While the Centers for Disease Control and Prevention (CDC) reports that significant progress has been made in preventing some types of healthcare-associated infections (HAIs), the agency points out that approximately one in 25 hospital patients has at least one HAI on any given day. According to the CDC, about 75,000 patients with HAIs died during their hospitalizations in 2011, and more than half of all HAIs occurred outside of the intensive care unit.1
Studies have shown that hospital surfaces are often contaminated with microbes known to cause HAIs, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), Clostridium difficile, Acinetobacter spp. and norovirus. Researchers have found that admission to a room contaminated with a pathogen increases a patient’s likelihood of acquiring it and suggest improved room cleaning and disinfection could reduce the risk of HAIs.2, 3
As more healthcare organizations deploy mobile processing units to kill surface microorganisms and pathogens, HPN explores how to choose, use and better understand today’s no-touch disinfection systems.
HPN: What challenges do healthcare facilities face when it comes to room decontamination?
Edmund Pearlstein, Vice President of Sales, Altapure: The greatest challenge the medical industry faces is the acceptance of the fact that medical science has reached the end of the antibiotic era, and the corresponding rapid increase in the number of multidrug- resistant pathogens. Since about 1945, doctors have had effective weapons to cure patients who contracted nosocomial infections. This is no longer the case. The recent failure of Colistin has completed the list of antibiotics that are no longer totally effective. This, coupled with the fact that big pharma is unwilling to make multi-billion dollar investments when the effective life of a new drug is limited.
Recognizing that the hospital environment is a reservoir of pathogens, hospitals need to acknowledge that they have a responsibility to provide an environment to its patients and staff that is reasonably safe and free of pathogens. The medical industry, as a whole, must establish a standard of cleanliness that has the greatest probability of eliminating, and not just reducing, dangerous pathogens from their environment.
Steven Baiocchi, COO, Steriliz (in collaboration with Getinge Group): The primary challenges health care facilities face when it comes to room decontamination include complex and dynamic environments where manual cleaning is difficult, pervasive cross-contamination in healthcare facilities, the need for adequate staffing levels and the ability to monitor and measure room decontamination procedures and efficacy.
Adam Buchaklian, PhD, Director of Clinical Research, Surfacide Manufacturing: Healthcare facilities have a nearly impossible task. They harbor some of the most problematic drug resistant pathogens that can remain viable and infective on surfaces for days and even months. In addition, they are required to clean and disinfect increasingly more complex rooms, including equipment, in a limited amount of time.
Chuck Dunn, CEO and President, Tru-D: Admittance to a room previously occupied by a patient colonized or infected with a multidrug-resistant pathogen results in the newly admitted patient having an increased risk in acquiring that pathogen by 39 to 353 percent. Further, studies show that pathogens can live anywhere—underneath surfaces, in shadowed areas and on medical equipment—for days, weeks and months. This is why it is imperative that every surface be decontaminated and not just high-tough or line-of-sight areas. This is why no-touch, total room disinfection technology is critical in reducing HAI rates.
Morris Miller, CEO, Xenex: Hospitals are busy and rooms need to be turned over quickly to accommodate patients who need care. It’s a physically impossible challenge for the EVS team to get a room disinfected in the time available using traditional cleaning methods. Another challenge is understanding the technologies available for room decontamination.
Josh Robertson, President, E-Mist Innovations: Dangerous pathogens are transferred from room to room when doctors and nurses fail to follow protocols. Recontamination occurs when they touch a keyboard, bedrail, or other high-touch surface in one room and move to another patient’s room and repeat the process. Thorough cleaning and disinfection is essential to curb the spread of deadly pathogens. Unfortunately, cleanliness is not a priority for hospital executives and administrators.
Maryalice St Clair, VP of Business Development at Halosil International: The overall challenge for healthcare facilities has become this: Do we choose the most efficacious systems that are the easiest to use and the most affordable, but find a way to deal with the issue of room turn-around time? Or do we choose less efficacious methods with very high capital and maintenance costs, but gain a bit in the drive for room turn-around time? Or do we simply stick with the old processes — ‘spray & wipe’ — that’s been used since the U.S. Civil War and allow C. diff, MRSA and other infections to plague our patients and our staff at historical rates? We suspect that the imposition by CMS and other insurers of fines and revenue penalties for HAIs will change the calculation in the coming years.
