The Robot Does Not Replace EVS: Why UV-C Must Remain an Adjunct to Cleaning

Series Introduction

As UV-C and other whole-room microbial reduction technologies become increasingly visible in health care, infection prevention, and environmental services, leaders face questions that extend well beyond whether the technology can kill microorganisms.

In this 3-part series based on a panel discussion at the Exchange26: AHE Education & Solutions Summit in New Orleans, Infection Control Today^® examines the issues health care organizations should consider before and after investing in UV-C, including FDA authorization and manufacturer claims, why the technology must supplement rather than replace manual cleaning, and how facilities can determine whether a device addresses a genuine infection prevention need.

Together, the articles offer a practical framework for moving beyond the appeal of new technology and asking a more important question: Does the evidence, implementation strategy, and intended use support safer patient care?

Find the first installment of the series here.

One of the most important messages from a recent expert panel at the Exchange26: AHE Education & Solutions Summit in New Orleans on UV technology and whole-room microbial reduction devices had very little to do with UV itself: The room still must be cleaned.

As hospitals increasingly explore UV-C and other whole-room microbial-reduction technologies, infection prevention and environmental services leaders risk allowing advanced technology to create a false sense of security. UV devices may provide an additional layer of microbial reduction, but panelists repeatedly stressed that they do not eliminate the need for thorough manual environmental cleaning and disinfection.

The speakers included:

• Sadé L. Rolon, MBA, CMIP, CHESP, T-CHEST, T-CSCT, the regional director of operations for Sodexo’s Healthcare Division,
• Julie Mangino, MD, infectious disease specialist at The Ohio State University Medical Center, Columbus, OH,
• James “JJ” Odom, MBA, CHESP, CMIP, T-CHEST, the university director of buildings & grounds at UConn Health, Farmington, Connecticut,
• Christopher Dugard, MS, director for the Division of Infection Control Devices in the Office of Surgical and Infection Control Devices, FDA/Center for Devices and Radiological Health,
• and Elizabeth “Liz” Claverie, MS, (retired CAPT, 0-6) vice president, regulatory strategic liaison for Steris.

In fact, the FDA's whole-room microbial reduction device classification specifically describes these technologies as being used to reduce microbial loads on medical device surfaces following cleaning and disinfection. Claverie explained that limitations, including shadowing and distance effects, mean that the UV technologies currently under review should not be viewed as providing standalone disinfection.

For environmental services (EVS) professionals, that distinction is critical.

Rolon described visiting an organization that had already incorporated UV devices into its environmental hygiene program. The technology was highly visible and had even become part of the hospital's marketing. When the devices stopped functioning and the organization could not afford repairs, however, infection rates did not change.

“One was authorized; the rest were not. And the one device, it had to be about 15 years old, no service contract, the bulbs were black,” Rolon said. “So, I question the safety and what's actually happening with this device, and I was kind of asking the clarifying question, what's the strategic intent here? What are we trying to solve? We have all these different devices. I don't have anyone looking at the devices from a collaborative perspective about what our HAIs are. Are we looking at the data? Are we looking at where the devices are being used? We're only using them for contact-enteric rooms or C difficile rooms, and only in the burn unit. But the bulbs are burnt. They're not effective.”

That experience raised a fundamental question: What problem had the devices been purchased to solve?

Odom highlighted another potential unintended consequence of technology adoption: EVS staff may come to believe the device will compensate for deficiencies in their own cleaning.

“My concern with these devices is…they feel that they don't have to clean to be as diligent because the robot's going to do the work for them,” Odom said.

That is precisely the mindset infection prevention programs need to prevent.

Manual cleaning physically removes soil and bioburden from environmental surfaces. As another Dugard emphasized, FDA evaluation of whole-room devices considers their performance after the room has been cleaned, including factors such as shadowing, material degradation, and microbial effectiveness.

The science of UV-C also helps explain why manual cleaning remains indispensable.

During the panel, Mangino presented clinical evidence demonstrating how factors such as distance, positioning, exposure time, organism type, and shadows influence the UV dose reaching a surface. As the distance between the UV emitter and the target increases, the amount of energy reaching the target decreases. Objects blocking direct exposure can further reduce effectiveness.

“The number of publications in the evidence-based literature is so confusing,” Claverie said. “I have 10 years of education after college, and I struggle with the verbiage, the distance, how they set the device up, what they smeared on the steel carriers, and how much they put on the steel carriers to have a log reduction. So, a simple fact: if you put 1,000 colony-forming units on a slide and want to achieve a 2-log reduction, that means it has to go from 1,000 down to 100, then to 10. Explaining that whole system of log reduction, which in and of itself is confusing. So, I think the literature is confusing.”

That means simply rolling a UV device into a patient room and starting a cycle does not guarantee that every surface receives an equivalent antimicrobial effect.

Deployment itself also matters.

Some systems require EVS personnel to reposition emitters during treatment. Others may require multiple cycles or strategic placement to reach bathrooms and other spaces. In one study, Mangino explained, Curtis Donskey’s group at Case Western evaluated several UV-C devices in a CT suite by placing pathogen carriers at the head, body, and foot of the CT table and measuring reductions in MRSA, VRE, and C difficile after 4-minute cycles. Standard devices produced less than a 1-log reduction in C difficile at the headrest, suggesting that a short cycle was insufficient. In comparison, nonstandard systems, including rotating vertical and horizontal emitters, a mobile robot, and a 3-emitter system, achieved substantially greater C difficile reduction. The study highlights an important consideration for EVS teams: device design, positioning, and cycle time can significantly influence UV-C effectiveness, so not all systems should be expected to perform equally.

Mangino explained that David Pegues’ study at the University of Pennsylvania examined the use of UV-C specifically in contact isolation rooms occupied by patients with C difficile. The study included both baseline and intervention periods and clearly documented its methods, which the presenter emphasized as particularly valuable: “That’s the whole point of evidence-based research: look at the methods and can you repeat it.”

During the intervention, a single-emitter UV-C device was deployed for 2- to 8-minute cycles on either side of the patient bed. One notable limitation was that the device was too large to fit in the bathroom, an important consideration given the risk of fecal contamination with C difficile. Despite plans for broader use, UV-C was actually deployed during only 21% of the intended opportunities over the 52-week intervention.

Even with relatively limited deployment, the additional burden on EVS workers was described as a “very insignificant increase in time.” The team also made adjustments to maximize the use of the available emitters. Most importantly, the presenter noted that the results showed a visible decline in infections, demonstrating how UV-C could be incorporated as a targeted adjunct to an existing C difficile prevention strategy rather than replacing environmental cleaning.

The message for infection preventionists and EVS professionals is not that UV-C lacks value. Research presented by Mangino during the discussion demonstrated meaningful microbial reductions and potential benefits when the technology was carefully deployed as part of a broader infection prevention strategy.

The distinction is between supplement and substitute.

Technology should enhance a strong environmental hygiene program rather than compensate for a weak one. Before introducing UV-C, facilities should ensure that EVS teams have adequate staffing, training, monitoring, products, processes, and time to perform effective manual cleaning.

As Rolon summarized, mechanical cleaning and removing bioburden from surfaces “always has to be done.” “I think that just really puts a focus on our value as [EVS] professionals. These devices were not meant to take away from what our teams do every single day, which is, you know, they're doing mechanical cleaning and removing the bioburden from surfaces. That always has to be done. That's step one of any infection program. But obviously, there's an opportunity to use devices in conjunction with what we already have in our practice, our everyday standard operating procedures.”

For infection prevention programs evaluating the next generation of environmental technologies, that may be the most important takeaway of all: The robot comes after the clean, not instead of it.