in an organism. When the chain is broken, the cell cannot reproduce. The lights in the ceiling of an operating room offer almost a 2-log reduction on MRSA with the lights modulated to full power between surgery cases. Upper-air fixtures take care of specific special care patient rooms and treatment rooms to reduce airborne contaminants in the space. Fixtures in the HVAC system keep systems clean and save maintenance and energy dollars. Mold and bacteria from the outdoors are not welcome here and wont be able to grow and flourish with UVC lights on the job. Duct contamination is eliminated without the food source from the cooling coils.

Infection preventionists have many issues in their facilities that need immediate resolution. UVC is one of the tools that they can put to use and see the results immediately. Whether it is a swab test to surfaces in a patient room to a contact plate test from the coil, or even before and after pictures from day 1 to day 2 or 3, UVC or UVGI as seen in some articles, though this has been around for some time, there are many facilities that have tried this and proven how well this can work for your medical facility. With HAI reporting in many states, infection preventionists are looking for ways to prevent situations from becoming problems and reducing number of reports to be written by taking action to eliminate the problem.

GermGard Lighting

Multiple hand sanitations at the point of care are recommended by the CDC in order to reduce accumulated bio burden on the hands due to constant recontamination of them from touching the surrounding hospital room environment, themselves, and the patient under care. Germgard can achieve this rapidly, with broad efficacy and cost effectively. The device is a small, fully automatic, three-second hand sanitizer. It is capable of recording who is using it and how often, and verifying only bare hands or gloved hands have been inserted. It is perfectly safe for bare hand and gloved hand use. The bare skin is protected from the UVC using a proprietary technique. It can be used well over 100 times per shift, ideally before each touch.

It is well established that UVC has excellent germicidal properties for infection prevention applications. Viruses typically require the lowest UVC dose, while spores typically require the highest. Bacteria require a dose somewhat in between. Germgard can inactivate all pathogens on the outer surface of a bare hand and a gloved hand in three seconds, including C. difficile spores, while producing no irritation whatsoever, which are unique capabilities for a hand sanitation product.

Germgard is priced to be approximately one-third the cost of alcohol rubs on a per-bed annual basis. After full implementation, it will save U.S. hospitals $2 billion in material expenses.

Lumalier

Tru-D is a patented, mobile room disinfection device engineered to deliver a measured, lethal dose of ultraviolet germicidal energy that quickly and effectively destroys environmental surface and air microbial contamination... without the use of corrosive chemicals or harmful ozone. TRU-D generates the precise wavelength of UV-C energy required to pierce the cellular wall of the targeted pathogen and rupture its DNA structure to prevent growth, reproduction and colonization. An array of sensors measures the germicidal energy reflected from walls, ceilings, floors and equipment. Exposed surfaces, including those within primary and secondary shadow, quickly achieve desired disinfection levels. Because there are no known pathogens resistant to a lethal dose of germicidal energy, TRU-D has been proven to be highly effective in neutralizing MRSA, Acinetobacter, C. difficile and other multidrug-resistant microbes.

Contamination of environmental surfaces is a known cause of infection. Environmental controls have been established for proper disinfection, however protocols are not always followed and human error is an ongoing concern. A number of unpredictable variables negatively affect current methods of chemical cleaning. Improper training, errors, use of contaminated cloths, an urgent need to reoccupy space, etc. often results in rushed sit-and-soak cycle times required for chemical disinfection. Studies show that about 50 percent of the surfaces in a cleaned room will generate positive cultures. TRU-D automates the disinfection process, self-adjusting to the dynamics of any room to quickly eliminate unknown variables and human error. Surfaces and air receive metered, lethal doses of cleansing ultraviolet germicidal energy. Sensors measure and monitor the reflected UV-C dose from within the room and real-time progress is transmitted to a hand-held remote to provide assurance that all surfaces, including shadowed surfaces, are disinfected.

