do’s and don’ts for hospital cleaningwebbertraining.com/photos/custom/teleclass handouts,...
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Do’sandDon’tsforhospitalcleaning
ProfessorStephanieDancerNHSScotland&EdinburghNapierUniversity
HostedbyProf. Jean-YvesMaillardCardiffUniversity,Wales
www.webbertraining.com April 25, 2017
A.DenverRussellMemorialTeleclassLecture
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Howshouldweapproachcontrolofantimicrobial
resistance?
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...butpatientsacquireresistantpathogensfromthecontaminatednear-patientenvironment
SocontrollingAMRrequiresattentionon:i)vertical (direct)effectsbyantimicrobialdrugsii)horizontal (indirect)spreadcausedbyinfectionprevention&controldeficits
DancerSJ,‘TheeffectsofantibioticsonMRSA’,JAntimicrobialChemother(2008)
Antimicrobialstewardship?
Antimicrobialdrugsmightbeencouragingresistance..
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InvisibleAesthetic bias
Pathogen detection Evidence-based science?
No accepted measureWomens’ workFabric deficits
Costly
Low paid; low status; and dirty
WHY are we still debating the value of cleaning?
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SurvivaltimeInfectiousdose
MRSA 7daysto>7months4cfu’s
Acinetobacter 3daysto>5months250cfu’s
C.difficile >5months5spores
VRE 5daysto>4months<103cfu’s
E.coli 2hrsto16months102-106cfu’s
Klebsiella 2hrsto>30months102cfu’s
Norovirus 8hrsto7days<20virions
Kramer,BMCInfectDis,2006;DancerSJ,ClinMicrobiolRev2014
Propertiesofhospitalpathogens
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Increased risk associated with the prior room occupant. The figures of difference in risk are unadjusted based on raw data.
Otteretal,AmJInfectControl2013Mitchelletal,JHospInfect2015
Isriskrelatedtoenvironmentallongevity?
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Where are the pathogens in a hospital?
Hayden et al, SHEA 2004 7
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Adamsetal,JHospInfect201710
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Fluorescent gel placed on chosen sites
After patient discharge, a site is considered cleaned if the fluorescent material is removed or disrupted
Carling et al, Am J Infect Control, 2006
Ecolab®
How do we measure hospital cleaning?
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Removal of marker may not correlate with cleaning of alternate sites on the same surface Sitzlar et al, ICHE 2013
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What’s the long term effect?
Maintenance of environmental services cleaning and disinfection in the ICU after a performance improvement project
Fitzgerald et al, AmJIC 201213
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Howdowemeasurehospitalcleanliness?
Whatisclean?
“whatanindividualthinksitis”
82-91% Visually clean
10-24% ATP clean
30-45% Microbiologically clean
GriffithCJetal,JHospInfect200014
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Surface evaluation using ATP bioluminescence
Swab surface luciferase tagging of ATP Luminometer
Used in the commercial food preparation industry to evaluate surface cleaning and as an educational tool for more than 30 years
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Site Before* After*Site Mean
ATP BeforeSite Mean
ATP After
Locker (M) RangeMean
15-316106
17-14847
120 69Locker (S) RangeMean
7-325134
5-20891
L Bed (M) RangeMean
4-243106
4-1512206
105 131L Bed (S) Range
Mean4-181103
32-11556
O/B Table (M) RangeMean
28-625116
13-7536
181 309O/B Table (S) RangeMean
33-550246
55-3846581
R Bed (M) RangeMean
3-409145
3-20060
132 57R Bed (S) RangeMean
0-266118
16-12854
ATP values (RLU’s) for sites on medical & surgical wards
Mulveyetal,JHospInfect2011*Benchmark=100RLU’s 16
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ChanMC,LinTY,ChiuYH,etal.ApplyingATPbioluminescencetodesignandevaluateasuccessfulnewintensivecareunitcleaningprogramme.JHospInfect2015;90:344–346.
ATPsystemsencouragecleaningeffectiveness,buttheydonotnecessarilymeasuresurfacecleanliness.HighATPvaluesdonot
necessarilymeanpresenceofmicrobialpathogens!
WhateffectdoesATPmonitoringhave?
