Environmental Hygiene Case Studies

Infection Control Today invited industry members to share mini case studies that reflect real-world situations in which evidence-based strategies were used to address environmental cleaning challenges.

Editor's note: For the September 2012 ICT cover story on environmental hygiene, CLICK HERE. 

Infection Control Today invited industry members to share mini case studies that reflect real-world situations in which evidence-based strategies were used to address environmental cleaning challenges.

Environmental Services Role in Reducing the C. diff Rate at Cincinnatis The Jewish Hospital Mercy Health

In 2009, the C. diff incidence rate at The Jewish Hospital Mercy Health in Cincinnati hit a high of 25.27 per 10,000 patients, owing primarily to an older population of patients, many of whom are in long-term care and at higher risk for C. difficile infection.

To ensure the health and wellbeing of its patients, hospital leadership formed a multidisciplinary task force comprised of nurses, physicians, administrators and experts from infection prevention, pharmacy and environmental services. This group focused on three areas most associated with infection -- broad-spectrum antibiotic use, standardization of clinical care, and environmental cleaning to bring down the rate to 3.08 per 10,000 in less than two years. This case study will examine the impact environmental services (EVS) had on reducing the C. diff incidence rate.

A key focus area was environmental cleaning and services because of its historical role in contributing to the spread of C. diff.
Among the items the EVS team looked at were the following:
How often we changed the curtains in rooms holding patients discharged from C. diff isolation
The processes associated with cleaning the bathrooms
The use of non-dedicated isolation equipment and improper use of personal protective equipment as contributing factors to a dirty environment

EVS then identified appropriate changes to procedures that had an immediate and effective impact on C. diff rates:
Changing the curtains during terminal cleaning of rooms used by C. diff patients is now an established part of our procedure for reducing and maintaining low C diff infection rates.
We clean bathrooms twice daily because bathrooms are a high source of C diff contamination and twice daily cleanings play a role in reducing incidences of C. diff in patients.
Bleach is effective in eradicating C. diff spores. We increased the use of bleach-based product. If we have two C. diff infections on the unit, we clean for three days using only bleach. We use bleach to clean the ICU every Wednesday. We use soap and water to clean our hands when treating C. diff patients. Alcohol gel products are not effective in killing spores but soap and water washes them away.
We use dedicated equipment, such as toilet scrubbers, that we discard after the patient goes home. This way we are not taking organisms out of the room.
We also use dedicated cloths and microfiber mop strips and we have multiple cloth changes -- six to seven -- per room.
We use a laundry sanitizer to kill bacteria on the mop strips and cloths.
We purchased a booster heater to heat water to 185 degrees to further ensure we kill any organisms on our mops and cloths.
We purchased a real-time adenosine triphosphate (ATP) cleaning, validation and tracking system, which we use in patient rooms following an environmental service cleaning to see if there is any bacterial residue left behind after cleaning. Based on the results, we provide staff with quick feedback that has helped them learn to do an effective job of cleaning the high-touch points in the room.

This program has driven employee engagement in EVS. Employees understand the role they play in keeping patients safe. We recognize their efforts regularly, so they know we value their work. Recently, when we had a small trend up in C. diff infections, we worked with EVS to review and reinforce processes. The infection rate trended downward immediately, showing EVS staff how important they are to the hospitals operations.

EVS efforts, together with those of the pharmacy and the lab, reduced the C. diff incidence rate from 25.27 per 10,000 patient days to 3.08 in less than two years, a remarkable achievement. The Jewish Hospital Mercy Health is actively sustaining the low incidence rate by providing continuing education for all staff and for new employees, holding staff accountable, providing positive feedback to staff and reporting infection rates to internal quality committees.
-- Sharon Wachter, director, Food & Nutrition Services, Environmental Services, The Jewish Hospital Mercy Health

Cone Health Reports 42 Percent Drop in HAIs & $2.3 Million Savings Resulting from Infection Control Program Including Room Disinfection System

The challenge
Despite implementing several MRSA infection prevention initiatives, the hospitals transmission rate remained unacceptably high. New health system senior management challenged the institution to eliminate the risk of infections.

Cone Health is committed to being a national leader in quality, service and cost. From December 2007 through December 2010 Cone Health participated in the VHA initiative to reduce MRSA infections. They implemented a number of interventions but despite all these efforts the MRSA transmission rate remained stagnate. This situation was particularly frustrating for members of the infection prevention team. Cone Healths president and COO, Terrance Akin, challenged the infection prevention team to make it happen and what followed was a remarkable transformation of Cone Healths infection prevention program. Using a combination of tools and technologies, including a pulsed xenon room disinfection system, they were able to reduce MRSA infections to zero in their ICUs and save more than $2 million.

Cone Health compared HAI data from the first and second quarters of 2010 to the same period in 2011. Using data from its MRSA screening program, an aggressive approach to HAI prevention was developed. Intervention methods included:
A new Step Up. Scrub Up. campaign to renew the organizations emphasis on consistent hand hygiene for everyone. The program assisted in gaining better hand hygiene compliance among the 8,600 employees of Cone Health as well as patients and their visitors. The basis of this program was the World Health Organizations 5 steps to hand hygiene.
Room-cleaning was supplemented with an automated room disinfection system that uses pulsed xenon UV light to quickly destroy microorganisms on high-touch surfaces, without using chemicals. 
MRSA surveillance testing was expanded from three units to patients in all ICUs, step-down units, high risk and pre-surgical areas.
Additional infection prevention professionals were added and/or promoted to new roles.
An electronic data mining system provided real-time data on whether a patient had MRSA so that measures could be taken to prevent spreading it.
Education of personnel, patients and visitors was expanded.

