Sources of Infection in Long-Term Care Facility - Environmental Issues William A. Rutala, Ph.D, M.P.H. University of North Carolina at Chapel Hill UNC Health Care

Nutrition and Food Services l Why? Job of providing food for residents that is wholesome, appetizing, economical and safe to eat. l What? General principles of protection, equipment, storage, preparation, service. l How? Rounding

Factors that Contributed to 725 Reported Foodborne Disease Outbreaks, FactorFrequency % (No) Inadequate refrigeration336 (46) Preparing food far in advance of planned service156 (22) Infected persons practicing poor personal151 (21) hygiene Inadequate cooking or heat processing140 (19) Holding food in warming devices at114 (16) bacteria-incubating temperatures Contaminated raw ingredient in uncooked food84 (12)

Factors that Contributed to 725 Reported Foodborne Disease Outbreaks, (cont) FactorFrequency % (No) Inadequate reheating66 (9) Cross-contamination58 (8) Inadequate cleaning of equipment57 (7) Obtaining foods from unsafe sources44 (6) Using leftovers23 (3) Storing acid foods in toxic containers19 (3) Intentional additives17 (2) Incidental additives8 (1) Bryan, FL J. Environ Health 38:74, 1975.

Institutional Foodservice – NURSING HOMES: Percent of Observations Found Out of Compliance for Each RISK FACTOR FDA Report on the Occurrence of Foodborne Illness Risk Factors in Selected Institutional Foodservice, Restaurants and Retail Food Facility Types (2009) p.54.

Institutional Foodservice – HOSPITALS: Percent of Observations Found Out of Compliance for Each RISK FACTOR FDA Report on the Occurrence of Foodborne Illness Risk Factors in Selected Institutional Foodservice, Restaurants and Retail Food Facility Types (2009) p.42.

Nutrition and Food Services Staff l Exclude employees with communicable diseases (skin, respiratory, gastrointestinal) from contact with food products or utensils in accordance with the occupational health policy l Routine culturing of food service personnel for enteric pathogens has not been shown to be cost-effective

Nutrition and Food Services Staff l Wash hands after: using toilet, handling raw food, contact with unclean equipment and work surfaces, soiled clothing; wash rags and touching the mouth, nose, ears, eyes and hair.

Nutrition and Food Services

l Amount of hand contact l Cleanliness of equipment l Length of time foods are held at bacteria-incubating temperatures

Nutrition and Food Services No Hand Contact

Nutrition and Food Services No Hand Contact, Serving Utensils

Nutrition and Food Services Food Preparation

Nutrition and Food Services Cooked Foods Reach Appropriate Temperature

Nutrition and Food Services Food Preparation

Nutrition and Food Services Cleanliness of Cutting Boards

Nutrition and Food Services Food Storage (First in, First Out)

Nutrition and Food Services l Fruits, vegetables l Dairy products l Meat, poultry 33 o F – 45 o F CMS guidance: Cold - 41°F and below

Nutrition and Food Services Monitoring Temperatures

Nutrition and Food Services Monitoring Temperatures Electronically

Nutrition and Food Services l Steam Tables Maintain hot foods at 140 o F or above. Should not be used to warm foods. l Cold Tables Maintain cold foods at 45 o F or lower. Should not be used to refrigerate foods. CMS guidance: Hot – 135 °F and above, Cold - 41°F and below

Nutrition and Food Services

Nutrition and Food Services Steam Tables at 140 o F

Nutrition and Food Services Automatic Washer-140 o F wash for 20s, 180 o F rinse for 10s

Nutrition and Food Services Pot Cleanup

Disinfection and Sterilization in Healthcare Facilities WA Rutala, DJ Weber, and HICPAC, Overview – Last Centers for Disease Control and Prevention guideline in 1985 – 158 pages (>82 pages preamble, 34 pages recommendations, glossary of terms, tables/figures, >1000 references) – Evidence-based guideline – Cleared by HICPAC February 2003; delayed by FDA – Published in November 2008

Efficacy of Disinfection/Sterilization Influencing Factors Cleaning of the object Organic and inorganic load present Type and level of microbial contamination Concentration of and exposure time to disinfectant/sterilant Nature of the object Temperature and relative humidity

Disinfection and Sterilization EH Spaulding believed that how an object will be disinfected depended on the object’s intended use. CRITICAL - objects which enter normally sterile tissue or the vascular system or through which blood flows should be sterile. SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process ( high-level disinfection [HLD] ) that kills all microorganisms but high numbers of bacterial spores. NONCRITICAL -objects that touch only intact skin require low-level disinfection (or non-germicidal detergent).

Processing “Critical” Patient Care Objects Classification: Critical objects enter normally sterile tissue or vascular system, or through which blood flows. Object:Sterility. Level germicidal action:Kill all microorganisms, including bacterial spores. Examples:Surgical instruments and devices; cardiac catheters; implants; etc. Method: Steam, gas, hydrogen peroxide plasma, ozone or chemical sterilization.

Critical Objects l Surgical instruments l Cardiac catheters l Implants

Sterilization of “Critical Objects” Steam sterilization Hydrogen peroxide gas plasma Ethylene oxide Ozone Vaporized hydrogen peroxide Steam formaldehyde

Processing “Semicritical” Patient Care Objects Classification:Semicritical objects come in contact with mucous membranes or skin that is not intact. Object:Free of all microorganisms except high numbers of bacterial spores. Level germicidal action:Kills all microorganisms except high numbers of bacterial spores. Examples:Respiratory therapy and anesthesia equipment, GI endoscopes, endocavitary probes, etc. Method:High-level disinfection

Semicritical Items l Endoscopes l Respiratory therapy equipment l Anesthesia equipment l Endocavitary probes l Tonometers l Diaphragm fitting rings

High-Level Disinfection of “Semicritical Objects” Exposure Time > 8m-45m (US), 20 o C Germicide Concentration_____ Glutaraldehyde > 2.0% Ortho-phthalaldehyde 0.55% Hydrogen peroxide* 7.5% Hydrogen peroxide and peracetic acid* 1.0%/0.08% Hydrogen peroxide and peracetic acid* 7.5%/0.23% Hypochlorite (free chlorine)* ppm Accelerated hydrogen peroxide 2.0% Glut and isopropanol 3.4%/26% Glut and phenol/phenate** 1.21%/1.93%___ * May cause cosmetic and functional damage; **efficacy not verified

Processing “Noncritical” Patient Care Objects Classification:Noncritical objects will not come in contact with mucous membranes or skin that is not intact. Object:Can be expected to be contaminated with some microorganisms. Level germicidal action:Kill vegetative bacteria, fungi and lipid viruses. Examples:Bedpans; crutches; bed rails; EKG leads; bedside tables; walls, floors and furniture. Method:Low-level disinfection (or detergent for housekeeping surfaces)

Low-Level Disinfection for “Noncritical” Objects Exposure time > 1 min Germicide Use Concentration Ethyl or isopropyl alcohol70-90% Chlorine100ppm (1:500 dilution) Phenolic UD Iodophor UD Quaternary ammonium UD Accelerated hydrogen peroxide 0.5% _____________________________________________________________ UD=Manufacturer’s recommended use dilution

Environmental Issues l Environmental Sampling l Hand Hygiene l Medical Waste l Linen l Plant Engineering l Nutrition and Food Services l Disinfection and Sterilization

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