Show me the evidence!

Investing in room-decontamination systems requires all due diligence

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Only a few years ago, no one ever heard of automated room disinfection. In a short time, room-disinfection systems have proved to be so efficient in thwarting hospital-acquired infection (HAI) that now the problem is not to figure out whether you need it but how to choose the right system for your medical facility.

The antimicrobial connection

Room disinfection plays an important role in antimicrobial resistance, too. Obviously, the less infection present, the less need for use of antibiotics. The less antibiotics used, the fewer opportunities for antimicrobial resistance to emerge.

Maryalice StClair, Vice President, Business Development, Halosil International, Inc., noted, “The vast majority of HAIs are related to antibacterial-resistant pathogens, and most deaths related to antibiotic resistance happen in healthcare settings. While the rise in bacterial resistance is largely driven by overuse of antibiotics, disinfection also plays a role. Methods that have subpar efficacy risk the formation of resistant bacteria.”

As Adam Buchaklian, PhD, Director of Clinical Research, Surfacide, explained, room disinfection “reduces the environmental bioburden, thereby minimizing the chances of antibiotic-resistant microorganisms emerging. Current multidrug-resistant organism contaminants are also eliminated before they have the chance to infect a patient.”

What to look for when choosing a system

One of the functions of room-disinfection systems is to kill pathogens residing in tiny nooks and crannies where mops and cleaning rags cannot reach. Just a few more concerns to address when purchasing a room-disinfection system are overcoming shadowing, delivering the right dose to room size, easy integration into existing workflow, time to achieve disinfection, and more.

The place to find these answers, as pointed out by Sarah Simmons, DrPH CIC, FAPIC, Science Director, Xenex Disinfection Services, is in published, peer-reviewed scientific literature. Simmons offered this advice: “The gold standard for assessing new technologies is evaluating the peer-reviewed literature. Best practice guidelines are based on peer-reviewed evidence, not anecdotes. Hospitals should ask ultraviolet (UV) vendors for peer-reviewed published studies demonstrating infection-rate reductions when that UV device was used for room disinfection.”

Simmons explained that the purpose of the peer-review process is to allow for outside experienced researchers to evaluate and verify the accuracy of data. The results in the published literature should be reproducible under the same conditions. Armed with that knowledge, hospitals can be confident that the information in the article is meaningful and helpful for decision making.

“Making decisions about new technologies to prevent HAIs can be challenging, especially given the barrage of conflicting information that may cross your desk,” acknowledged Simmons. “Hospital decision-makers need to ask tough questions when it comes to evaluating room-disinfection technologies. Ask the vendor to show you peer-reviewed studies from hospitals that saw reductions in infection rates. If they don’t have peer-reviewed and published infection-rate–reduction studies, then the technology has not met the standard for evidence-based decision-making.”

Xenex LightStrike pulsed xenon UV robot

Simmons described attributes of their peer-reviewed product which operates on pulsed xenon ultraviolet light, and explained how it differs from competitors. “Xenex’s LightStrike Germ-Zapping Robots are faster than older technologies and destroy pathogens in a scientifically different way. Hospital cleaning teams like Xenex robots because they don’t require warm-up or cool-down time, don’t damage other equipment, and can be used quickly and easily throughout healthcare facilities.”

Simmons cited an example of one of their peer-reviewed studies that demonstrated infection reduction as well as cost savings. Lowell General Hospital saw a 46 percent reduction in class-I surgical-site infections, resulting in $478,055 savings.1 Other studies are available upon request.

Total efficacy

Kathy Kane, Vice President, Sales and Marketing, Altapure, weighed in on important features to look for in room disinfection. “The number one most important thing customers should look for is efficacy. Whole-room disinfection systems should meet adopted EPA standards for hospital and healthcare markets to achieve high-level disinfection. They should disinfect the entire room, including under beds, behind rails, under toilet seats, in open drawers, etc.”

Kane pointed out that Altapure’s AP-4 is easy to use and is controlled remotely, so the environmental-services staff can do other work while it’s running. “It’s extremely fast, with about a 45-minute patient-room turn-around time,” noted Kane.