Cone Health was the first hospital in North Carolina to implement this automated room disinfection system, which uses pulsed xenon ultraviolet light to destroy viruses, bacteria and bacterial spores in patient areas without contact or chemicals. Uniquely designed for ease of use and portability, the device can be operated by a hospitals cleaning staff without disrupting hospital operations or requiring the use of expensive chemicals. The system is capable of disinfecting dozens of rooms per day, so hospitals can use the system continuously to reduce contamination levels throughout their facilities, including patient rooms, ORs and ICUs.

Education and empowerment
During a terminal room clean, it is impossible for cleaning staff to disinfect every square inch (ceilings, walls, floor, art, phone, furniture, switches) in the time available, which is about 30 minutes, or with the available resources and supplies, which are ineffective. To achieve a comprehensive room clean of all surfaces, it would take one cleaning team member multiple hours plus the cost of the cleaning supplies. 

The device enables Cone Health to eliminate dangerous pathogens from the rooms in an efficient manner in minutes without disruption of the hospitals operations. The manufacturer conducted on-site trainings for Cone Healths housekeepers and other individuals who operate the devices. In those trainings, the important role that housekeeping plays in infection control was emphasized as trainees learned exactly how the system fit into their overall infection control program.

Return on investment
During the time period studied, Cone Health saw the number of hospital days associated with infections decrease from 2,038 to 685, the number of HAIs drop from 72 to 30, and the number of MRSA infections in its ICUs decrease to 0. This translated into a $2.3 million reduction in infection-associated hospital costs.
-- Mary Jo Cagle, Chief Quality Officer, Cone Health


Infection Control at Your Fingertips

As infection preventionists one of our primary goals is to prevent patient-to-patient transmission of infectious microorganisms, as well as keeping our visitors and fellow associates safe. At Advocate Lutheran General Hospital and Lutheran General Childrens Hospital, we frequently brainstorm various strategies to make our facility safer for everyone. One of the initiatives we chose, to make an immediate infection prevention impact, was environmental hygiene.

Virtually every patient, visitor and associate touches or comes into contact with someone or something in the hospital environment. Not only are we mandated to keep the patients safe, but we also dont want family and visitors to take away any souvenir organisms to share at home.

Cleaning and disinfection of non-critical surfaces and mobile equipment in a patient care area is a part of standard precautions. It is critically important that frequently touched items and surfaces are cleaned effectively and often.

On clinical units, tubs of disinfectant wipes had been made available. However, we soon realized that departments, such as transportation, needed to use the wipes between seeing patients but found it took too long to locate them on the clinical unit. Radiology and the emergency department associates said they faced similar difficulties with cleaning mobile equipment between patients.

We believed the implementation of a novel point-of-use product would be embraced by these and other associates. They would no longer have to spend time hunting down a disinfectant wipe to clean the wheelchair, gurney or X-ray machine. Truly they would have infection control at their fingertips.

The first option investigated was individual single use packets. However, this did not meet our expectation for consistent use and availability. There was a limit as to how many an associate could keep handy either on a gurney or X-ray machine due to limited space and configuration of equipment. 

We became intrigued with the idea of using a surface disinfection cloth that came in a flat package. More importantly the flat pack needed to adhere to all kinds of surfaces. The product we selected had disinfectant wipes in a flat plastic package with two adhesive strips on the back. A sample trial was done to see how well this novel flat pack would adhere to mobile equipment, especially wheel chairs, vitals monitors in ER, ultrasound equipment, scales and radiology equipment. The adhesive backed flat pack stayed on all the mobile equipment without falling off during transport or service. 

Associates were asked for input and gave positive response about the ease of availability and use of the flat pack. They liked having a disinfectant wipe available as soon as they finished a procedure. Associates especially liked not having to take extra time to find a disinfectant wipe in the various departments and could effectively clean equipment before moving on to the next patient.
Clinical staff in the pediatric unit developed their own motto and reminder for using the disinfectant wipes, Clean on the way in and Clean on the way out.Our infection control team developed a motto when encouraging the use of tube and flat pack disinfectant wipes: Clean Hands, Clean Equipment, Clean Environment. Thank you for helping to protect our patients.

Our observation is that having disinfectant wipes available at the point of care increases compliance with cleaning equipment between patient uses. This is an important part of our infection prevention strategy to reduce the incidence of hospital-acquired infections.

