Asking the Right Questions When Selecting Infection Prevention Technology

April 16, 2012

Editor's note: This article was published in the April 2012 print issue of ICT as the Vendor Viewpoint column.

By Mark Stibich, PhD

The answers come easily when we ask the right questions; if I had one statement to post on my wall, it would be this one. Every time I have been "stuck" trying to solve a problem, design a research study or develop a new solution, I try to remind myself that the answer is out there, I'm just asking the wrong question. If you get the question right, the answer will emerge.

As the chief scientific officer for Xenex Healthcare Services, I see firsthand the selection process for room disinfection systems at many facilities. As with any hospital purchasing process, multiple individuals are involved. The biggest difficulty is that the people involved may all be asking different questions. Some individuals may get very interested in the different technologies while others will only care about the economics of the purchase. I believe that by taking the group through a question forming exercise, the selection process can be streamlined. Of course, before getting to the question, it is best to understand the problem.

Defining the Problem
Why #1: Why do we need an automated room disinfection system?
Studies have shown that there is HAI risk attributed to the environment, specifically that the subsequent patient admitted into a room previously occupied by someone with an HAI is at greater risk.

Why #2: Why does the environment contribute to risk?
An inadequate amount of pathogenic microorganisms are removed at discharge cleaning.

Why #3: Why is current cleaning inadequate?
Studies have shown that hospital housekeepers miss a large percentage of important surfaces while disinfecting. This is because: 1) they are under tremendous time pressure to "turn" a room -- some estimate that it would take one housekeeper about 3 hours to thoroughly disinfect all surfaces in the room; 2) the chemicals used are misapplied -- the data for the chemicals may be great in a lab, but housekeepers have difficulty following dwell time guidelines, mixing guidelines and may make things worse through reusing wipes, causing cross-contamination; 3) as more potent chemicals are chosen, fumes cause housekeepers to use them less. There is just not enough time for thorough manual cleaning without error.

I'll stop the "Why" chain here - but you get the idea. Now we can see clearly what the problem is, so we can make a first stab at a solid question: "Which area disinfection technology is best?"

The word "best" is too vague and subject to interpretation. We need to define "best."  I think of this as putting specific constraints, based on our goals and reality, into the question. Here are some categories that, most likely, make up "best" in the aforementioned question.

Speed: All other factors being equal, the technology that can disinfect the most rooms per day is the "best."

Evidence: Evidence should drive the decision, but it is important to consider the level of evidence appropriate for the decision. If your facility requires case-controlled experimental studies to purchase an automated area disinfection system, you will be waiting a long time. Such a study is not feasible or appropriate. The FDA regulates these systems as a "cleaning device," essentially the same as a vacuum cleaner. You should expect to review scientific data including laboratory kill data, environmental effectiveness data in operational, real-world settings and case studies (at a minimum) from customers who have had success with the product.

Effectiveness: The "best" technology is not necessarily the most effective. There are methods that will, essentially, sterilize a room - but they cost more and take hours. The "best" technology from an effectiveness standpoint is one that delivers adequate protection by reducing the amount of pathogens on important surfaces below the transmisivity level.

Cost per room:  When considering cost, simply comparing the sticker price of two systems is not correct. What must be considered is the cost per room, which indicates the number of patients that will be protected by the technology (the "coverage" of the technology). To determine the cost per room, use the formula below:
(a+b+(c x d x 365)+e)/(c x 365)
a= annual cost of the technology
b= annual cost of service plans
c= average number of rooms that can be treated per day
d= usage cost per room (e.g. chemical cost)
e= estimated additional labor cost

The Rewrite
Now let's put those ideas back into our question and see what we have: "Which area disinfection system has a low cost-per-room, adequate effectiveness to reduce transmisivity, adequate data to back-up claims and is quick enough to not disrupt hospital operations?"

If everyone on the selection committee agrees that this question (or one like it) is the correct one, the selection process becomes a lot easier. Of course, your facility may rewrite the questions based on a specific need, but this process leads to efficient and effective decision-making, especially when numerous departments are involved.

Room disinfection systems have proven to help hospitals reduce the microorganisms which cause HAIs isnt it time your facility began asking the right questions and enjoying improved infection control results?


Mark Stibich, PhD is a founder and chief scientific officer of Xenex Healthcare Services.