Altapure’s AP-4 high-level, whole-room disinfection system

“Patient care is greatly improved, because Altapure’s AP-4 eliminates Clostridium difficile (C. diff), as well as other problematic bioburden, in the entire room,” continued Kane. “One system typically handles the discharge load percentage of 150 staffed beds requiring terminal clean procedures. Besides being more effective, it is also cheaper than UV light, which often requires multiple units per room. The AP-4 is safer than any hydrogen-peroxide device, as it utilizes 98.58 percent distilled water, 0.18 percent peroxyacetic acid, and only 0.88 percent hydrogen peroxide. The system is operated remotely from outside the room to enhance safety.”

Kane referred to a published scientific study supporting efficacy of the AP-4. Mana et al found that the AP-4 achieved 100 percent pathogen kill and remained in compliance with the new air-quality standard.2

Tru-D’s Cathy Campbell, Director of Program Management, advised purchasers considering room disinfection products to understand that “A distinction should be made between partial or spot disinfection using chemicals versus total room disinfection and UVC. Tru-D’s Sensor360 technology compensates for room variables—such as size, shape, and amount of equipment in the room—to deliver the precise dose of UVC energy needed to disinfect all surfaces in an entire room from one position.”

“Adding Tru-D to existing cleaning protocols provides an added layer of protection against harmful pathogens for both patients and staff,” averred Campbell. “Tru-D lowers the risk of patients developing unnecessary and preventable infections transmitted by the environment such as C. diff, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), norovirus, and more.”

Tru-D uses chemical-free UVC energy to provide total room disinfection.

Campbell explained how Tru-D’s Sensor360 technology kills pathogens. “Some organisms may build a resistance to chemical solutions, but they cannot fight the wavelength of energy that disrupts the DNA/RNA at 254 microwatts/cm2, the peak of cell deactivation. Unseen pathogens left on the surfaces within a patient room continue to survive and multiply. Tru-D’s tested and proven capabilities to measure reflective dose within the entire room ensure that organisms cannot continue to replicate.”

Noting that the direct medical cost of HAIs to healthcare facilities exceeds $30 billion annually, Campbell added, “Reducing the incidences of HAIs by eradicating the pathogens that lie hidden in healthcare environments is Tru-D’s guarantee of an immediate cost avoidance.”

Campbell also referred to published scientific evidence to support Tru-D’s claims. “Tru-D was the only device chosen for the first and only randomized clinical trial on UVC disinfection. Funded by the Centers for Disease Control and Prevention, and conducted across nine hospitals in the Duke Infection Control Outreach Network, the Benefits of Enhanced Terminal Room Disinfection (BETR-D) study,3 proved that adding Tru-D to standard cleaning protocols reduced the risk of acquisition and infection among patients admitted to the same room by a cumulative 30 percent. Tru-D’s efficacy has also been validated by more than a dozen other independent, third-party studies.”

Triple threat

Buchaklian explained how their UVC technology differs from others’. “Surfacide has developed the next-generation triple-emitter UVC disinfection system that overcomes the limitations of single-emitter systems. UV disinfection is a direct-line-of-site modality. Triple emitters substantially minimize shadows and reduce the distances to surfaces. These factors provide an easy-to-use, fully automated system that integrates easily into standard workflow, with much shorter total disinfection times than those achieved by single-emitter UV or hydrogen-peroxide vapor.

“The Surfacide Helios UV-C disinfection system delivers validated whole-room disinfection in a single cycle, ensuring greater total energy delivery in less time, with less labor,” added Buchaklian. “Single-emitter UV systems require multiple positions, whereas Surfacide’s whole-room, single disinfection cycle leads to shorter times, providing the opportunity to disinfect more rooms.” Disinfecting more rooms in less time translates to money. Buchaklian said that some facilities using Surfacide have documented $1 million in savings in the first year of use.

Surfacide Helios multiple-emitter UV-C disinfection system

Buchaklian also highlighted published scientific studies to support their claims of efficacy. Data from Faxton St. Luke’s hospital in Utica, NY, demonstrated the ability of the Surfacide system to contribute to a 41 percent reduction in hospital-acquired C. diff infections.4 He also mentioned that the Jersey Shore University Medical Center attributed reductions in rates of catheter-associated urinary tract infection and central-line associated bloodstream infection to Surfacide.5

Definitive dosage

According to Steven Baiocchi, COO, Steriliz ’s RD Rapid Disinfector is the only system able to measure the UVC dose achieved at the targeted areas of interest, a feat accomplished by patented wireless sensors. “There will be fluctuations in time necessary to achieve this delivered dose, based on the dynamics of the room, i.e., size, shape, color, shadows, etc. The UV sensors take the guesswork out of determining where the UV light goes or, just as importantly, where it does not go.”