  - CDC Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
  - MMWR, CDC Guideline for Hand Hygiene in Health-Care Settings.
- Centers for Disease Control and Prevention (2003). Guidelines for Environmental Infection  Control in Healthcare Facilities. Morbidity, Mortality Weekly Report: 52 (RR10) 1-42.
- Rutala, W.,Weber, D. and Healthcare Infection Control Practices Advisory Committee (HICPAC) (2008). Centers for Disease Control and Prevention. Guidelines for Disinfection and Sterilization in Healthcare Facilities.
- Centers for Disease Control and Prevention (June 2007). Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

-- Marguerite Gribogiannis, SM (ASCP)MT, CIC; Lynn Guibourdanche, RN, BSN, CIC, and Mark Kiezel, RN, BA, CIC, Advocate Lutheran General Hospital and Lutheran General Childrens Hospital


An Environmental Services Quality Improvement Project

For the past 30 years, I have been involved with environmental services (EVS) and during that time I have encountered comments such as, How do you know the patients room was cleaned properly?  I never had an effective come-back to those comments because, frankly, I didnt know for sure unless I cleaned the room myself.  Then, in 2011 I read an article about how the marketing department used a fluorescent powder, which is visible only under ultraviolet light, to help children appreciate that germs can stay on hands if they are not washed properly.  I started thinking perhaps this product could be used in patients rooms as well.  I wanted to be confident that when a patients room is cleaned it is done in such a manner that we can be sure that the organisms were either killed or removed. 

We had been training our EVS techs on cleaning high-touch areas in the room such as the door handles, IV poles, bed rails etc., and why it was important to disinfect all of those areas during a discharge cleaning.  I just wasnt sure if the proper cleaning was being done.  I discussed this dilemma with our infection preventionist and she suggested I use a fluorescent powder to train, improve and monitor the cleaning process; that it would be a great process improvement project. I borrowed her fluorescent powder and had one of my lead EVS techs test the patients room in the surgical intensive care unit by applying the powder to several of the high-touch areas before it was cleaned. After the room had been cleaned, we checked the room using an ultraviolet light. I was shocked to find that none of the high-touch areas had been cleaned.  The lead tech commented that since this was the first time using fluorescent powder, I should accompany her in showing the results to the EVS tech that had cleaned the room.  I brought in the tech and showed her the powder on the areas missed using the ultraviolet light.  At first she denied missing those areas, assuring me that she had cleaned them.  I gently explained the process to her and reassured her that she was not in trouble, but that she truly missed cleaning those areas as the powder was clearly visible with the light.  I wiped some of the powder off and showed it to her on my hand.  It took some time to convince her that the purpose of this test was not to discipline her, but was used for training.  I then brought her and another EVS tech to the next room that had been treated and cleaned.  The majority of that rooms high-touch areas had been cleaned properly.  Of note, one of the things we learned during this process is that rough or textured surfaces held onto the powder more so than smooth surfaces. That taught us those areas are more difficult to clean.

I chose two of my charge EVS techs to lead this project. Their job was to powder as many rooms as possible, then inspect the rooms afterwards and determine their efficacy rate. They were charged with building a checklist of the areas that were tagged with powder and use it as a monitoring tool. They also were to take the employee back into all the rooms inspected and show them what was missed.   I initially introduced the program to the staff as a training project. I explained that after the training project was over, we would take the monitoring to a new level.  I scheduled weekly meetings with the two charge techs to review their progress using graphs of the cleaning results, the compliance levels the staff had reached and where we would take the program.  We retrained the staff on high touch areas and how to service a discharged patients room properly. I established a threshold score of 85 percent.  Any tech with a score below 85 percent qualified for retraining in proper cleaning procedures.  If a tech required training more than twice in a six-month timeframe, they were counseled.  In November we posted the scores without the names attached. In December we posted the scores with names attached to the best scores and told staff that next month all names would be attached to their scores. In January, the scores were posted with all the names for the staff to see how they did. No one fell below 90 percent; in fact, several frequently received 100 percent on their rooms.

Looking back on this project, we recognized that at first the staff was not pleased their rooms were being inspected in that manner. They felt they were being spied on. However, by the end of the first month, they realized no one had been written up in spite of their scores and each one had been shown what they had missed and they had been challenged to do better with the next room. The charge techs applying the powder and doing the inspection had to be careful not to be seen when contaminating a room because they found the staff had become experts in cleaning the high-touch areas and missed many other areas. The charge techs decided to apply the powder using random areas of the room.  With proper training the staff became very efficient in cleaning the rooms and welcomed having them checked. They even started asking what their scores were. When cleaning empty beds in double rooms, patients began questioning why we were doing this type of inspection. They soon realized their bed had been cleaned thoroughly as well. Not only did this allow our staff to take great pride in their work, this was also a great patient satisfier.

During a meeting about disinfectants, I had the opportunity to answer that question again, How did I know that room was really clean? Now, I have the best possible answer. We continue to use a fluorescent product, but now in lotion form; it is completely invisible to the eye without the ultraviolet light. 

Below are the results of our process improvement project.
Trial start month, October 2011
- Touch surfaces cleaned: 530  
- Touch surfaces missed: 211         
- Total surfaces surveyed:  741
- Percentage of compliance during training: 72 percent

November 2011 through February 2012
- Touch surfaces cleaned: 3936  
- Touch surfaces missed: 401  
- Total surfaces surveyed 4,337
- Percentage of compliance during training: 91 percent

-- Glen Baker, director, Environmental Services, Regional Medical Center

UV-C as Another Tool in Our Infection Prevention Tool Belt

In 2009 the University of Rochester Medical Center (URMC) was the first hospital in our area to implement UV technology for surface disinfection due to an increased incidence of healthcare-associated Clostridium difficile infection (CDI). 