Studyin2ICUsinapublic1800-bedhospitalinTaiwan
CleaningefficacywasmonitoredbyATPbioluminescenceaftercleaning;<45%of221surfacespassed
Afteranewcleaningprotocol,88%of270surfaceswerecleanaccordingtoATPcriteria.CombinedHAIratesintheICUsapparentlydecreasedbyhalf!
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5 cfu/cm2 45 cfu/cm2
Slide from Chris Griffith
Would microbiological standards help?
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Standard1Thereshouldbe<1cfu/cm2 pathogen(MRSA;
C.difficile;VRE;etc)onhealthcaresurfaces
Standard2AerobicColonyCount(ACC)ortotalmicrobialgrowthlevelfrom
ahandtouch surfaceshouldbe<5cfu/cm2
Thesestandardsarebaseduponfoodindustrycountsasappliedtofoodpreparationsurfacesbutcouldbeutilisedfor
frequenthandtouchsurfacesinhospitals
DancerS,JHospInfect2004
Microbiologicalstandardsforsurfacehygieneinhospitals
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Istherearelationshipbetweenenvironmentalbioburdenandhospital-acquiredinfection?
White et al, AmJIC 2008
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.
Sowhichisthebestmethodformeasuringhowcleanahospitalis?
Aimforasystemwhichshowsmeasurablebenefitforpatients:aesthetics,cleaningfocus,cleanersurfaces,
andifyou’relucky,HAIrates;but….wouldn’titbenicetohaveasystemthatgivesusearly
warningofanimminentoutbreak?
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Correlatingcleaningeffectagainstsurfacecleanlinessindicators
Boyce et al, ICHE 2011
Fluorescent marker vs ACCs; how well have surfaces been cleaned
Fluorescent marker vs ATP; which surfaces need cleaning
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Correlatingcleaningeffectagainstsurfacecleanlinessindicators
Boyce et al, ICHE 2011
Fluorescent marker vs ACCs; how well have surfaces been cleaned
Fluorescent marker vs ATP; which surfaces need cleaning
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Whatistheevidenceforcleaningasaviablecontrolmechanismforhospital-acquiredinfections?
BBC website, 2008
Twomatchedwardsreceivedoneextracleaner(MondaytoFriday),witheachwardreceivingenhancedcleaningforsixmonthsinacross-overdesign;
Enhancedcleaningledtoa33%reductioninlevelsofmicrobialsoilathand-touchsites;and27%reductioninnewMRSAinfections,despitehigherbedoccupanciesandMRSAcolonisationpressures(p=0.032:95%CI7.7%,92.3%).
Dancer et al, BMC Med, 200924
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Totalaerobiccolonycounts(ACC)fromhand-touchsitesontwomatchedwards;thecleanermovedfromWardAtoWardBatweek26
Danceretal,BMCMed,200925
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Keepyourcleaningstaffin-house!
Toffoluttietal, SocialScience&Medicine2017;174:64–69
MRSA Incidence rate by type of cleaning service in 2010
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Clostridium difficile infection incidence for units A and B combined, before and after the intervention
HAI, hospital-acquired CDAD; INC, overall CDAD incidence; PD, patient days; PT, patient.
Orenstein et al, ICHE 2011
WipingOutClostridiumdifficile
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BasichygienemeasuresreducedVREincidence
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=Hand Hand-touch site
...isequalandoppositeDancerSJ,ICHE2010
The Hand-Touch equation:
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Onesurprising! findingwasthatpatienthandhygienewasassociatedwithreducedcontaminationofenvironmentalsurfaces………….
Sunkesulaetal,ICHE2016
ImpactofaHand-HygieneInterventiononContaminationofPatient’sHandswithHealthcare-AssociatedPathogens
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Dailycleaning?
TheTelegraph,UK,2008
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Contact plates from patient locker surfaceLeft to right: Pre clean, 1 hour, 2 hour, 3 hour assessment
MRSA rapidly recontaminates high-touch sites in ICU after H202 vapourHardyKJetal,JHI2007
Mike Rollins, Osprey
Howlongdohospitalsurfacesstay‘clean’?
