Clean and clear

Air- and water-borne diseases are on a sharp increase according to the Centers for Disease Control and Prevention (CDC). One in four patients who contract the serious respiratory illness called Legionaires’ disease during a hospital stay, for example, ends up dying. This is according to CDC’s latest Vital Signs report. But the report also states that most problems leading to U.S. healthcare-associated outbreaks of Legionnaires’ disease could be prevented with effective water management.

“Unfortunately for the patients, employees and guests of these facilities who are by nature the susceptible population — aged, immunosuppressed — exposure to these waters inoculated with Legionella can cause this ever more prevalent illness,” said John Baum, CWT, President, Craft Products Company, Inc.

Pathogens in the air are also of grave concern and a major reason why patients develop surgical site infections, one of the leading causes of longer hospital stays and preventable readmissions.

“Airborne pathogens are a well-documented source of surgical site infections, accounting for 20 percent of hospital-acquired infections (HAIs), including in the operating room,” said Kassandra Keller, Senior Vice President, Business Development, WellAir. “Influenza, norovirus, MRSA, C. diff, A. niger, and formaldehyde are just some of the viruses, bacteria, mold, and VOCs that healthcare facilities have to tackle. Given that pathogens are continually entering the air, it’s important to implement a solution that can be deployed on a 24/7 basis.”

Kim Miles, Director, Global Marketing Communications, STERIS Corporation, added, “The primary sources of bacteria transmitted to the surgical site through the air are squames, or skin scales. Approximately 1.15 × 10⁶ to 0.9 to 10⁸ squames are generated in a typical two to four hour surgical procedure, according to a study published by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). This can occur in spite of proven hygiene-related prevention practices, suggesting that airborne-related contamination control offers one area that could play a larger role in preventing SSIs.”

Airing on the side of caution

Where does your facility stand in the fight against these air and water invaders? Hopefully in the proactive category in which healthcare organizations make it a top priority to invest in products and practices that have been proven to keep patients safe from air- and water-borne pathogens, especially those who are most vulnerable to exposure. What follows are a few examples of how to stay protected from the potential dangers of contaminated air and water.

“Current requirements for airflow conditions in hospital operating rooms are regulated by ASHRAE Standard 170-2008; while this standard contains airflow requirements such as the number of exchanges and the temperature and humidity of the air, it does not address airborne contaminant levels,” Miles cautioned. “CLEANSUITE, conversely, exceeds the stringent requirements by delivering gapless, HEPA-filtered, laminar-flow, similar to the quality of air found in cleanroom environments.  Additionally, it is the only validated ISO Class 5 solution.”

Keller discussed other solutions as well, including a new product called the Defend 1050 which “uses ultra-low energy plasma technology and a multi-stage high performance filter system from Camfil to reduce infection, adsorb odors, neutralize volatile organic compounds (VOCs), and trap particulate as small as 0.12µm. Independent tests completed to date demonstrate <99 percent reductions in influenza, VOCs, mold, and staph bacteria. It also produced a Clean Air Delivery Rate of 513 CFM when testing against PM2.5. Additionally, we are excited to share details on the continued development of our Indoor Air Quality (IAQ) Portal. The WellAir sensors and monitoring software are offered with full building deployments as part of our overall ecosystem. Sensors are installed to track indoor air quality and clients can review the information captured using a web-based portal. Sensor readings are complemented by hyper-local historical, current, and forecast information across multiple, relevant sources. This rich data set includes overall outdoor air quality, weather, and pollen levels as well as real time insights into six different outside air pollutants such as ozone, PM10, and PM2.5 levels.”

Speaking of outside pollutants, the goal is to keep them out as much as possible. The Commercial High Performance 10 air curtain from Berner International have a variety of features to do this and more. Berner International’s Marketing Communications Manager, Miranda Berner, explains how the products are used in hospital entrances of the main lobby and emergency room to keep pollutants out and save energy in these busy, high-traffic areas.

“Hospitals use these on their main doors to keep the interior comfortable when the door opens, to save energy, and to keep vehicle, such as ambulance, fumes out of the waiting areas. Being able to maintain a comfortable environment free of vehicle exhaust when the door is open contributes to a positive impression,” Berner said. “Having multiple speeds allows these units to be adjusted based on outside conditions and supplemental electric heat gives hospitals the option to temper the air at the doorway. For flying insect control, the air stream is difficult for mosquitoes and other insects to fly through.

“For new construction or major renovation, being able to use an AMCA-certified air curtain instead of a vestibule, allows the hospital to decide if it wants to forgo the installation and operation costs of a vestibule,” Berner continued. “The best combination for maintaining interior temperatures while saving energy inside an entry that sees a lot of foot traffic is a combination of both a vestibule and an air curtain. Research shows that the next best option is a properly selected and installed air curtain. Berner air curtains are shipped fully assembled and designed to be simple to install which helps to keep installation costs low. The energy savings from a properly selected and installed air curtain typically pay for the air curtain within one to three years.”