At the recent APIC conference in San Antonio, William Rutala, PhD, MPH, CIC, one of the keynote speakers, highlighted the importance of improving environmental cleanliness in healthcare.  He stated, "There is increasing evidence to support the contribution of the environment to disease transmission, and that we pick up pathogens at the same level by touching the environment as we do by touching the patient. Unless we inactivate or remove these microbes, they are going to be present in a patient room for a long time. Just entering a room previously occupied by a MRSA, VRE or C. difficile patient significantly increases the risk of contacting that pathogen.

There is recent third-party scientific evidence performed by Moog Medical Device Group demonstrating the effectiveness of UV-C radiation by reducing the spore count of C. diff > 3.4 log10 after delivering a measured dose of 46,000 µW-sec/cm² to the targeted area.

In 2011 four hospitals in Rochester, N.Y. formed a collaborative to reduce the incidence of CDI.  A variety of prevention strategies have been initiated to date, including UV surface disinfection. This was done to help prevent cross-contamination of patients by effectively eliminating biologic contaminants found on surfaces within the patients room.  Frequent proactive operation of the UV system, along with routine and terminal cleaning, should in theory break the chain of infection related to the transmission of pathogens including C. diff.  Ultraviolet germicidal irradiation (UVGI) has been used worldwide over the years to prevent healthcare associated infections (HAI).  Irradiating contaminated air and surfaces with a proper, measured and controlled dose of UV germicidal energy has been shown to reduce or even eliminate microorganisms that can cause infection.

We use a system that is dose based rather than time based. Remote challenge device UVC sensors are used to measure the definitive intensity and dosage delivered to each point of interest. UVC irradiation remains active until the programmed lethal dose of energy for the specified microorganisms has been delivered to the targeted areas. Disinfecting shadowed areas in rooms can be a challenge. This system can be paused, repositioned, and then the disinfection job resumed, thereby maximizing efficiency by reducing treatment time and eliminating shadowed areas. Critical data is captured so we can measure, record and analyze our disinfection protocol in real-time. This is an advantage over manual recording.

Because certain pathogens have characteristics which allow them to survive in the environment for a long time, the environment itself can be an important reservoir for HAI. Contaminated hands of healthcare workers are a vehicle of transmission either by direct contact with the patient or the environment.  Patients can also become colonized by direct contact with a contaminated surface. C. diff is an example of an epidemiologically important pathogen with documented environmental transmission. Despite vigorous attempts at routine cleaning and disinfection, multiple studies have shown that C.diff can be cultured on surfaces up to five months after inoculation.  The thoroughness of cleaning in hospitals remains suboptimal for a variety of reasons including rapid room turnover, difficult to reach surfaces, complex equipment and the presence of spore forming organisms. The use of UVC does not replace the need for routine cleaning and disinfection, but rather holds promise as an adjunct measure to improve the efficacy of environmental disinfection, thereby decreasing HAI.

-- Ann Marie Pettis, director of Infection Prevention, University of Rochester Medical Center


Successful Comprehensive Approach to Environmental Hygiene Expands Beyond the Patient Room

Over the past decade, many studies have shown that a comprehensive approach to environmental hygiene that combines appropriate chemistries, tools, best practices, staff training and objective monitoring, can improve cleaning outcomes in the patient room setting. The experience of the environmental services team at a hospital in Washington State further supports this after adopting a comprehensive approach to environmental hygiene.

The hospital implemented a comprehensive environmental hygiene program that helps hospitals improve patient room hygiene and prevent the spread of infections by focusing on accurate dispensing of clinically proven chemistry, state-of-the-art tools such as microfiber mops and cloths, training on best practice cleaning processes with a focus on cleaning high-touch objects, an objective method to monitor the thoroughness of cleaning and real-time reporting on results to drive continuous improvement. 

Since it began using the program, the hospital has increased high-touch object cleaning from 66 percent to 95 percent.

Based on this improvement, and the best practice of measuring performance toward improving quality, the hospital has implemented the program in other patient-care areas where the environment can play a role in the transmission of pathogens, namely in the operating room (OR).

Historically, OR cleanliness evaluations have been based on subjective visual inspections despite the fact that patients are particularly vulnerable to the introduction of pathogens during surgical procedures. It is only within the last few years that research on thoroughness of high touch object cleaning has extended to evaluate the cleanliness of high-touch surfaces in the OR. In one study, just 25 percent of the targeted OR surfaces were cleaned properly, but researchers also found that with additional staff feedback on thoroughness of cleaning, and training on best practices, significant improvements were made.(1)

In a study presented as a poster at the 2012 annual meeting of the Association of periOperative Registered Nurses (AORN), it was demonstrated that a programmatic approach to environmental hygiene in patient rooms could translate to improved thoroughness of cleaning in the OR.(2) The study, conducted in 79 ORs across five hospitals, determined that focused training on best practices, proper products and tools, combined with an objective environmental monitoring tool and timely staff feedback, could improve the effectiveness of disinfection cleaning.

The study found a 22 percent improvement in thoroughness of disinfection cleaning, moving from the baseline average of 51 percent of high-touch objects cleaned to a post-intervention average of 73 percent. Most importantly, cleaning of all high-touch objects improved in the post-intervention period.

By standardizing the cleaning process, training staff how to clean to prevent cross contamination of rooms and within patient areas, using objective monitoring and automated reporting, and providing cleaning tools and products specifically designed to meet the needs of the OR, the hospital has significantly improved the thoroughness of cleaning, making it a safer environment for patients and staff.