TRU-D is automated to eliminate human error and to disinfect surfaces and air. Treating both air and surfaces simultaneously prevents surface recolonizing from airborne pathogens. Rooms can be disinfected and available quickly, with no advance notice and little prep time, and disinfection cycles can be interrupted at any time for immediate entry or emergency use of the space. TRU-D is easy to use and can disinfect most rooms in minutes (15-16 rooms per shift). TRU-D is operated from a simple, wireless remote control that communicates real time disinfection progress, requires no complicated training, no mathematical calculations or formulations, and no EPA certification. Net operating costs are very low, with no recurring expendables, no chemical residue, and no electronic equipment corrosion. Tru-D has been validated by numerous peer-reviewed and published studies and is proven to achieve repeatable 3 to 4 log reduction of pathogens in shadowed areas.

Apollo Corporation

Apollo Corporation offers on all of its whirlpool bathing systems a technology called the Remedy® ultraviolet light water purification system. This system kills bacteria, viruses and other harmful pathogens that become waterborne during the course of a bath by constantly circulating contaminated water past two chambers housing ultraviolet lights. By reducing the number of harmful pathogens during the bath, urinary and respiratory infections can be reduced by up to 50 percent. Preventing infections not only reduces liability exposure, but saves time as well. On average, one UTI can require 25 hours to chart, treat and track. Preventing just one UTI per month can mean annual time savings of approximately 300 staff hours. Swab samples taken between baths reveal Remedy-equipped tubs culture approximately 33 percent fewer CFUs.

Germicidal ultraviolet light (UV-C) is one of four spectrums of light that also include UV-A, UV-B, and black light. Each type of light is characterized by a different wavelength, with UV-C having the shortest wavelength, generally between 200-280 nanometers. This wavelength is the most effective in killing microorganisms, and is also referred to as UVGI or ultraviolet germicidal Irradiation. The UV light destroys or inactivates a pathogens DNA making it impossible for it to colonize and cause infections. Germicidal UV light has been used for 100 years, first to kill pathogens such as bacteria, mold, yeast and viruses in air ducts, then for other applications such as drinking and waste water. Today, germicidal UV light is widely accepted as a viable means of purifying air and water, and is recognized by the EPA and CDC. Apollos Remedy is patented and FDA approved.

Prior to purchasing an Apollo bathing system equipped with the Remedy® UV-C water purification system, or any bathing system, we encourage our clients to analyze very carefully what actually transpires during a nursing home or hospital bath. Until now, bathing system disinfection protocol focused only on the between bath disinfection step, without considering the very real risk of people self infecting by the very bacteria that wash off their body while bathing. During a bath, bacteria levels skyrocket up to 500,000 percent, putting residents who are immuno-compromised, frail, or who have open areas as risk of self-infection. At the end of a 10-minute bath, the Remedy system has killed up to 99 percent of the bacteria released into the water, greatly reducing the chance of infection. In all, this system makes a sound addition to any comprehensive infection control protocol.

Steril-Aire

Contaminated air ventilation systems have been associated with sick building symptoms. In the healthcare environment, there is strong evidence linking microbial growth on the air conditioning coils with HAIs and poor indoor air quality. The systems are also the vehicles for the spread of microorganisms disseminated in the occupied space. Steril-Aires multi-patented UVGI Emitters eradicate air ventilation system surface and airborne microorganisms, significantly reducing the spread airborne infection transmission. By continuously cleaning coil and drain pan surfaces of biofilm (bacteria, viruses and mold), Steril-Aire UVGI improves patient outcomes as well as staff performance and satisfaction. Evidence-based design studies have shown improved clinical outcomes and shorter hospital stays in neonatal units and orthopedic wards, resulting in reduced direct and indirect third party costs and legal liabilities. By continuously cleaning the coils and drain pan of biofilm, Steril-Aire UVGI improves ventilation system heat transfer and efficiency, resulting in reduced energy costs. Steril-Aire UVGI supports healthcare facility bottom line goals by making a vital contribution to infection control, operational excellence, risk management and environmental stewardship.

The C-wavelength is the most germicidal in the UV spectrum. It targets the DNA of microorganisms, destroying cells or making replication impossible. Directed at a cooling coil and drain pan in the HVAC system, UVC energy destroys surface biofilm, a gluey matrix that grows in the presence of moisture. Biofilm is widely prevalent in HVAC systems and leads to a host of indoor air quality and operational issues that are sometimes mistakenly attributed solely to mold. Steril-Aire UVC also destroys airborne viruses and bacteria that circulate throughout the system. Steril-Aire UVC will successfully deliver contaminant destruction rates above 90 percent, when properly installed and applied in combination with air-exchange rates.

