1. Environmental Disinfection: New Technologies and Current Issues Gwenda R. Felizardo, BSN, RN, CIC Infection Prevention Consultant felizardo2@comcast.net 253-682-7476 May 2014

2. Disclosure Not paid by any company whose products are shown Not paid by any company whose products are shown Products shown or described are to provide illustration examples-not to endorse Products shown or described are to provide illustration examples-not to endorse Before using any environmental disinfectant or device, review all relevant package inserts on use, precautions, indications, contradictions Before using any environmental disinfectant or device, review all relevant package inserts on use, precautions, indications, contradictions Appreciation to William Rutala & San Raphael Hospital for several slides Appreciation to William Rutala & San Raphael Hospital for several slides

3. Objectives Review the critical aspects of environmental microorganism transmission in relation to HAIs Review the critical aspects of environmental microorganism transmission in relation to HAIs Describe the various technologies and chemicals currently on the market and applicability to the ambulatory setting Describe the various technologies and chemicals currently on the market and applicability to the ambulatory setting Discuss must know resources Discuss must know resources

4. Colonized or infected host Touch Person-Supplies-Equipment- Instruments

5. Environmental Contamination Endemic & Epidemic MRSA A number of healthcare surfaces/devices showed contamination of 7-40% on items tested. More identified with endemic contamination.

6. Furnishings Furnishings should be cleanable, including waiting room furniture. Vinyl preferred for chair coverings Furnishings should be cleanable, including waiting room furniture. Vinyl preferred for chair coverings Wood furniture & cabinet finishes deteriorate with cleaning- porous Wood furniture & cabinet finishes deteriorate with cleaning- porous Infection Prevention & Environmental Services should have input into decisions about furniture purchases Infection Prevention & Environmental Services should have input into decisions about furniture purchases Carpet does not belong in health care. It cannot be disinfected, looks poorly after a short time, difficult to clean Carpet does not belong in health care. It cannot be disinfected, looks poorly after a short time, difficult to clean

7. CarpetCloth sofa

8. Mattresses Tears, cracks, holes not cleanable

9. Toys All toys must be washable or given to child All toys must be washable or given to child Crayons in 4-pack & coloring sheets Crayons in 4-pack & coloring sheets Bin for clean toys, child picks one Bin for clean toys, child picks one Bin for used toys, child places on leaving Bin for used toys, child places on leaving Toys washed with dish soap & water, dried Toys washed with dish soap & water, dried CLEAN USED

10. How long can MRSA live in the environment?

11. Environmental Survival of Key Pathogens on Dry Surfaces Acinetobacter baumannii Outbreak/sporadic strains 26-27 days Norovirus 21-40 days Clostridium difficile Vegetative cells 24 hours Spores 5-18 months MRSA up to 9 months VRE up to 6 months

12. How Do I Know What Works Best? What organisms does it target? What organisms does it target? How long does it take to destroy organisms? How long does it take to destroy organisms? Does the method require cleaning first? Does the method require cleaning first? Is it EPA approved for healthcare? Is it EPA approved for healthcare? Is it compatible with surfaces? Is it compatible with surfaces? How easy is it to use? How easy is it to use? What does the manufacturer recommend? What does the manufacturer recommend?

13. Mechanical Disinfection

14. So what is available to clean and disinfect New Approaches to Room Contamination UV light Vapor (peroxide) Still requires manual cleaning with friction

15. UV Room Decontamination 1.Fully automated, self calibrates, activated by hand held remote 2.No special room ventilation needed 3.Uses UV-C to decontaminate surfaces 4.Measures UV reflected from walls, ceiling, floors & calculates time & dosage to kill pathogens 5.Will power down and audibly notifies the operator 6.Reduces colony counts of pathogens by >99.9% within 20 minutes

16. Hydrogen Peroxide Vapor

17. Comparison of HPV & Bleach

18. Downsides of UV & HPV Time Time UV= 15-25 minutes for vegetative bacteria and 50 minutes for C difficile spores UV= 15-25 minutes for vegetative bacteria and 50 minutes for C difficile spores Nanoscale reflective paint reduces time to 5-10 minutes Nanoscale reflective paint reduces time to 5-10 minutes HPV =takes approximately 2.5 hours HPV =takes approximately 2.5 hours Cost Cost Not practical for most AMCs or ASCs

19. Self Disinfecting Surfaces Heavy metal impregnated surface Heavy metal impregnated surface Silver Silver Copper Copper Reduces bacterial burden Reduces bacterial burden Costly Costly Must still manually clean Must still manually clean

20. Surface Inhibition Products Sharklet Patterned Material Sharklet Patterned Material Film that inhibits bacterial survival, growth, transfer and migration through pattern alone. Surface is comprised of millions of tiny diamonds arranged in a distinct pattern that mimics the microbe resistant properties of sharkskin. Film that inhibits bacterial survival, growth, transfer and migration through pattern alone. Surface is comprised of millions of tiny diamonds arranged in a distinct pattern that mimics the microbe resistant properties of sharkskin. Film applied to surfaces Film applied to surfaces

21. Green Cleaning Products Cleaning is not disinfecting Cleaning is not disinfecting Watch out for terms that say natural disinfectant or Eco friendly Watch out for terms that say natural disinfectant or Eco friendly Look for EPA registration number Look for EPA registration number