1. Jefferson J, Whelan R, Dick B, Carling P. AORN J. A novel technique for identifying opportunities to improve environmental hygiene in the operating room. 2011 Mar;93(3):358-64.
2. Wolf B, Homan L. A programmatic approach to improve environmental cleaning in the OR. Poster presented at 59th annual AORN Congress, March 2012.

-- Linda Homan, RN, BSN, CIC, senior manager, clinical and professional service, Ecolab Healthcare


UV-C Disinfection in the Healthcare Environment

There is a growing awareness of the need for enhanced environmental decontamination as reports of environmentally mediated healthcare-associated infections (HAIs) continue to accumulate.  Numerous pathogens including Acinetobacter baumannii (Maragakis, et al.), Vancomycin-resistant enterococci (VRE) and Clostridium difficile (C. diff) (Weber, et al. 2010) have been found to survive for extended periods of time in the patient care environment despite application of post-discharge cleaning protocols by environmental services (EVS).

 The modest efficacy of standard room disinfection (Boyce, et al.  2011 and Streed, et al.  2012) using long-standing protocols and germicidal agents, principally quaternary ammoniums (quats) has led infection preventionists to investigate alternative methods of post discharge room decontamination in an effort to improve patient safety by reducing/eliminating the residual carryover bio-burden present in the hospital environment.  These methods chiefly involve fogging the room with hydrogen peroxide or exposing the room to ultraviolet light with a wavelength of 254 nanometers, referred to as UV-C.

In a poster abstract presented at the 39th APIC Annual Educational Conference, Streed, et al. (2012) investigated the efficacy of UV-C in disinfecting rooms following post-discharge cleaning by EVS.  This work led to two major conclusions: The first was that, as described in previous studies, there is a substantial residual of viable microbes following EVS cleaning. Using standard RODAC plates and sampling six high-touch surfaces in 30 patient rooms, the average colony counts were found to be 32.5/plate (pre-cleaning) and 16.9/plate post-cleaning, a 48 percent reduction (p < 0.00001). In other words, 52 percent of the viable bacterial bioburden remained after EVS cleaning. The second conclusion was that post-cleaning exposure to UV-C offered a substantial additional reduction of the residual bioburden. Specifically, the average colony count post-UV-C treatment was found to be 1.6 colonies/plate, a reduction of an additional 90 percent when compared to the post-cleaning average of 16.9 colonies/plate (p < 0.00001). It should be noted that there was no difference in colony counts between the post-cleaning samples and a series of control samples that were collected from sites protected from exposure to UV-C. 

Ultraviolet germicidal irradiation (UVGI) uses short-wave ultraviolet (UV-C) energy to inactivate viral, bacterial and fungal organisms by irreparably damaging their DNA structure.  It is a well established photochemical technology that disinfects a contaminated surface by exposure to a spectrum of electromagnetic radiation in the UVGI range (200 to 280 nm). The low-pressure mercury-argon lamps used in this study generated a UV-C wavelength of 254 nm - near optimal for inactivation of microorganisms.  Photons of UV energy permanently damage the DNA of the microorganism through creation of pyrimidine dimers rendering it inactive or unable to replicate. An organism that cannot reproduce is thus incapable of causing infectious disease.

Current environmental cleaning practices using standard processes and EPA-approved chemicals often fail to adequately remove viable bacteria from the care environment.  The incidence of HAIs caused by pathogens present in the environment has prompted infection preventionists to investigate measures to supplement room disinfection through the application of emerging technologies that reach and disinfect all relevant touch surfaces in the healthcare environment. Clinical studies of UV-C area decontamination technology indicate significant disinfection enhancement compared to established cleaning protocols with commercially available chemical disinfectants.  While further research is advisable, our studies show that UV-C disinfection adjunct to EV practices yields significant surface disinfection improvement.

- Boyce, J.M., Havill, N.L., Moore, B.A. (2011).  Terminal Decontamination of Patient Rooms Using an Automated Mobile UV Light Unit.  Infect Control Hosp Epidemiol 2011;32(8):737-742
- Maragakis LL, Cosgrove SE, Xiaoyan S, et al. (2004), An Outbreak of Multidrug Resistant Acinetobacter baumannii Associated With Pulsatile Lavage Wound Treatment. JAMA 2004;292:3006-3011.
- Streed SA, Price A, Andrews J, Knoke, C, and Hauser E. (2012) Preliminary Assessment: Efficacy of Room Sanitizing With Controlled Exposure to UVC Light. Presented at the 39th Annual APIC Educational Conference, June 4-6, 2012.
- Weber DJ, Rutala WA, Miller MB, et al. Role of hospital surfaces in the transmission of emerging healthcare associated pathogens: Norovirus, Clostridium difficile, and Acinetobacter species.  Am J Infect Control 2010;38:S25-33.

-- Steve Streed, Lee Memorial and Ashish Mathur, PhD, UVDI


What Does It Take to Prevent the Transmission of C. difficile From Environmental Surfaces?