Comparing performance is critical because all UVC is not created equal. For optimum performance, use a high-output device manufactured to deliver an output of 9 microwatts per linear inch of glass measured from a distance of 1 meter, tested at an air velocity of 400 feet per minute and at a temperature of 50 degrees F. The recommended location for installation is horizontally across the full width of the face of the coil, on the supply side of the system downstream from the cooling coil on 24 inch centers and above the drain pan. Since UVC industry standards are still evolving, check independent testing. The best independent information to consult is a series of test reports commissioned by the Environmental Protection Agency in conjunction with the National Homeland Security Research Center through its Technology and Testing Evaluation Program. The testing provides a useful benchmark for comparing performance of various UVC devices.

UltraViolet Devices, Inc.

A great deal of attention has been made recently to the dangers of harmful microbial organisms such as methicillin-resistant Staphylococcus aureus (MRSA), toxic mold and viruses like H1N1. Their presence in hospitals, offices and even homes has been brought to light with major media reports and warnings from healthcare and government agencies. UltraViolet Devices, Inc. (UVDI) recently challenged their popular Mobile Room Sanitizer with rigorous testing by an independent testing services laboratory. The Mobile Room Sanitizer is a portable, ultraviolet technology product designed to eradicate bacteria, viruses and molds. It can easily move from location to location in hospitals and anywhere else there are concerns about surface and air contamination by harmful pathogens. The units are capable of safely disinfecting a room using UV-C energy in as little as a few minutes.

In June 2009, the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) and their board of directors approved the release of an official ASHRAE position document, Airborne Infectious Diseases. The document expresses the views, supporting documentation, analysis and/or rationale and recommendations by the society on the topic of airborne infectious diseases. The document was compiled by the societys Airborne Infectious Diseases Position Document Committee. It states that, Airborne infectious disease transmission can be reduced using dilution ventilation, specific in-room flow regimes, room pressure differentials, personalized and source capture ventilation, filtration and UVGI. The ASHRAE document goes on to discuss the three general ultraviolet germicidal irradiation (UVGI) strategies which include installation into ventilating ducts, irradiation of the upper zones of occupied spaces, and in-room irradiation after one occupant and before the next.

UVDIs Mobile Room Sanitizer is certified by UL and CSA standards and FCC CFR47 Part18. The independent test protocols that the Mobile Room Sanitizer were tested to were specifically designed to determine effectiveness for surface disinfection at 8 and 17 foot distances in a controlled environment. Using Staphylococcus aureus as the test organism, the Mobile Room Sanitizer was proven to be successful at destroying 99.9 percent of the target organisms in 5 minutes at the 8-foot range and in as little as 10 minutes at the 17-foot range.

Antimicrobial Metals

Agion

The cornerstone of Agion technology is silver, a naturally occurring and highly effective antimicrobial agent. Silver has long been known for its antimicrobial properties and Agions zeolite carrier provides many benefits over other antimicrobials that are alcohol-, chlorine-, or ammonium-based. Agion technology operates at the surface of a product through the controlled release of silver ions which attack microbes and inhibit their growth in three different ways. We offer a variety of silver-based technologies to suit various manufacturing and product requirements. Silver ions attack multiple targets in the microbe to prevent it from growing to a destructive population. This tri-modal action fights cell growth in three ways: prevents respiration by inhibiting transport functions in the cell wall; inhibits cell division (reproduction); and disrupts cell metabolism. Depending on the microorganism, Agions antimicrobial technology has been shown to initially reduce microbial populate ions within minutes to hours while maintaining optimal performance for years.

Agions silver-based antimicrobial technology can be incorporated into plastics and coatings used to manufacture high-touch surfaces and medical devices. The key to the technology is the carrier (a ceramic powder similar to sand, but less than one-tenth the diameter of a human hair) that provides controlled delivery of silver to the treated surface. For example, Agion is used in CVCs as well as other 510K approved medical devices. The addition of Agion to the polyurethane during manufacturing produces a material with the embedded powder particles distributed across both the outer and inner surfaces of the catheter. The silver being delivered by these particles inhibits colonization on the catheter surface. Studies have been done related to these particular CVCs and their success in reaching the desired outcome, proving the usefulness of implementing these types of antimicrobial treated devices.