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gg
Stewart et al, ICHE 2014
Effectofdetergent(blueline)anddisinfectant(redline)cleaningontotalACCathand-touchsitesover48hours
5cfu/cm2
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Stewart et al, ICHE 2014
EffectofdetergentanddisinfectantcleaningontotalMSSA/MRSAathand-touchsitesonone30bedwardover48hours
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Vickery et al, J Hosp Infect 2015
Dobiofilmsonhospitalsurfacesprotectviablepathogensfromcleaning?
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‘Chemzyme Plus’AsoupofBacillussubtilis!
Adisinfectantcontaininggoodbacteriareduced‘bad’bacteriaby1,000-foldcomparedwithstandardcleaning
PhagedisinfectantsBacteriophages thattargethospitalpathogenscanbeincorporatedintodisinfectants
NeutralElectrolysedwater
New disinfectants on the Block
http://www.phageworks.com
http://chemexuk.com
MeakinNetal,JHospInfect2012
Normaltapwaterwithaddedsaltthathashadanelectriccurrentpassedthroughit
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ElectrolysedwaterWhatisit?
Electrolysedwaterisnormaltapwaterwithaddedsaltexposedtoanelectriccurrent.Non-toxic!
Itismicrobiocidalduetothepresenceofhypochlorousacid.ThisacidisonlypresentinverylowconcentrationssothattheproducthasaneutralpH,thesameasordinarywater.
Howgoodadisinfectantisit?Isitbetterthanbleach?
Alsoeffectivefordecontaminatingsensitiveclinicalequipment
MeakinNetal,JHI2012;Danceretal,HealthcareInfection201537
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ColdPlasmaTechnologyreducessurfacebacterialcounts
Multiple-jet air decontamination of patient tray tables over 8 weeks (n= 6; NS, non significant; *P< .05). Claro et al, Infect Control Hosp Epidemiol 2017
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Song et al, AmJIC 2012
EffectofbleachvssteamagainstE.coli biofilm
<1secondsteamachievesbetterdisinfectionthan10ppmsodiumhypochloritefor10-20minutes
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Antimicrobial surfaces
• Copper(toiletseats,sinks,handles,etc)• Silver(textiles,etc)• Triclosan(tootpaste,choppingboards,etc)• Paintscontainingpolyurethanes,epoxymaterials,styreneacrylics• Polymer‘conjugatedpoly-electrolyte’plusfluorescentlight• Nanocoating(nanotubespluslysostaphin)
PageetalJMaterChem2009
‘….antimicrobialcoatingsmustnotunderminetraditionalhygienemethodsandneithershouldconventionalcleaningberelaxedifantimicrobialcoatingsareemployed’
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Failureofcopper-basedNanoCote/Aqua-Basedantimicrobialpaintinahospitalsetting
LaminatedwoodbedsidetablecoatedwithNanoCotefollowingwaterspillage
LaminatedwoodbedsidetablecoatedwithNanoCoteHD-WR(beforecuring).Close-upviewshowingunevendistributionafterapplication
Ramsdenetal,JBiologPhysChem,201641
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Pailhoriès et al, ICHE 2016
FourMSSAandfourMRSA;Twodifferentorientationsofoakused
Potentialantimicrobialactivityofoak(Querceusspp.)wastestedagainstapanelofS.aureusisolates
Oakshowedantimicrobialactivitytowardsalltheisolatestested;BUT….diameterofthewoodendiscswas9mm,asopposedto2mmforastandardantibioticdisc
‘Oakinhospitals,theWorstEnemyofStaphylococcusaureus?’
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Disinfecteverything…..
DancerSJ,ClinMicroRev2014;
Po&Carling,ICHE201043
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DoesH202 improvedisinfectionofICUrooms?
ProspectivecrossoverstudyinaFrenchhospital;roomswerecleanedwithquat&sodiumhypochlorite,followedbyeitherH2O2vapouroraerosolizedH2O2combinedwithperaceticacid;
BEFOREanyH202disinfection,only23(1.5%)of1,456sampledsurfacesand15(8%)of182roomswereMDRO-positiveafterpatientdischarge;
H2O2disinfectionreducedESBLsonly,sincenootherMDROswerefoundafterroutinecleaning;
TheseESBLswerefoundmostlyfromsinks..