Infected patients shed pathogens into the environment, resulting in increased risk of infection for the subsequent occupant of the room by a factor or two or more.(1) For example, in one study, patients admitted to rooms previously occupied by patients with C. difficile infection (CDI) were 2.8 times more likely to develop CDI than patients admitted to rooms disinfected using conventional methods. Thus, most agree that more needs to be done to reduce contamination with C. difficile spores in order to interrupt transmission. However, what level of disinfection is required to prevent the transmission of C. difficile?

A consideration of data relating to the infectious dose of C. difficile is a useful first step. In hamster studies, Larson and Borriello showed that only one or two spores of C. difficile were required to initiate infection in clindamycin-treated hamsters.(2)  This indicates that very low levels of C. difficile spores can initiate infection.

Lawley, et al.(3) developed a murine model that provides useful background data on infectious dose. A dose-response relationship was established between the concentration of contamination in the cages and the proportion of healthy mice that developed CDI. All mice became infected when exposed to 100 spores/cm2 and 50 percent of mice became infected when exposed 5 spores/cm2.  The point at which none of the mice became infected was a concentration of less than one spore per cm2. The mice were exposed to the contaminated cages for one hour. In the healthcare environment, room exposure times are usually measured in days and so these estimates are likely to be conservative. Although translating data from animal models to meaningful clinical practice is difficult, it appears from these animal models that a low concentration of contamination is able to transmit spores to a susceptible host, as is the case with other healthcare-associated pathogens such as norovirus.(4

The low infectious dose of C. difficile is not the only challenge to disinfection. Bacterial endospores can survive on surfaces for many months(5) and are resistant to several commonly used disinfectants.(6) Patients with CDI result in widespread fecal contamination with C. difficile present in the feces of infected individuals at concentrations in excess of 106 spores per gram.(7)

Lawley, et al. examined which disinfectants were able to interrupt the transmission of C. difficile and established a relationship between the level of inactivation of C. difficile spores in vitro and the degree to which transmission was interrupted.

The oxidizing agents sodium hypochlorite (bleach) and hydrogen peroxide vapor (HPV) were the only agents tested that achieved a 6-log reduction on C. difficile spores in vitro and completely interrupted the transmission of C. difficile. Notably, both bleach and HPV disinfection can reduce the incidence of CDI in healthcare applications.8-9  Based on these findings, the CDC recommends that surfaces potentially contaminated with C. difficile spores should be disinfected using EPA-registered sporicidal agent (such as bleach) or sterilants.

Recent data highlight the fact that agents with in vitro efficacy may not effectively eradicate hospital pathogens from surfaces due to limitations with achieving adequate distribution and contact time using conventional cleaning methods. (1,10) The emergence of no-touch automated disinfection methods provide an alternative to reliance on a manual operator for the inactivation of pathogens on surfaces. Hydrogen peroxide vapor (HPV)  is an EPA-registered sterilant that achieves a 6-log reduction on C. difficile spores in vitro, eradicates C. difficile spores from surfaces and reduces the incidence of CDI and successfully mitigates the increased risk from the prior room occupant. (5, 9, 11-13)

In summary, given the fact that a small number of C. difficile spores are sufficient to cause CDI in susceptible individuals, disinfectants with an EPA-registered sporicidal claim or sterilants should be used for disinfecting rooms used by patient with CDI. No-touch methods, such as HPV, remove reliance on the operator to achieve adequate distribution and contact time and are appropriate for the terminal disinfection of rooms used by patients with CDI.

1. Otter JA, Yezli S, French GL. The role played by contaminated surfaces in the transmission of nosocomial pathogens. Infect Control Hosp Epidem. 2011; 32:687-99.
2. Larson HE, Borriello SP. Quantitative study of antibiotic-induced susceptibility to clostridium difficile enterocecitis in hamsters. Antimicrob Agents Chemother 1990; 34:1348-53.
3. Lawley TD, Clare S, Deakin LJ, et al. Use of purified clostridium difficile spores to facilitate evaluation of health care disinfection regimens. Appl Environ Microbiol 2010; 76:6895-900.
4. Yezli S, Otter JA. Minimum infective dose of the major human respiratory and enteric viruses transmitted through food and the environment. Food Environ Microbiol 2011; 3:1-30.
5. Otter JA, French GL. Survival of nosocomial bacteria and spores on surfaces and inactivation by hydrogen peroxide vapor. J Clin Microbiol 2009; 47:205-7.
6. Humphreys PN. Testing standards for sporicides. J Hosp Infect 2011; 77:193-8.
7. Al-Nassir WN, Sethi AK, Nerandzic MM, Bobulsky GS, Jump RL, Donskey CJ. Comparison of clinical and microbiological response to treatment of clostridium difficile-associated disease with metronidazole and vancomycin. Clin Infect Dis 2008; 47:56-62.
8. Mayfield JL, Leet T, Miller J, Mundy LM. Environmental control to reduce transmission of clostridium difficile. Clin Infect Dis 2000; 31:995-1000.
9. Boyce JM, Havill NL, Otter JA, et al. Impact of hydrogen peroxide vapor room decontamination on clostridium difficile environmental contamination and transmission in a healthcare setting. Infect Control Hosp Epidem. 2008; 29:723-9.
10. Manian FA, Griesenauer S, Senkel D, et al. Isolation of acinetobacter baumannii complex and methicillin-resistant staphylococcus aureus from hospital rooms following terminal cleaning and disinfection: Can we do better? Infect Control Hosp Epidemiol 2011; 32:667-72.
11. Passaretti CL, Otter JA, Lipsett P, et al. Adherence to hydrogen peroxide vapor (hpv) decontamination reduces vre acquisition in high-risk units. 48 th  annual interscience conference on antimicrobial agents and chemotherapy (icaac) and the infectious diseases society of america (idsa). Washington dc, USA, 2008. Abstract k4124b.  2008.
12. Manian FA, Griesenauer S, Senkel D. Impact of an intensive terminal cleaning and disinfection (c/d) protocol involving selected hospital rooms on endemic nosocomial infection rates of common pathogens at a tertiary care medical center. Fifth Decennial meeting of SHEA. Abstract lb6.  2010.
13. Cooper T, O'Leary M, Yezli S, Otter JA. Impact of environmental decontamination using hydrogen peroxide vapour on the incidence of clostridium difficile infection in one hospital trust. J Hosp Infect 2011; 78:238-40.

