Recent Advances in Environmental Asepsis Heather Hohenberger, BSN RN CIC CNOR Quality Improvement Consultant Indiana University Health, Academic Health Centers

Conflicts of Interest The presenter has no conflicts of interest to disclose

Objectives After attending this course, participants will be able to: List several recent studies addressing the role that surfaces play in the transmission of healthcare-associated infections Identify trends in environmental asepsis in the procedural environment Describe new technologies that can be used to routinely evaluate the quality of environmental hygiene

2014 Updates to the AORN Recommended Practice for Environmental Cleaning

Additions Recommendations for cleaning and disinfection in the Pre/Post operative patient care area Operating and Procedure Rooms Sterile Processing areas Enhanced cleaning recommendations for multi-drug resistant organisms Quality and process improvement recommendations for evaluation of thoroughness in all applicable areas

Multidisciplinary Approach Strong recommendation for collaboration between Infection Prevention, Environmental Services, and organizational leadership regarding Selection of cleaning chemicals Selection of cleaning materials, tools, and equipment Establishment of cleaning frequencies When enhanced environmental cleaning procedures should occur Personnel responsible for cleaning patient care areas and equipment

Cleaning Chemicals Environmental protection agency (EPA) registered hospital-grade disinfectants should be used on environmental surfaces and equipment Surfaces should be cleaned with a detergent prior to disinfection Disinfectants should be applied and reapplied as needed to ensure proper dwell time Spray and misting methods should not be used to apply cleaning chemicals in procedural areas

Regulations Safety data sheets must be available and reviewed Follow manufacturer’s instructions for use along with local, state, and federal regulations for the preparation, handling, storage, and disposal of all chemicals If the cleaning chemical is removed from the original container, ensure the secondary container is labeled with the chemical name, concentration, and expiration date

Patient Safety Assess the environment frequently for cleanliness Floors should always be considered contaminated Protective barrier coverings should be used to cover surfaces if the surface cannot withstand disinfection or is difficult to clean Equipment should be cleaned and disinfected before being brought into the patient care area All patient positioning equipment should have a moisture-resistant and intact covering

Patient Safety A clean environment should be reestablished after the patient is transferred from the patient care area Procedural areas should be terminally cleaned An established schedule should be determined for terminal cleaning

Staff Safety All personnel should take precautionary measures to limit transmission of microorganisms when performing environmental cleaning and handling of waste materials Appropriate personal protective equipment (PPE) use

Education Requirements All personnel should receive initial and ongoing education and competency verification on their understanding of the principles and the performance of the processes for environmental cleaning Cleaning / disinfection products available PPE requirements for chemical use Reconstitution ratios (if applicable) Product expiration parameters Storage, handling, and disposal requirements Safety data sheet location

Cleaning Policies Policies and procedures for environmental cleaning processes and practices should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting

Quality Assurance Personnel should participate in quality assurance and performance improvement activities consistent with the facility’s plan to improve understanding of and compliance with the principles and processes of environmental cleaning Ongoing feedback can show if problems are improving, stabilizing, or worsening Obtaining data from quality assurance or performance improvement tools can tell if benchmark goals are met identify areas where additional help is needed

Process Monitoring Process monitoring is a necessary part of every facility’s environmental cleaning program Process monitoring must include compliance with regulatory standards review of products and manufacturers’ instructions for use cleaning procedures monitoring cleaning and disinfection practices reporting and investigation of adverse events outbreaks, product issues, corrective actions, evaluation What is process monitoring? This means a standard way to look at what is occurring in the facility; are we following regulations, do we have access to the product instructions for use, and are we cleaning and disinfecting correctly. And if something happens, an “adverse event”, how does this get reported? How is it corrected so it does not happen again? If a procedure is changed, we look at how the change affects our cleaning processes. For example, did the change make a positive difference?

How should cleanliness be measured? Thoroughness of cleaning is the focus of performance improvement Measure cleaning practices visual observation of the cleaning process visual inspection of cleanliness fluorescent marking ATP monitoring cultures Multiple measures should be used as a comprehensive assessment of environmental cleaning practices. Identify what types of measurement are used in your facility for team members now. Explain the process used at your facility so team members have clear idea and expectations. The information gathered by measuring cleaning practices can be used to drive process improvement activities, encourage compliance with established cleaning protocols, educate team members, and verify the competency of team members.