BlazejewskiCetal,CritCare201544
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ButtheriskofacquiringClostridiumdifficile,MRSAandmultidrug-resistantGram-negativebacilliwas‘notsignificantlyreduced’;
ThesignificancequotedfortheoverallresultcamefromtheVREdataonly.
Patientswere64%lesslikelytoacquireMDROsand80%lesslikelytoacquireVRE(P < 0.001)followingH202 terminalcleaning……...
Passarettietal.ClinInfectDis,56(2013):27–35
TerminaldecontaminationofroomsusingH202vapour
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AnEnvironmentalDisinfectionOdyssey:evaluationofsequentialinterventionstoimprovedisinfectionofC.difficileisolationrooms
Sitzlaretal,ICHE2013
35%ofroomsremainedculturepositiveforC.difficileafteruseofUVdevices46
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Theeffectofdistanceontheefficacyofthe
PX-UVdevice
Nerandzicetal,ICHE2015
Good
Poor
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IncidenceofMDROsandClostridiumdifficile fromJanuary2009untilApril2013;pulsedUVlightintroducedMay2011
HaasJetal,AmJIC201448
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IncidenceofMDROsandClostridiumdifficile fromJanuary2009untilApril2013;pulsedUVlightintroducedMay2011
HaasJetal,AmJIC2014
$$$
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Dancer et al, IJAA 2013
*
**
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Hydrogenperoxidecan’tpenetratelinen,pillowsorsoftfurnishings
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CanUVCwavesgoroundcorners?
That’saNO,then?52
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Toxicity?
HumansSurfacesPlasticsPlantsAnimals
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Timetakenfordecontamination
Needtoremovethepatient;
NeedtototallysealoffaroombeforeH202exposure;NeedtorepositionUVCapparatusforuniformcoverage;
Needtotrainstaff;Needtoprepareroom;Needtoremovesoftfurnishings;
Can’tdoopenplan….
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..iscurrentevidenceonclinicalbenefitsufficientlyplentiful,andindeed,robust,toallocatescarcehealthcareresourcesforthesesystems?’ DancerSJ,FloorWarsletter,JHI2013
‘TheH202robotsystemcostsaboutUS$40,000;theUVlightsystemcostsmorethanUS$100,000……..
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Aggressivemarketingbyrobotcompaniesencourageshealthcaremanagerstochoosethesemethods…
…butnooneknowswhetherplainoldsoapandwatermightactuallydothejobjustaswell,formuchlesscostandminimaleffectonpeopleandenvironment
Buy my robot! It kills all known germs
My robot’s called Jim
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Man-agersaremorelikelytochoosepush-buttongadgetsratherthanreducebedoccupancyorengage
morecleaners
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true
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true
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AlfaMJetal,BMCInfectDis2010,10:268
Theefficacyofanycleaning/disinfectantagenttestedisdependentonphysicalaction....
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Evenifalltheroomsaredecontaminatedbyrobots,westillneedstafftomanuallypickuplitter…
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Time to get PHYSICAL!C.difficile and cleaning – alternative options to using chlorine-releasing disinfectants……..could C.difficile be removed by routine physical cleaning?
Awadel-Kariem et al, J Hosp Infect 2011
PhysicalremovalofC.difficilesporesismoreimportantthansporicidalinactivation Rutala et al, ICHE 2012
A single clean can reduce contamination by around 90%.....
Speight et al, J Hosp Infect 2011
When surfaces are wiped 3 or more times, detergent wipes are just as effective as disinfectant wipes Berendt et al, AmJIC 2011
Detergent gives the same result as disinfectant for cleaning clinical equipment
Petti et al, AmJIC 2012
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CONCLUSION
DOvaluetraditionalcleaning
DOmonitorcleaners;cleaning;orwhatisleftbehind(howeveryoulike)
DO keepyourcleanersin-house!
Don’tprioritisehandhygieneovercleaning
Don’twastemoneyonrobotsorantimicrobialpaint
Don’t believeeverythingthatsalesmentellyou!64
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NB.Nodisclosures
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