Baiocchi stressed the importance of doing your homework before purchasing a room-disinfection system. He also outlined features to look for in a system. “In a day of evidence-based medicine, value-based purchasing, and the drive toward delivering high-reliability health care, technology choices should be carefully researched. Critical features should include the dose, the need for dose-based performance to achieve virus, bacteria, and spore eradication; time, the need for efficient and rapid room turnover, to ensure throughput is not adversely affected; measurement, the ability to measure that the dose set on the device is actually delivered to the targeted areas.

RD Rapid Disinfector from Steriliz

“Remote UV sensors allow for real-time job status via browser-enabled devices, utilization-data availability, and pause-and-reposition functionality, for faster throughput and assured dose delivery.” Baiocchi believes that these features make the RD less expensive to purchase, less expensive to operate, faster, and more effective.

Baiocchi pointed to published studies to support his claims. “The RD Rapid Disinfector is clinically proven to be the fastest and most effective UVC disinfection system available. The R-D method of UVC measurement produces higher inactivation efficacy while being much faster.6 A four-year case study at a 528-bed hospital in New York yielded a 56 percent C. diff reduction and greater than $8 million in cost avoidance.7

Other Options

John Neister, President, Far-UV Sterilray, talked about qualities that separate their UV room-disinfection system from their competitors’. “Patented Far-UV Sterilray Technology is based on a different part of the UV spectrum than traditional UVC. Far-UV Sterilray destroys pathogens; UVC just alters their DNA so they don’t replicate.” This product contains no mercury, as do some UVC room-disinfection systems.

“Unlike traditional UVC devices, Far-UV Sterilray can be used while the patient(s) is present. The quick application time improves disinfection productivity, and patient care and comfort, by bringing effective disinfection to patient rooms without having to move the patient.” Neister pointed out this feature is a plus for situations where a contagious patient is occupying the room or has occupied a room. “Far-UV Sterilray devices can be integrated easily into the room-cleaning and -disinfection protocols,” said Neister.

Far-UV Sterilray’s Pathogen Reduction Box

Comparing the Far-UV Sterilray with UVC, Neister stated, “The Far-UV Sterilray wavelength destroys pathogen cells and capsids in just a few seconds, a 99.99 percent reduction achieved in a single pass (in 1/5 of a second), in a duct system, with full-power Far-UV Sterilray lamps; UVC achieved less than 1 percent. This superior killing power reduces time of treatment and increases effectiveness,” stated Neister. “Far-UV Sterilray devices kill all pathogens. Independent laboratory and customer tests indicate a complete kill of antibiotic-resistant pathogens, e.g., MRSA, C. diff, and VRE. Pathogens cannot mutate to form resistance.”

“Far-UV Sterilray lamps were supplied to Boeing for their lavatory mockup and lamp-performance testing,” said Neister.

StClair, Halosil, offered this advice: “Buyers should consider evaluating whole-room disinfection systems using Halosil’s five-star, 6-log approach: efficacy, safety, usability, affordability, and versatility.” This approach allows Halosil’s Halo Disinfection System (HDS) to stand up against the worst of pathogens. “Infection prevention and environmental services professionals agree that C. Diff remains the most concerning HAI in hospitals today,” noted StClair. “The HDS provides true whole-room surface disinfection. Pairing the dual killing mechanism of HaloMist disinfectant (5 percent hydrogen peroxide and 0.01 percent ionic silver) with the turbulent aerosol-generating HaloFogger, the HDS delivers an EPA-validated kill of 99.9999 percent of C. Diff spores in a whole room. Only vapor and fogging systems validated by the EPA or FDA can legally make this claim.”

StClair said the HaloFogger FLX model facilitates faster sequential fogging of rooms, includes accessories for safe and quick room preparation, and is cost-effective to employ. “Only one run cycle per treated space is required—the average patient room requires a 10- to 15-minute fog—and no repositioning is necessary. Aeration time can be decreased with the use of a standard dehumidifier.”

StClair said that many publications cite the high cost of UV and vaporized or ionized hydrogen-peroxide systems, but the Halo System retails for approximately one-tenth of the cost of other technologies.