-- Jon Otter, PhD, scientific director, Bioquell Healthcare

Methodist University Hospital Achieves 45 Percent Reduction in C. diff Cases by Integrating Advanced Environmental Ultraviolet Disinfection System Into Daily Cleaning Protocols

Methodist Le Bonheur Healthcare is a not-for-profit regional healthcare system based in Memphis, Tennessee, and includes 1709 total licensed beds across a regional, seven-hospital system.  Methodist University Hospital (MUH) is a 661-bed urban facility that serves as an academic campus for the University of Tennessee Health Science Center.

The issues
Infection preventionists at MUH carefully track all healthcare-associated infections. While Clostridium difficile has become a growing concern in urban center healthcare facilities nationwide, C. diff rates at Methodist University Hospital had remained stable and well below national averages until the first quarter of 2010 when MUH noted an increase in the occurrence of healthcare-associated CDAD. 

During the first six months of 2010, Methodist University Hospital logged 128 new cases of C. diff, an average of 21.3 new cases per month. C. diff infection rates were not only tracked and reported by number of infections, but also calculated by the number of new cases per 10,000 patient days to remove facility size and occupancy variables from reported results. The 128 new cases reported in the first six months of 2010 equated to an average C. diff infection rate of 21.3 cases per month, or 19.2 cases per 10,000 patient days. Management then compared the Methodist University Hospital C. diff rate to C. diff rates reported at sister regional hospitals within the Methodist-LeBonheur system.  Three smaller system facilities experienced C. diff infection rates of 3.01, 2.82, and 4.77 (per 10,000 patient days) during the same period.

A number of additional internal efforts and protocols had been implemented to control and reduce C. diff rates, including greater enforcement of handwashing, additional PPE, more restrictive patient isolation, additional EVS training, and implementation of more stringent terminal cleaning standards upon patient discharge, including greater use of bleach and chemical disinfectants.   Despite increased efforts, C. diff rates remained constant over these two quarters; from 20 new cases reported in January, to 21 new cases in June.

Specific costs related to each CDAD infection proved to be difficult to isolate and quantify.  HAI cost data published by Emory University(1) cited an average cost of $13,973 per incidence of infection. Using this data, the cost directly attributed to C.diff infection at Methodist University Hospital over the first two quarters of 2010 totaled more than $1.78 million or an average of $298,000 per month (21.3 infections x $13,973/infection).  Administrators clearly understood that any reduction in the number of new C.diff infections would result in a substantial bottom-line financial gain, but more importantly, a better and more desirable outcome for MUH patients. 

The project
While researching options regarding reduction of C.diff spores within the healthcare environment, hospital investigators noted a study performed at the Cleveland VAMC(2) that confirmed significant reduction of C. diff spores using a portable, automated ultraviolet germicidal disinfection instrument.

Bryan Simmons, MD, Methodists infectious disease specialist, and his infection control team researched the claims of several emerging disinfection technologies. MUH engaged the manufacturer of an automated ultraviolet germicidal disinfection instrument  to determine if the environmental contamination of isolation rooms caused by patient-shed C. diff spores, could be significantly reduced.

In July of 2010, Methodist staff integrated this advanced environmental ultraviolet disinfection system into its daily cleaning protocols. All C. diff patient discharge rooms were treated with the system before being occupied by a newly admitted patient. In the month following the intervention, reported C. diff. cases decreased by more than 45 percent and remained stable at the lower rate. By the end of November of 2010, MUH reported an average of 11.6 new C. diff infections per month, a 45.5 percent reduction. Infection rates per 10,000 patient days also dropped, averaging 10.8 per month, a 44 percent reduction.
Cost savings associated with the reduction in reported cases (from 21.3/month to 11.6/month), and directly attributed by management to the use of the portable Ultraviolet disinfection instrument, totaled $677,000 from July to November, or more than $135,000 per month.

 "Automated portable UV germicidal technology had an immediate, positive impact in our commitment to excellence, with improved patient outcomes and a reduction in hospital stays, says Chuck Lane, CFO. Based on those findings, additional units are being deployed into Methodist Le Bonheur Healthcare facilities.

1. Schwegman D. Prevention of Cross Transmission of Microorganisms Is Essential to Preventing Outbreaks of Hospital-Acquired Infections. Emory University.
2. Sitzlar B, et al. Decontamination with Ultraviolet Radiation to Prevent Recurrent Clostridium difficile Infection in 2 Roommates in a Long-Term Care Facility. Infect Control Hosp Epidem. Vol 33, No 5. May 2012. 