The type of flooring that is placed inside a hospital can also impact IAQ and either help to curb or increase air- and water-borne pathogens, says Tim Cole, Vice President, Marketing, nora systems, Inc. “nora’s low-emission, low-pollutant premium rubber flooring contributes to healthier IAQ in several ways,” he said. “Its dense, homogenous surface helps repel dirt, so floors stay clean longer and can be easily maintained with regular dust mopping. The absence of finishes and chemicals (which is not always a guarantee with other rubber flooring products) benefits everyone in a healthcare setting — particularly those who are sensitive to smells or suffer from asthma or allergies. In addition, nora’s no-wax protocol never requires stripping or waxing, so patients do not need to be moved while floors are recoated. Made from mostly natural materials and containing no PVC, phthalates or other plasticizers, nora flooring contributes to a healthier indoor environment for both healthcare workers and their patients.”

Puneet Pandit, Glassbeam CEO and co-founder points to air humidity and temperature as potentially damaging to a facility’s medical equipment if not regulated and monitored properly, which can negatively impact patient safety, surgical efficiencies, and a hospital’s expenses.

“The equipment that supports the operation of medical equipment is made up of multiple computer systems, servers and other delicate communications assets. This support equipment needs to be treated in the same way that equipment in a server room is treated. If the support equipment is damaged, then the medical equipment would be inoperable, thus cancelling all patient care until the support equipment is restored.”

For example, if there is too much humidity, condensation could damage a system’s electronics. Too little and electrostatic discharge could develop causing damage to the systems’s ICs, Memory and CPUs. As for temperature, Pandit explained that if it’s too high a “lack of cool airflow could cause individual components to overheat, and power supplies and hard drives to shut down. Overall system performance may become erratic and unreliable. Extreme temperatures can contribute to premature aging of critical circuitry.” He added that low-temperature environments, unless extreme, usually have no bearing on medical equipment function. If the temperature does reach a critically low stage, and is later introduced to a warmer environment, there could be trouble. “Extreme temperature swings can contribute to premature aging of critical circuitry,” Pandit said.

“The Glassbeam Environmental Variable Monitoring product monitors the health of the medical equipment,” he continued. “It acts as the first line of defense to detect symptoms of specific physical, mechanical, electronic, or electrical issues that may impact equipment performance. Glassbeam’s advanced analytics enable the ability to detect these symptoms or failures before major escalations or catastrophic system shutdowns. In addition, monitoring the environmental variables of the support equipment can prolong the life of the medical equipment.”

Healthcare professionals breathe easier

Keeping healthcare professionals safe from certain drugs, chemicals and other irritants that pose health and safety risks is also a necessary step in a healthcare facilities’ safety plan. Whether it be using proper surgical smoke evacuation tools in the operating room, protecting pharmacists and nurses that handle dangerous chemotherapy agents, or avoiding chemical exposure in the sterile processing department, products and practices exist to keep everyone under the healthcare umbrella safe.

Monitoring technology works to protect healthcare workers and maintain compliance requirements for a variety of chemicals used across departments. The Assay Technology air samplers, for example, are used to detect formaldehyde and xylene in sample prep labs; ethylene oxide, glutaraldehyde, OPA, hydrogen peroxide, and acetic acid in sterile processing departments, as well as nitrous oxide and halogenated anesthetic gases on the OR.

“Our samplers have a list of over 200 vapors that may be collected using the samplers and then analyzed by our AIHA accredited laboratory,” said Beth Green, Marketing Manager, Assay Technology. “Personnel need to be monitored periodically, in order to determine any exposure levels to these regulated chemicals. This is particularly important for pregnant women working in areas with anesthetic gases. It can be a challenge to collect samples with traditional air sampling methods of pump and tube/cassette, as they are heavy and cumbersome.

“Assay Technology air samplers are lightweight, easy to use, and cost-effective,” she continued. “On average, the cost per badge, pre-paid for analysis is about $50 each. It is an inexpensive way to meet JCAHO requirements to monitor. These samplers are about the size of a quarter and simply opening the sampler cover starts the collection. Then, the sampler is closed when the sampling time is complete. We also have an app available to use on your smart device that logs the ID, test date and time, and sample for testing, and then generates the documents needed to submit with the samplers for testing. We sell samplers as a complete kit — use instructions, the sampler, and lab request form — with prepaid testing services, so there is only a one-invoice event.”

Ripple affect of water treatment

John Baum from Craft Products Company, which sells the Sanipur line, said because of the rise in Legionnaires (450 percent increase in cases since the turn of the century) facilities are seeking help to keep the bacteria out of their water system.