StClair recounted the experiences of two facilities that have used the HDS with success. “Riverside University Medical Center, a 439-bed hospital located in the City of Moreno Valley, CA, reduced the number of patients who contracted hospital-acquired C. Diff infection by 60 percent after implementing the HDS. Pennsylvania Hospital reduced their C. Diff infection rates by 66 percent subsequent to implementation of the HDS.”

The Halo Disinfection System, from Halosil

Class 1 Inc, offers the Asept.2x room-disinfection system. Two towers are recommended “for extra disinfection power within a patient room. We can disinfect a patient room, log-6, in five minutes for C. Diff,” according to Keith McGlone, Director, IPS, Business Development. “Pathogens cannot become resistant to UVC, as they no longer can reproduce.”

Class 1 Inc, also provides something a little different. They offer room-disinfection systems for bathroom, utility, and equipment rooms that stay in place permanently, providing continuous disinfection. “This provides results without the labor cost of moving any equipment from location to location,” said McGlone. “Our Asept.1x, is the world’s first wall-mounted, fully automatic disinfection system designed for bathroom, utility, and equipment rooms. The area will be disinfected automatically with UVC after each room visit or use”

McGlone explained how it works. “Once installed, the system uses multiple safety sensors to ensure the room has been used and is currently not occupied. After every visit, a five-minute cycle of UVC is completed. In bathrooms, aerosolized material and surfaces are disinfected with the cycle, initiated 30 seconds after the patient leaves the room. As the system is automatic, the space will be disinfected a minimum of 6 times a day and after every visit.”

Asept.1x, from Class 1 Inc., is a wall-mounted UVC disinfection system designed for bathroom, utility, and equipment rooms.

McGlone cited a study on Asept.1x by Cooper et al8 in an older hospital, Lion’s Gate Hospital in North Vancouver, where multiple patients share a bathroom. The study concluded: “Toilet flushing can contribute to disease transmission by generating aerosolized bacteria and viruses that can land on nearby surfaces or follow air currents. Aerobic and anaerobic bacterial bioaerosol loads, and bacterial counts on two surfaces in a bathroom with a permanently installed, automated UVC irradiation device, were significantly lower than in a comparable bathroom without the UVC device. Permanently installed UVC lights may be a useful supplementary decontamination tool in shared patient bathrooms.” McGlone said that more than 20 units are in use within Vancouver Coastal and Island Health areas.

References

1. Catalanotti A, Abbe D, Simmons S, et al. Influence of pulsed-xenon ultraviolet light-based environmental disinfection on surgical site infections. Am J Infect Control. 2016 Jun 1;44(6):e99-e101.

2. Mana TS, Sitzlar B, Cadnum JL, et al. Evaluation of an automated room decontamination device using aerosolized peracetic acid. Am J Infect Control. 2017 Mar 1;45(3):327-329.

3. Anderson DJ, Chen LF, Weber DJ, et al. Enhanced terminal room disinfection and acquisition and infection caused by
multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study: a cluster-randomised, multicentre, crossover study. Lancet. 2017 Feb 25;389(10071):805-814.

4. Bernard H, Little J. The impact of ultraviolet (UV) disinfection system coupled with evidence-based interventions on the incidence of hospital onset Clostridium difficile (HO-C. diff). Association for Professionals in Infection Control and Epidemiology, Inc, Annual Conference; June 2015; Nashville, TN. Abstract #2-122.

5. Hanrahan S, Haraschak C, Buckalew G. Impact of UV light disinfection on CLABSI and CAUTI rates in a major medical teaching hospital’s MICU. Presented at IDWeek; October 2016; New Orleans, LA. Abstract# 264.

6. Wong T, Woznow T, Petrie M, et al. Postdischarge decontamination of MRSA, VRE, and Clostridium diffcile isolation rooms using 2 commercially available automated ultraviolet-C–emitting devices. Am J Infect Control. 2016 Apr 1;44(4):416-20.

7. Spencer M, Vignari M, Bryce E, et al. A model for choosing an automated ultraviolet-C disinfection system and building a case for the C-suite: Two case reports. Am J Infect Control. 2017 Mar 1;45(3):288-292.

8. Cooper J, Bryce E, Astrakianakis G, et al. Efficacy of an automated ultraviolet C device in a shared hospital bathroom. Am J Infect Control. 2016 Dec 1;44(12):1692-1694

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