Only a system of strategies involving technology developers, device and equipment manufacturers, doctors, nurses, cleaning staff and hospital administrators can address the challenges faced by hospitals today. As part of that system, antimicrobial surfaces offer a new and novel approach to the issue of maintaining clean surfaces 24/7 often a struggle in hospital environments. When evaluating an antimicrobial solution, track record and experience are important, especially with respect to medical devices that require 510k clearance. EPA regulations surrounding antimicrobials prohibit claims that pertain to health benefits. FDA 510K antimicrobial devices do have the ability to make statements about efficacy, so understanding and researching the numerous studies that have been done on antimicrobial surfaces and their role is key. In addition, preventionists should work hand in hand with facilities to develop and drive adoption, and participate in studies that will support the need for expanding this type of clean environment thinking.

Copper Development Association

Laboratory testing shows that when surfaces in which copper is incorporated are cleaned regularly, antimicrobial copper is designed to kill greater than 99.9 percent of the following bacteria within two hours of exposure: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecalis (VRE), Staphylococcus aureus, Enterobacter aerogenes, Pseudomonas aeruginosa, and E. coli O157:H7.

Science suggests that copper surfaces affect bacteria in two sequential steps: the first step is a direct interaction between the surface and the bacterial outer membrane, causing the membrane to rupture. The second is related to the holes in the outer membrane, through which the cell loses vital nutrients and water, causing a general weakening of the cell. Every cells outer membrane, including that of a single cell organism like a bacterium, is characterized by a stable electrical micro-current. This is often called transmembrane potential, and is a voltage difference between the inside and the outside of a cell. It is strongly suspected that when a bacterium comes in contact with a copper surface, a short circuiting of the current in the cell membrane can occur. This weakens the membrane and creates holes. Now that the cells' main defense (its outer envelope) has been breached, there is an unopposed stream of copper ions entering the cell. This puts several vital processes inside the cell in danger. Copper literally overwhelms the inside of the cell and obstructs cell metabolism. These reactions are accomplished and catalyzed by enzymes. When excess copper binds to these enzymes, their activity grinds to a halt. After membrane perforation, copper can stop the cell from transporting or digesting nutrients, from repairing its damaged membrane, from breathing or multiplying. It is also thought that this is why such a wide range of microorganisms are susceptible to contact action by copper.

Antimicrobial copper surfaces are a supplement to and not a substitute for standard infection control practices. Just like other antimicrobial products, they have been shown to reduce microbial contamination, but do not necessarily prevent cross contamination; users must continue to follow all current infection control practices. Michels, et al. [Lett Appl Microbiol, 49:191-195, 2009] demonstrated that antimicrobial copper outperforms two commercially available silver-containing coatings under typical indoor conditions.

Antimicrobial Textiles

Vestagen

Vestexs fluid barrier protection is the first line of defense. Contaminated liquids literally bead up and fall from the fabric. Vestex technology changes the surface of fabrics on the nano level, giving the fabric a lower adhesion level. Fluids and dirt particles lie only on the peaks of the nano particles they are instantly repelled or can simply be rinsed off. Vestexs second line of defense is fast-acting, broad spectrum antimicrobial. Imagine it as a layer of electrically charged swords. When a microorganism comes in contact with the treated surface, a C-18 molecular sword punctures the negatively charged microbe cell membrane and the positive electrical charge zaps the cell. Vestex is also built for comfort with moisture wicking technology and quick drying properties similar to performance athletic wear.

It is well-documented in the medical literature that textiles with fluid barriers reduce bioburden in the clinical setting. Vestex uses fluid barrier protection as its first line of defense. Contaminated liquids literally bead up and fall from the fabric. Vestexs second line of defense is its embedded fast-acting, broad-spectrum quaternary ammonium chloride antimicrobial. Healthcare workers and their uniforms move around the hospital more than anything else in the clinical environment. Vestex protects garments from contamination.