Kathryn C. Worrilow, PhD, Founder and CEO, LifeAire Systems: Unfortunately, many current operating procedures designed to maintain room sterility, such as hand washing and surface disinfection protocols are susceptible to human error. Factors from the type of disinfectant used to the protocol used to clean can affect the level of contaminants in a room. Although many automated in-room decontamination systems compensate for human errors, these systems are effective only to the point that they are operational. Not only does the room often need to be taken offline for the in-room disinfection to occur, the potential for recontamination returns immediately after the system leaves the space. Decontamination efforts have primarily focused on surface sterilization with air quality being addressed with HEPA filters. Many pathogens responsible for HAIs are not adequately remediated by HEPA filtration.
What steps can healthcare facilities take to improve room decontamination practices?
Pearlstein: Room decontamination can be greatly enhanced by selecting a technology that offers the greatest probability of eliminating pathogenic bioburden and not just accepting a mere reduction. The peer-reviewed literature does not report a level of bioburden that is safe for patients and staff. With the end of the antibiotic era, greater emphasis has to be placed on eliminating the risk of nosocomial infections. The adoption of a ZERO tolerance standard for bioburden should encourage hospital administrators to establish policies that will improve patient safety, reduce the risk of having Medicare reimbursements being reduced, while limiting the legal exposure to litigation resulting from hospital acquired infections.
Baiocchi: The first step would be to set up cross functional teams that meet frequently to discuss an implementation plan that consists of best practices with goals and objectives that focus on measuring and improving decontamination practices. Necessary protocols such as frequent and proactive decontamination must be established to address cross contamination to continually reduce the total pool of pathogens present in the environment. Communication and alignment between departments leads to better results.
Buchaklian: Thorough room cleaning and disinfection takes a multifaceted approach. First, hospital staff and management must be dedicated to providing a clean and safe environment for patients and staff alike. Oftentimes this means providing EVS staff with the supervision, training, tools and time they need to disinfect every surface.
Dunn: Hospitals should develop robust, strategic manual cleaning and disinfection protocols that include mandatory hand-washing compliance. After manual terminal cleaning, a validated, no-touch, total room disinfection method must be used, particularly after discharge of patients on contact precautions. Tru-D’s validation is the CDC-funded Benefits of Enhanced Terminal Room Disinfection (BETR-D) randomized clinical trial. The BETR-D study concluded improved terminal disinfection with this no-touch method resulted in decreased rates of infection in patients subsequently admitted to a room in which the prior occupant was infected or colonized. Additionally, this method resulted in a decreased rate of facility-wide colonization and/or infection.
Miller: Hospitals that use pulsed xenon UV have the opportunity to reduce infections by destroying the pathogens that cause them — which can save or change patient lives. Hospitals engaged in HAI reduction programs using Xenex’s LightStrike Germ-Zapping Robot have analyzed their HAI data and proven that the more they run the robot, the better a reduction in infection rates can be achieved.
Robertson: We agree with Dr. William Rutala’s surface disinfection recommendations: 1) Review of the CDC Guideline for Disinfection and Sterilization, 2) Review of best practices for environmental cleaning and disinfection, 3) Review of disinfectants and disinfectant activity, 4) Evaluation of environmental cleaning and disinfection, and 5) Review of “no touch” methods for decontamination.
St Clair: Choose a system and use it. Equipment that sits in a closet is useless. Establish a protocol for truly and deeply disinfecting every isolation room upon discharge, for instance, and to periodically disinfect ORs, ancillary treatment rooms and non-isolation patient rooms on a periodic, rotating basis.
Worrilow: Surface decontamination is a part of the solution, but facility managers also need to understand that one of the biggest threats to patients is in the air. Between 69 to 80 percent of pathogens (bacterial, fungal and viral) responsible for secondary infections are airborne. Over 90 percent of surface pathogens originate from the air.4 Surface and aggressive air decontamination need to be performed in tandem to effectively remediate pathogens that are responsible for HAIs.
What promising new technologies are available to assist in this effort?
Pearlstein: The recognition that current methods of disinfection are sub-optimal has led to the adoption of “no touch” technologies such as vaporized hydrogen peroxide (VHP), chemistries applied by spray devices, UV light products and an ultrasonic technology being marketed by Altapure that utilizes a very dilute solution of Peracetic Acid (PAA). Altapure’s technology, which uses aqueous PAA, has consistently demonstrated its capability to achieve a predictable kill greater than 6+ log for both dry spore pathogens and vegetative bacteria. It boasts a 2.3 to 2.6 D-Value (meaning a 90 percent kill within only 2.3 to 2.6 minutes of treatment) for G. stearothermophilus, the gold standard for showing pathogen kill, as reported by Raven Biological Labs (Mesa Laboratories, Inc.).