-- Suzanne McCarthy, RN, administrative director, Methodist University Hospital Perioperative Services 


Steam Vapor for Environmental Surface Disinfection

Hospital-acquired Infections are a major global problem. In the U.S. alone, among the approximately 35 million annual admissions to acute-care facilities, 1.7 million people get a secondary infection; some 100,000 are fatal. The odds of getting infections grows with the time a person spends in a hospital.

 Many pathogens associated with these infections survive well on surfaces, thus surfaces play a role in transmitting infections between persons. Therefore, cleaning and disinfection of surfaces is playing a more prominent part in prevention planning. Simultaneously, there has been a push to utilize more environmentally benign approaches to cleaning and disinfecting.

Therefore, my colleagues, Jonathan D. Sexton, MS; Benjamin D. Tanner, PhD; and Sheri L. Maxwell, BS, and I recently undertook a research project involving a novel steam vapor sanitation device to determine surface disinfection efficacy with the tap-water-only method in a major Arizona hospital.

The study was carried out in eight occupied rooms of a long-term care wing of a hospital. Six surfaces per room were swabbed before and after steam treatment and analyzed for heterotrophic plate count (HPC), total coliforms, methicillin-intermediate S. aureus and methicillin-resistant Staphylococcus aureus (MISA and MRSA), and Clostridium difficile

 The resulting research report published online on June 8, 2011 in the American Journal of Infection Control (AJIC) stated,  The steam vapor device consistently reduced total microbial and pathogen loads on hospital surfaces, to below detection in most instances and that the system provides a means to reduce levels of microorganisms on hospital surfaces without the drawbacks associated with chemicals.

 According to our data, treatment reduced the presence of total coliforms on surfaces from 83 percent (40/48) to 13 percent (6/48). Treatment reduced presumptive MISA (12/48) and MRSA (3/48) to below detection after cleaning, except for one post-treatment isolation of MISA (1/48). A single C. difficile colony was isolated from a door push panel before treatment, but no C. difficile was detected after treatment."

 In short, the steam vapor system reduced bacterial levels by >90 percent and reduced pathogen levels on most surfaces to below the detection limit. The steam vapor system provides a means to reduce levels of microorganisms on hospital surfaces without the drawbacks associated with chemicals, and may decrease the risk of cross-contamination.

 Moreover, the steam vapor system was effectively able to reduce bacterial counts by at least 1 log10 at all sites with the exception of the sink, where the reduction was 0.78 log10. We believe these reductions can be improved by increasing the contact time between the devices head and the surface and altering the head to provide better surface contact.

-- Charles P. Gerba, PhD, professor of environmental microbiology in the Departments of Microbiology and Immunology, and Soil, Water and Environmental Science, University of Arizona, Tucson

Finding the Right Disinfection System

Located in Phoenix, St. Josephs Hospital and Medical Center is a 673-bed hospital that provides a wide range of health, social and support services, with special advocacy for the poor and underserved. Maurice Croteau has been an environmental services (EVS) supervisor and infection control liaison at St. Josephs Hospital for the past six years.

As the EVS supervisor, Croteau was concerned that the efficacy of the hospitals disinfection system was being sacrificed in order to meet the time allotment for room cleaning. St. Josephs requires us to have the room disinfected for the next patient in under 55 minutes, says Croteau. The hospitals disinfecting system at the time, an open bucket filled with a quaternary amine disinfectant solution and cotton rags, required 10-plus minutes of dwell time. According to Croteau, This long dwell time was not attainable due to the quick turnover time, and rooms were not cleaned to the highest standard because surfaces were wiped dry before dwell time was reached. Therefore, Croteau decided to search for a different disinfection system which would solve for St. Josephs turn-time criteria and ensure efficacy for disinfecting patient rooms.

As part of his investigation, Croteau found that St. Josephs use of an open-bucket with a cotton rag was ineffective due to the quaternary amine disinfectant binding to the cotton rag fibers, rather than being released onto the intended surface. The reduced amount of disinfectant applied to the surface using this method raised concerns about optimal disinfection. Croteau was introduced to a closed-bucket disinfection system and found that this design, along with disposable wipers, ensured consistent disinfectant application. In addition, he began using sodium hypochlorite, given its EPA-approved kill claims for Clostridium difficile spores and norovirus. However, he knew that high concentrations of sodium hypochlorite had proven corrosive to stainless steel surfaces so he diluted the solution to a point where it still maintained its efficacy but minimized the potential for equipment damage.  However, to ensure efficacy against Clostridium difficile spores, Croteau increased the solubility in isolation areas where spores were identified.

After using the closed-bucket system with sodium hypochlorite for one year, St. Josephs ES team achieved significant results with no incidence of corrosion or equipment damage. The EVS department began meeting turnover time and disinfection standards, due in part to a 40 percent reduction in necessary dwell time. Croteaus innovative use of this disinfection system along with sodium hypochlorite reduced surface adenosine triphosphate (ATP) rates by 84.7 percent against his original baseline measurement taken when using the open bucket system. Croteau also believes the hospital has seen cost savings due to a reduction of healthcare-associated infections. 

-- Steven Hohol, Market Development Manager, Kimberly-Clark Professional