22. AHP oxidizes as it cleans and disinfects AHP oxidizes as it cleans and disinfects Broad spectrum- Broad spectrum- MDRO 30 sec-1 minute MDRO 30 sec-1 minute Norovirus 3 minutes (wipes) spray 1 min Norovirus 3 minutes (wipes) spray 1 min TB 4-5 minutes TB 4-5 minutes 5 log reduction (99.9%) in 30 sec-5 minutes 5 log reduction (99.9%) in 30 sec-5 minutes Accelerated Hydrogen Peroxide 0.3%

23. Other Low Level Disinfectants Kills/inactivates most bacteria, viruses, fungi Kills/inactivates most bacteria, viruses, fungi Appropriate for non critical medical devices and environmental surfaces Appropriate for non critical medical devices and environmental surfaces Quaternary ammonium compounds (Quats) are low level disinfectants Quaternary ammonium compounds (Quats) are low level disinfectants Quats with alcohol-quick drying and very effective Quats with alcohol-quick drying and very effective Cleans and disinfects Cleans and disinfects

24. Bleach-Sodium Hypochlorite Range 5.24%-6.25% Range 5.24%-6.25% Best used for diarrheal illness & Clostridium difficile Best used for diarrheal illness & Clostridium difficile At store can be misleading –don’t rely on the Manufacturers name (Clorox). May not contain bleach. At store can be misleading –don’t rely on the Manufacturers name (Clorox). May not contain bleach.

25. Cleanliness of the surface Cleanliness of the surface Amount & type of contamination Amount & type of contamination How is surface cleaned: manual, extractor, steam How is surface cleaned: manual, extractor, steam Dilution of cleaner & disinfectant Dilution of cleaner & disinfectant Contact time of disinfectant Contact time of disinfectant Manufacturer’s instructions Manufacturer’s instructions Factors Affecting Cleaning & Disinfection

26. Critical Tips MUST USE FRICTION MUST USE FRICTION Microfiber best-releases even amount Microfiber best-releases even amount Use multiple wipes or rags Use multiple wipes or rags Don’t overload with debris-makes it ineffective Don’t overload with debris-makes it ineffective Make sure chemical has not expired Make sure chemical has not expired Dilute according to manufacturer’s instructions Dilute according to manufacturer’s instructions

27. References www.disinfectionandsterilization.org www.disinfectionandsterilization.org www.disinfectionandsterilization.org 2008 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities 2008 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities 2003 CDC Guidelines for Environmental Infection Control in Healthcare Facilities 2003 CDC Guidelines for Environmental Infection Control in Healthcare Facilities 2003 CDC Hand Hygiene Guideline 2003 CDC Hand Hygiene Guideline 2008 CDC Isolation Precautions Guideline 2008 CDC Isolation Precautions Guideline

28. References http://www.cdc.gov/mrsa/environment/ http://www.cdc.gov/HAI/toolkits/Evaluating- Environmental-Cleaning.html Elements of a program Monitoring Checklist

29. Resources http://www.epa.gov/pesticides/reg ulating/nanotechnology.html http://www.epa.gov/pesticides/reg ulating/nanotechnology.html http://www.epa.gov/pesticides/reg ulating/nanotechnology.html http://www.epa.gov/pesticides/reg ulating/nanotechnology.html http://www.epa.gov/oppad001/che mregindex.htm http://www.epa.gov/oppad001/che mregindex.htm

31. Handouts Cleaning & Disinfectant Table Cleaning & Disinfectant Table Environmental Cleaning Guideline Environmental Cleaning Guideline ASC Cleaning Responsibilities ASC Cleaning Responsibilities

32. Cleaning & Disinfectant Solutions Table

33. Environmental Cleaning Guideline General principles General principles What to do What to do After each patient visit After each patient visit End of day End of day Weekly Weekly Monthly Monthly Special Event Cleaning Special Event Cleaning Bed bugs, body fluid, incontinence Bed bugs, body fluid, incontinence

34. ASC Cleaning

35. Question Which chemical agent should be used to disinfect an area where blood is on the floor or surface? 1. Alcohol 2. Quaternary ammonium compound 3. Bleach/chlorine 4. Glutaraldehyde 5. Hydrogen Peroxide 6. Phenolic All except glutaraldehyde

36. Question Your boss wants you to purchase a “green” disinfectant from the grocery store. What do you do? Your boss wants you to purchase a “green” disinfectant from the grocery store. What do you do? Go to EPA website to see if product is listed Go to EPA website to see if product is listed Pull testing data from the company (if any) Pull testing data from the company (if any) MSDS MSDS Studies Studies Provide alternative or support what you currently are using Provide alternative or support what you currently are using

37. Question Do you need to close a room down when it has been occupied by a patient with MRSA? This is primarily a contact organism. Do you need to close a room down when it has been occupied by a patient with MRSA? This is primarily a contact organism. No, Clean normally

38. Question What equipment should be disinfected after a patient leaves an exam room? What equipment should be disinfected after a patient leaves an exam room? All equipment & surfaces touched or used All equipment & surfaces touched or used

39. Question Patient with influenza or pertussis has occupied the exam room. These are droplet diseases. How do you clean? Patient with influenza or pertussis has occupied the exam room. These are droplet diseases. How do you clean? Clean normally-room does not have to be shut down Clean normally-room does not have to be shut down

40. Question List 3 strategies that reduce environmental and supply contamination? List 3 strategies that reduce environmental and supply contamination? Hand hygiene Hand hygiene Barriers Barriers Frequent cleaning Frequent cleaning

41. Remember It takes a bundle of strategies consistently performed at appropriate times to minimize or eliminate cross contamination

42. What are you dealing with?