Baiocchi: There is now sufficient clinical data that supports the intervention of UV-C as an adjunct to manual cleaning. A UV-C system should verify, in real-time, that the method and applications used for decontamination scientifically support the claims being made by the vendor.
Buchaklian: New automated disinfection technologies have been developed that provide an additional level of disinfection to eliminate pathogens remaining on surfaces after cleaning. Automated UV-C disinfection systems are becoming the standard of care of many hospitals throughout the U.S. and the world.
Dunn: Validated no-touch UV disinfection technologies, such as the pioneer in the industry, Tru-D SmartUVC, provide automated terminal room disinfection. Tru-D SmartUVC provides total room disinfection from a single position, eliminating any chance of human error in the disinfection process and guaranteeing up to 99.9 percent of deadly pathogens on all room surfaces are eliminated during the disinfection cycle.
Miller: Xenex’s LightStrike Germ-Zapping Robot disinfects a typical patient room in 8 to 2 minutes using two 3- to 4- minute cycles, one cycle on either side of the bed and one in the bathroom. Only the Xenex robot uses pulsed xenon (not mercury bulbs) to create full spectrum germicidal light that quickly and efficiently destroys the pathogens that can cause infections. This is like the difference between using a garden hose or a power washer to clean a deck or driveway at a house. Intensity matters! The Xenex robot doesn’t require warm-up or cool-down time and destroys the pathogens lurking on high touch surfaces that you can’t see but can pose a risk to the next patient in that room.
Robertson: One promising new technology is the application of disinfectants using electrostatics. Electrostatics has been around and used for decades in the automotive, agriculture, inkjet and photocopier industries. Our company has developed and patented an electrostatic system to prevent and control healthcare infections. The E-Mist system applies EPA-registered water-soluble disinfectants. These systems place a positive ( + ) charge on the disinfectant droplets as they leave the spray nozzle. The dispersed droplets spread out more evenly and seek out a negative ( — ) or neutrally charged surface. The end result is that the disinfectant is more targeted, provides more uniform coverage with less waste, and like a magnet, is attracted to the surface with remarkable force. Healthcare operators are finding that this new technology is not only effective in reducing deadly pathogens, but also reduces labor costs up to 45 percent, and reduces chemical costs up to 50 percent.
Infection Control System
St Clair: Halosil has introduced the HaloFogger FLX. This model HaloFogger is designed to be positioned outside the room to be treated. When the fogging is completed, a detachable nozzle assembly is removed, the Halo is then moved outside the next room to be treated, and another assembly attached. This facilitates more rapid room turnover and saves money as the nozzle assemblies cost less than additional machines.
Worrilow: Ultraviolet light and other newer technologies hold promise. Perhaps the right formula is a combination of technologies, i.e. in-room UV for surface sterilization and continuous and comprehensive in-duct air purification using LifeAire Systems’ technology.
What advice would you give to healthcare facilities when evaluating these technologies?
Pearlstein: In light of the greatly diminished availability of antibiotics to treat nosocomial infections, hospitals must select disinfection technologies that provide the greatest probability of eliminating the risk to patients and staff acquiring untreatable infections. This can only be achieved by moving beyond the sales hype and slick advertising claims and actually challenge the technology using the dry spore of G. sterathermophilus placed in locations and distances that mirror reality. Every disinfection option should be tested under the same circumstances and treatment time. Because hospitals owe a responsibility to its patient and staff to provide a safe environment, disinfection products should be vigorously challenged before making a selection. When purchasing chemistry, one must be aware of the ‘wet’ contact time because this will play a key role in the effectiveness of the product.
Baiocchi: Use a multi-disciplinary approach to choose a system that the entire team understands and can benefit from (not a one-dimensional outsourced EVS department only approach). Not all UV-C systems are the same — there are systems that measure a UV-C dose and systems that don’t — so base your evaluation on scientific evidence that measures results. UV-C dose measurement, proof of compliance, operational management tools, fastest throughput and lowest cost of ownership should all be considered when evaluating UV-C technologies.