All infection control measures will need to continue to pass the test of the four Ps:

1. Is it Plausible biologically? (repellency prevents gross contamination of garments; bulk contaminant shed in order for an antimicrobial to be effective)

2. Is it Practical to implement? (easy to use and sustainable)

3. Is it Politically acceptable? (safe for humans and the environment)

4. Will Personnel use it? (comfort leads to compliance)

Air/Room Disinfection Technology

Activeion

The ionator EXP by Activeion Cleaning Solutions is a handheld device that uses electrical charges to temporarily alter regular tap water to clean and kill germs without using cleaning chemicals. The activated water product does not cause harm to skin, eyes, or when ingested or inhaled, and does not carry any chemical-related health warning labels. This multi-surface cleaner kills the 2009 pandemic H1N1 influenza A virus and more than 99.9 percent of most harmful bacteria (E. coli, VRE, Salmonella, MRSA, Pseudomonas, Staphylococcus, Listeria and E. coli O157:H7) when used as directed. It has an EPA Establishment Number, and is considered a sanitizing device.

The process, called irreversible electroporation, sends a low level electrical charge into germs and bacteria that permanently ruptures their cell membrane. Also, a blended stream electrolysis process produces charged nanobubbles which help attract, dislodge and remove dirt. Its efficacy involves physics and electrical engineering more than chemistry. The technologies used in Activeion products are an outgrowth of science that has been available for decades. The science of water electrolysis is over 100 years old, and the science of electroporation has been around for decades. Activeion was the first company to put them together to clean and sanitize in a commercial product.

Cleaning is always the first line of defense to prevent infections. While there is no substitute for EPA-registered disinfectants where needed, many areas in healthcare facilities just need regular cleaning and sanitizing. Activated water accomplishes this without the use of toxic chemistries.

Advanced Vapor Technologies

Advanced Vapor Technologies patented TANCS® steam vapor sanitation systems offer a simple water-only cleaning and disinfection process with scientifically documented results. This alternative method of surface disinfection is more compatible with the goals of eco-friendly and sustainable facility care. With fewer chemical cleaners and disinfectants to purchase or manage responsibly, steam vapor makes cleaning and sanitation efforts safer, faster, easier and more thorough. The high temperature TANCS steam vapor rapidly kills a wide range of pathogenic microorganisms and emulsifies soil, grease and oil, hidden within surface pores on environmental surfaces. Removing and penetrating embedded surface contaminants is an essential part of a comprehensive, successful disinfection program, as organic contaminates harbor pathogens from the active ingredients in chemical disinfectants, and supply nutrients for their survival.

Heat is a time-tested process used to control microorganisms on inanimate surfaces. Our process makes use of a saturated steam vapor, as it is an efficient means of transferring thermal energy onto surfaces, while penetrating even the tiniest surface irregularities, yielding a more effective treatment. Studies show this disinfection device destroys viruses, fungi, and antibiotic-resistant bacteria very rapidly, whereas liquid chemical disinfectants usually require 5 to 10 minutes wet dwell time, thermal disinfection takes place in 3 to 5 seconds. Since targeted heat, not chemicals, is the active ingredient, there is no specter of chemical cross-resistance to antibiotics, surfaces do not become degraded over time, cross contamination potential is reduced, and staff can disinfect as frequently as necessary without long-term chemical exposure concerns or negative impacts on sensitized populations. Since pre-cleaning is not required, and contact times for disinfection are on the order of seconds, process outcomes improve.

Many steam vapor systems remove surface soil. The effective delivery of adequate heat to pathogens may vary. If the system is to be used for disinfection purposes, then it should carry an EPA Establishment Number as required for a disinfection device. Third-party documentation should be available, in the form of test results by independent GLP test laboratories, showing efficacy and contact times required for the pathogens of concern. Systems must be individually validated for surface disinfection, because a steam vapor systems germ-killing power depends on a variety of factors. Well-designed systems deliver saturated steam through a variety of insulated, easy to use tools that allow the steam to remain trapped for maximum use of the available heat. An onsite demonstration of the product and process is helpful in evaluating the proposed product, as is customer training and after market support.