“The bacteria thrive in the water systems in facilities due to the functional temperatures of water in these systems (80 — 120o), and it can be very difficult to isolate and prevent,” Baum explained. “Of the increasing cases of Legionnaires disease, while many outbreaks (defined as 2 or more cases from the same source) are the result of cooling towers, 80 percent or so of overall cases are the result of domestic hot water exposure. This exposure can be prevented by utilization of secondary disinfection, which, if the most effective technology is properly applied, can provide nearly flawless results.

“Multiple independent third-party researchers world-wide have confirmed that applying site generated monochloramine to the domestic hot water system is the most effective method of remediating systems that are inoculated with Legionella bacteria. This is because the presence of higher levels of bacteria are found there, and in the fixtures served by that water, not in the cold water source or piping.”

Craft Products’ Sanikill is a patented monochloramine generation system that applies the technology while preventing any possible by-products as it consistently provides a targeted effective level of disinfectant. Baum explains further. “Treating ONLY the domestic hot water, and not the entire flow of water into the facility, the system where the bacteria multiply and create dangerous exposure is effectively rendered harmless while the rest of the water in the facility does not contain additional chemicals or potentially dangerous by-products. Every installed unit is monitored on-line 24 hours/7 days via the internet and has multiple alarm features so that operation is generally uninterrupted, providing extremely consistent results.” (Please contact Craft’s Products Company for scientific studies on the efficacy of Sanikill technology).

When it comes to tackling Legionella pneumophila, Dan Mueller, Director, aqua-tools, says facilities have even greater reason to act, reminding readers of the recent new standards, ASHRAE 188, released earlier this year. They affect anyone involved in design, construction, installation, commissioning, operation, maintenance and service of centralized building water systems and components. The standard includes a description of environmental conditions that promote the growth of Legionella and annexes and bibliography with suggestions, recommendations, and references to additional guidance.

“More recent data is pointing to other waterborne pathogens as Pseudomonas Aeruginosa and Acinetobacter baumannii as sources of infections in hospitals,” Mueller added. “Point-of-Use water filters have been proven to be an effective strategy as a physical barrier to water borne pathogens and prevent infections. However, the cost and frequent changing out of the point-of- use filters can be an obstacle.

“The U.S. is behind other areas of the world, such as Europe, in recognizing water as a source of infections and implementing guidelines such as point-of-use filters on shower heads and faucets of immune compromised areas such as the NICU, Transplant, Burn, ICU,” Mueller continued. “However, with new recent standards ASHRAE and CMS implementing measures, hospitals are forced to ensure they prevent exposure of these pathogens and related infections.”

The FILT’RAY 2G point-of-use filters by aqua-tools utilizes a technology called Bubl’air Wash, a patented membrane cleaning mechanism which allows for longer lasting filters (up to 4 months, compared to 1 or 2 months for other filters) so facilities can reduce risk with less expense and time. A poster presented recently at the NSF Legionella conference focused on the longer lasting, cost-effective benefits of the aqua-tools technology. (Please contact aqua-tools for scientific references.)

Hospital sink drains are another notorious harbinger of many waterborne pathogens, including Pseudomonas Maltophilia, Carbapenem-Resistant Enterobacteriaceae, Klebsiella, Pseudomonas Aeruginosa, Candida, Acinetobacter, Burkholderia Cepacia and E. Coli, says Samantha Simmons, MBA, Director of Innovation, Boehringer Laboratories, LLC. And once these pathogens become aerosolized, trouble lurks. “This happens when the faucet is turned on and the water hits the biofilm residing in the sink drains,” said Simmons. “These microscopic biofilm particles are then released into the air, spreading the pathogens contained in the biofilm throughout the patient room. For immunocompromised patients, such as the patients in the intensive care units and burn units, this is a major concern. Any unit in which immunocompromised patients can expect a long length of stay are particularly susceptible to waterborne gram negative infections.”

Facilities now have access to an effect and inexpensive innovation from Boehringer called the BioDome, a plastic, disposable sink drain cover that prevents water backsplash and aerosolization of pathogens without disrupting water flow. The solution was recently presented in a poster presentation by Dr. Curtis Donskey, an infectious disease specialist, at the Society for Healthcare Epidemiology of America (SHEA) in April 2018.

“Before BioDome, the only effective solution to mitigate drain-borne pathogens was to remove sinks from patient care areas, which is costly and difficult to implement,” said Simmons. “Pouring disinfectants down sink drains was thought to be an additional option, however this resulted in only transient suppression of bacterial colonization as published by SHEA. As a result, the BioDome sink drain cover is the only available and effective solution in preventing dispersal of gram-negative bacilli from contaminated sink drains.”

It’s also affordable, costing less than $1.00 a day. “The Environmental Services staff simply places BioDome in the sink, securing it in place with its suction fittings,” said Simmons. “After five days or upon patient discharge, Biodome is then removed, disposed and replaced.”