Buchaklian: Be sure to understand the basic principles and limitations of the technology and then decide if the device you are evaluating overcomes or minimizes those limitations. Also be wary of marketing claims that describe extremely short operating times, whether it be energy or a chemical these processes simply take time to deliver the proper dose to kill pathogens. One example is in UV-C disinfections, where surfaces must be exposed to the energy in the direct line of sight for efficient and maximal disinfection. Some single emitter systems require additional labor to move the UV-C energy source to different positions in the room. This requirement may result in the technology simply not being used. Newer systems on the market like Surfacide use a multiple emitter platform that allows the operator to set up the system a single time and run just one single cycle thereby minimizing the labor requirements while providing better whole room coverage.
Dunn: In the case of UV disinfection, closely read the scientific literature available and do not rely solely on company marketing pitches. Unfortunately, the overall quality of HAI reduction studies with most UV disinfection offerings is poor and authored by company shareholders. At a minimum, be sure your technology choice is independently validated to eliminate clinically relevant numbers of pathogens from actual room surfaces. Then look to device-specific validations from well-controlled randomized clinical trials on HAI reduction.
Miller: There is a lot of misinformation in this market, so buyers need to ask the right questions. Not all UV is the same — and the only UV vendor that has had multiple hospitals report infection rate reductions and publish their results in peer-reviewed journals is Xenex. As professionals are analyzing UV technologies, they need to look at the peer-reviewed literature supporting the device’s claims with regards to reducing infection rates at hospitals. We repeatedly hear the mercury UV vendors tell hospital decision-makers that all UV is the same and that their device works just like pulsed xenon UV. And it’s not true. There are scientific differences between the way that pulsed xenon UV and mercury UV emit germicidal UV-C light.
Robertson: To improve patient safety, we suggest evaluating infection prevention policies and practices, implementation of evidence-based practices, and using a multimodal strategy for environmental cleaning and disinfection.
St Clair: Facilities are fighting deadly pathogens. Disinfecting against them takes planning, follow through and surveillance to ensure compliance. When evaluating a system, be sure to do your homework, request and review actual EPA registration information, and consider the implications (to your facility, to your patients and to their families) of not truly minimizing HAI rates in your facility. Finally, always follow the manufacturer’s use instructions — we are here to save lives and to try to make you successful.
Worrilow: With the understanding that a significant percentage of pathogens responsible for HAIs are airborne, implement comprehensive air purification to complement surface decontamination. Assess true value of different systems as they relate to down time as well as decontamination effectiveness.
What other factors contribute to effective room decontamination?
Baiocchi: It has to be driven as a top down multidisciplinary approach — facilities that collaborate, communicate and are solution based are more successful in lowering their HAI rates. The ability to monitor and measure for efficacy, operator accountability and proof of compliance is critical. Early adoption and frequent and proactive use contribute to more effective and consistent room decontamination. Continual education, training and sharing best practices are all part of setting the gold standard for room decontamination.
Buchaklian: Monitoring, supervision, training, and education are all critical elements to equip the frontline staff with the tools they need to achieve effective room disinfection.
Dunn: Education and compliance are critical in achieving effective room decontamination. EVS staff should understand the importance of the steps they are taking and why they are valuable in preventing the spread of infectious diseases in order to ensure full effort is given to adhere to the established guidelines. Current best practice includes the addition of a validated, no-touch disinfection method after discharge of a colonized and/or infected patient, the highest risk rooms for new patients admitted to your hospital.
Miller: Staff education and training is imperative when it comes to a successful infection prevention campaign. Hospitals should ask vendors about the implementation and training they provide to ensure infection reduction success. Xenex, for example, sends in an implementation team to work with the hospital’s EVS and IP staff to determine the optimum protocol for running the robots. Xenex team members also train the employees who run the robots. Hospital administrators are given access to a portal where they can review robot usage in real-time, and measure their HAI reduction benchmarks.
Robertson: According to the CDC, hand hygiene is the simplest approach to preventing the spread of infections. Additionally, environmental hygiene, patient screening, vaccinations, surveillance, and with the increasing rates of deadly “superbugs”, antibiotic stewardship and program review and applications.
St Clair: Teamwork. Pennsylvania Hospital, which began using the Halo Disinfection System in 2011, stresses that IP, EVS, and Nursing all must ‘buy into’ the concept, the importance and the protocols of whole room disinfection for the best results to be achieved.
References:
- http://www.cdc.gov/hai/surveillance/index.html
- http://www.ncbi.nlm.nih.gov/pubmed/23743816
- http://www.ncbi.nlm.nih.gov/pubmed/20569853
- Kowalski, 2012, Hospital Airborne Infection Control, CRC Press.
Kara Nadeau | Senior Contributing Editor
Kara Nadeau is Sterile Processing Editor for Healthcare Purchasing News.