AORN Environmental Cleaning toolkit

AORN Environmental Cleaning toolkit Purpose educate all team members about the recommended practices on cleaning the perioperative environment promote patient safety prevent the spread of infection in the perioperative environment Available at http://www.aorn.org/Clinical_Practice/ToolKits/Environmental_Cleaning_Tool_Kit/Environmental_Cleaning_Tool_Kit.aspx

AORN Environmental Cleaning toolkit Resources Modules – Power Point presentations used for orientation, review, annual competencies Checklists – Specific for each practice setting, the cleaning checklists can be used for documentation and education Posters – Helpful tools for quick reminders when providing targeted education for staff

Toolkit Modules Module 1 - Environmental Cleaning: Basics Module 2 - Environmental Cleaning: Preoperative and Postoperative Areas  Module 3 - Environmental Cleaning: OR and Procedure Rooms   Module 4 - Environmental Cleaning: Sterile Processing Areas   Module 5 - Special Cleaning Procedures  Module 6 - Quality and Process Improvement 

End of Procedure Cleaning in the OR or Procedural Room Discuss this slide with personnel. Have them point out objects in the picture and identify the frequency of cleaning. Make this interactive so personnel can really understand the purpose behind the recommended cleaning practices. Adapted with permission from Perioperative Standards and Recommended Practices. Copyright © 2014, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.

Terminal Cleaning in the Preoperative and Postoperative Care Area Have team members identify items that are to be cleaned and talk through the process. Adapted with permission from Perioperative Standards and Recommended Practices. Copyright © 2014, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.

What should be cleaned first? Clean from top to bottom clean to dirty areas Clockwise or counter-clockwise cleaning may be performed when used along with clean-to-dirty and top-to-bottom cleaning methods

Cleaning Discuss this slide with personnel. Have them explain what this means. Make this interactive so personnel can really understand the purpose behind the recommended cleaning practices.

Sample Cleaning Checklist Pre/Post Procedural Areas Pre- and Postoperative Areas Cleaning Checklist—Patient Discharge Completed Patient monitors   Patient beds Over-bed tables Television remote Call lights Mobile and fixed equipment Suction equipment Medical gas regulators Imaging monitors Radiology equipment Warming equipment Floors and wall if soiled or potentially soiled (eg, splash, splatter, or spray). Patient transport vehicles including the straps, handles, side rails, and attachments should be cleaned and disinfected after each patient use.

Cleaning & Disinfection Chain of Infection Microorganism Reservoir Portal of Exit Means of Transmission Portal of Entry Susceptible Host Cleaning & Disinfection Hand Washing The chain of transmission is a series of well defined events or entities that need to occur in a pattern for an infection to happen. We can decrease the chance of a patient getting an infection by breaking any one of the links in this chain. (describe the links) By targeting the means of transmission (the way germs get around) and the reservoir (hiding places where germs can live on surfaces) we decrease the amount of infectious agents (the germs) before they can ever reach the susceptible host (the patient who could get sick). Waste Removal Hand Washing

Hand Hygiene Hand hygiene must always be performed when you remove PPE as soon as possible after hands are soiled Discuss with personnel that hand hygiene is the number one way to stop the spread of infection. Lack of proper hand hygiene can not only potentially infect the personnel, but other patients if a microorganism is on their hands. Talk about hand hygiene using alcohol based hand rubs and traditional hand washing with soap and water. If hands are visibly soiled, washing hands with soap and water is required.

Current Discussions in Healthcare Environmental Asepsis

Hot Topics One-step vs. Two-step cleaning / disinfecting ATP testing / Fluorescent marking Ultraviolet / Solar disinfection Copper / Silver containing disinfectants

One-step verses Two-step

Cleaning / Disinfection The absence of visible dust, soil, debris, blood, or other potentially infectious material The “first step” Disinfection A process that kills most forms of microorganisms on inanimate surfaces The “second step”

One-step verses Two-step One-step product – combines detergent and disinfectant, typically packaged as single-use wipes Two-step products – separate detergent and disinfectant, requires user to perform cleaning and disinfection in two separate steps *Products shown are for demonstration only

One-step Wipes Various terminology used by wipe manufacturers make it difficult to choose which wipe will best fit the organizations needs Sanitizing Disinfectant Germicidal Sporicidal Virucidal Antibacterial *Products shown are for demonstration only