BioQuell

BIOQUELL uses hydrogen peroxide vapor systems to provide a three dimensional sterilization of hospital rooms and spaces. The hydrogen peroxide vapor will provide a full six log kill of endospore forming bacteria, including Clostridium difficile, on both porous and non porous materials. The process eliminates the environment as a source of hospital-acquired pathogens helping infection preventionists reduce the risk of infection for subsequent patients admitted to the space. Though not a standalone procedure, BIOQUELL has been successfully deployed in numerous facilities to help reduce infection rates both long-term and in response to clusters or outbreaks.

Hydrogen peroxide liquid is vaporized and dispersed in to an enclosed space until the concentration of gas in the space exceeds the saturation vapor pressure of hydrogen peroxide. Once the saturation vapor pressure is exceeded the hydrogen peroxide forms a micro condensation layer 2 to 5 microns thick on all the surfaces in the room. This produces a concentrated layer of hydrogen peroxide on all of the surfaces in a room where pathogens may have accumulated producing a rapid kill. After an appropriate dwell time, typically 10 to 15 minutes, the aeration units are used to scrub the hydrogen peroxide form the air breaking it down to form oxygen and water leaving the room free from residual biocides and ready for re-occupancy.

The company providing the technology must be able to demonstrate to the purchaser biological and clinical efficacy data that shows not only can they sterilize hospital rooms (6-log kill for the pathogen of concern) but that in doing so they can reduce the rate of hospital acquired infection. To comply with U.S. law any product (chemical or device) making a public health claim must be registered with the EPA and should have a product label that matches the claims made, for instance a disinfectant will provide a four log kill of a specified pathogen when applied in accordance with the label instructions, make sure that the vendor provides a copy of their EPA registration, there are no exceptions. Remember, the EPA registers products but never approves or endorses. Verify with third parties the vendors experience in other hospital facilities and their record of success at those hospitals.

Xenex

The Xenex system was developed to reduce the risk of healthcare-associated infection (HAI) by automating the disinfection of the patient environment using pulsed xenon ultraviolet (PX-UV) light. Designed for speed and ease of use, the Xenex system can disinfect a typical patient/procedure room in 9 to 12 minutes or a large operating room suite in less than 20 minutes. The result is a 3- to 6-log reduction of viruses, vegetative bacteria and bacterial endospores for both surfaces and air with no disruption to hospital operations. The portable Xenex PX-UV device contains a single xenon flashlamp that retracts into a heavy-duty case that is easily wheeled from room to room by one person. The device also contains a UV feedback sensor for dose assurance, a simple four-button control panel, a remote control and a door sensor for additional safety. The technology has been certified green by Practice Greenhealth.

Environmental contamination and infection/colonization by prior room occupant(s) has been shown to increase the risk of HAIs and current cleaning procedures have been shown to be inadequate. In hospital trials using the Xenex system, the bacterial heterotrophic plate count from samples of high touch surfaces is more than 20 times lower after using the Xenex PX-UV system compared to standard terminal cleaning in VRE isolation rooms (p=0.0149), and the Xenex system eliminated all environmental VRE on tested surfaces. The Xenex PX-UV system produces broad-spectrum UV irradiation resulting in the disinfection of surfaces and air, including large amounts of energy in the germicidal spectrum (200-320 nm). UV irradiation in the spectrum between 200-320 nm deactivates microorganisms through the creation of thymine and cytosine dimers due to absorption of the UV by cellular DNA, and a photohydration effect that causes the pyrimidines cytosine and uracil to bond with elements of water molecules.

Infection preventionists should evaluate room disinfection technology using the following key considerations:

Impact on operations: Will the technology significantly delay patient admissions or other procedures? Is the technology practical enough for continuous use throughout a facility?

Ease of use: How long will training take? What level of professional is needed to operate the new technology? Is routine maintenance needed?

Cost per use: What is the cost per use? Are there consumables such as chemicals that must be ordered and stored?

Cost/benefit: How many infections must be prevented to pay for the technology? How probable is that?

Patient/staff acceptance: How will patients or staff perceive the technology? Could it help drive patients to the facility?

Environmental impact: Are toxic materials used in the manufacturing or use of the technology?

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