Disinfectant Wipes While wipes have gained tremendous popularity, there is poor evidence to support efficacy at the point of care Effectiveness of the wipe depends on… Detergency – ability to remove dirt on a visibly soiled surface Wetness – ability to leave a layer of disinfectant on the surface of objects / equipment Disinfectant efficacy – once the surface is dry disinfection stops, if residue is left behind there is no further antimicrobial effect

Wipe it Out Royal College of Nursing produced “The Selection and Use of Disinfectant Wipes” Ultimate resource for thorough understanding of benefits and limitations of one-step wipe products Available at http://www.rcn.org.uk/__data/assets/pdf_file/0011/382538/003873.pdf

Infection Control Resources “Proper Use of Healthcare Disinfectants: The Implications Associated with Off-Label Use of Disinfectants” Available at http://www.infectioncontroltoday.com/webinars/2012/09/proper-use-of-healthcare-disinfectants.aspx “Infection Control Facts: How to Select an Ideal Disinfectant” Available at http://view.officeapps.live.com/op/view.aspx?src=http%3A%2F%2Fwww.csao.net%2Ffiles%2Fppt%2FHow%2520to%2520Select%2520an%2520Ideal%2520Disinfectant.ppt

ATP testing verses Fluorescent marking

ATP testing vs. Fluorescent marking CDC recommends all facilities develop programs to evaluate the thoroughness of high-touch object cleaning Emerging technologies take evaluation of cleaning and disinfecting beyond direct observation and checklists Subjective evidence verses objective evidence

Objective Methods for Evaluation Direct practice observation Swab cultures or agar slide cultures ATP bioluminescence Fluorescent markers

ATP Testing Measurement of adenosine triphosphate (ATP) on surfaces using a luciferase assay and luminometer Method Before room cleaning / disinfection occurs, a specialized swab obtains a sample from the surface area or object The swab is placed in the portable hand-held luminometer which identifies the amount of ATP in the sample After cleaning / disinfection has occurred, the items are swabbed and analyzed again

ATP Testing Advantages Disadvantages Easy to use Immediate teaching and feedback Disadvantages Results vary between systems A threshold value has not been determined in the healthcare setting for determining clean / contaminated Significant amount of ATP in the environment is non-microbiological Bleach based disinfectants alter the bioluminescence reaction Viruses and bacterial spores do not contain ATP

Fluorescent Marking Fluorescent powder, gel, or lotion can be used to mark objects prior to cleaning Method Objects are marked before cleaning occurs Evaluation occurs by shining a UV (black) light over the object to see if the product has been removed

Fluorescent Marking Advantages Disadvantages Ease of use Immediate teaching and feedback Disadvantages Some markers can be seen after the mark is applied, alerting the individual to clean the tagged object more thoroughly Some marking products can be difficult to remove from surfaces and equipment, leaving permanent stains

Comparison Method Ease of Use Identifies Pathogens Useful for Teaching Directly Evaluates Cleaning Direct Observation Low No Yes Swab cultures High Unknown Not determined Agar cultures Good Limited ATP Fluorescent marking

Comparing ATP Monitoring Units Article on ISSA Web site “Using an ATP Monitoring System in Healthcare Settings” Representatives from each major industry provider of ATP monitoring systems in healthcare contributed their perspective of ATP integration into practice Available at http://www.fmlink.com/article.cgi?type=Magazine&title=Using+an+ATP+Monitoring+System+in+Health+Care+Settings&pub=ISSA+Today&id=41190&mode=source

Current Research - ATP Sciortino, C.V., & Giles, R.A. (2012). Validation and comparison of three adenosine triphosphate luminometers for monitoring hospital surface sanitization: A Rosetta Stone for adenosine triphosphate testing. American Journal of Infection Control, 40(8), pp. e233. Validation occurred for all three meters tested, but only one could be verified due to variations in system performance between units Recommends careful consideration of technologic application in the healthcare environment

Current Research – Marking Presentation at the International Conference on Healthcare-Associated Infections (2010) by Rupp, M.E., Adler, A, Schellen, M., Cassling. K., Lyden, E., Fitzgerald, T., Sholtz, L., & Carling, P. “Hospital-wide Assessment of Patient Room Environmental Cleanliness” With the use of fluorescent marking, 10 high-touch surfaces were evaluated for cleaning efficacy 74% of high-touch surfaces were adequately cleaned

Several studies have shown us two certainties… Cleaning practices are often subpar Improvements made through education and feedback do not last This leads us to reach out for new technologies that can be applied to the healthcare environment

Ultraviolet verses Hydrogen peroxide

Ultraviolet vs. Hydrogen peroxide Manual cleaning / disinfection relies on the individual to follow manufacturer’s stated contact time and appropriate distribution of the chemical across surfaces Even with vigorous cleaning, multidrug resistant organisms (MDROs) can remain in the environment for months Both methods have published evidence of reduction of contamination in the healthcare setting

Ultraviolet Light Acts by breaking down the molecular bonds of DNA, causing cell destruction Requires appropriate intensity, exposure time, air movement, and bulb strength Can be used as an adjunct to manual cleaning / disinfecting practices

Hydrogen peroxide Acts by releasing the oxygen (oxidizing) from within the cell membrane of organisms, leading to cell death Available as a vapor, aerosolized dry mist, and vaporized hydrogen peroxide Active against bacteria, fungus, viruses, and spores Numerous systems available in various price ranges Can be used as an adjunct to manual cleaning / disinfecting practices

Comparison Method Advantages Disadvantages UV light Effective against a wide range of organisms Ease of use No need to seal off air supply Expense Requires furniture movement Must be placed in middle of the room Use in unoccupied room only Hydrogen peroxide Effective against a wide range of pathogens More effective than manual disinfection No toxic by-products Disinfection of complex equipment Room must be unoccupied Requires sealing room and air supply Time Logistical issues

Current Research – UV light Rutala, W., Gergen, M., & Weber, D. (2010). Room decontamination with UV radiation. Infection Control & Hospital Epidemiology, 31(10), pp. 1025-1028. Boyce, J., Havill, N., & Moore, B. (2011). Terminal decontamination of patient rooms using an automated mobile UV light unit. Infection Control & Hospital Epidemiology, 32(8), pp. 737-742. Both studies showed significant reduction of organisms despite high levels of contamination, including C diff spores

Current Research – Hydrogen peroxide Falagas, M., Thomaidis, P., & Kotsantis, K. (2012). Airborne hydrogen peroxide for disinfection of the hospital environment for infection control: A systematic review. Journal of Hospital Infections, 78(3), pp. 171-177. Study shows vapor or dry mist distribution of hydrogen peroxide can effectively disinfect the hospital environment

Copper verses Silver-containing Disinfectants

Copper Acts by altering the structure of proteins, leaving them unable to perform their natural functions (inactive) Used in self-disinfecting surfaces Not a cleaning / disinfection strategy, rather this is a proactive approach to decreasing microbial load

Silver Containing Disinfectants Action is not entirely understood, but believed to have a germicidal effect on some bacteria, viruses, algae, and fungi Not toxic to humans Testing and standardization is difficult in the healthcare setting Used in self-disinfecting surfaces Not a cleaning / disinfection strategy, rather this is a proactive approach to decreasing microbial load

Comparison Method Advantages Disadvantages Copper Not user dependent Continuous action Corrosion Can irritate skin Expense Few studies available for result validation Silver No studies in the healthcare environment

Current Research – Copper Karpanen, T., Casey, A., & Lambert, P. (2012). The antimicrobial efficacy of copper alloy furnishing in the clinical environment: A crossover study. Infection Control and Epidemiology, 33(1), pp. 3-9. Study found a reduction in organisms in the healthcare environment with the use of copper alloy materials However, the items must contain greater than 58% copper

What is on the horizon for cleaning and disinfecting in healthcare?

Healthcare Cleaning “Bundles” Havill, N.L., (2013) “Best practices in disinfection of noncritical surfaces in the health care setting: Creating a bundle for success” American Journal of Infection Control, 41(5), supplement, pp. S26-S30. Steps include Creating policies and procedures Selection of cleaning products Determining method of application Education Monitoring Providing feedback

References AORN Recommended Practices for Environmental Cleaning (2013). AORN Environmental Cleaning toolkit (2014). Association for the Healthcare Environment of the American Hospital Association. (2012) Practice Guidance for Healthcare Environmental Cleaning (2nd Ed.) Royal College of Nursing. (2011) Wipe it out; One chance to get it right.

Questions?

Contact Information Heather Hohenberger, BSN RN CIC CNOR Quality Improvement Coordinator Indiana University Health, Academic Health Centers (317) 963-1344 – office hhohenberger@iuhealth.org