1. Improving Environmental Cleaning and Disinfection in Healthcare Settings Massachusetts Coalition for the Prevention of Medical Errors March 26, 2008 A New Metric for an old Job

2. How Important is Environmental Contamination in Hospitals? Philip C. Carling, M.D. Director of Infectious Diseases and Hospital Epidemiology at Carney Hospital and Faculty of Boston University School of Medicine

3. Contaminated Surfaces Bed Rails +++++++ + +++ Bed Table ++++++ + Door Knobs ++ ++ + Doors +++ + Call Button +++ + ++ Chair ++ + ++ Tray Table +++ ++ Toilet Surface + ++++ Sink Surface + + +++ Bedpan Cleaner + VRE MRSA C. difficile P. Carling, M.D. 3/08

4. Surface Contamination of Near-patient Environment 23 Studies P. Carling, M.D. 3/08

5. Survival of Pathogens on Environmental Surfaces C. Difficiele – > 5 months MRSA – 90 to > 236 d. VRE – 7 to 120 d. E. coli O157 – > 60 d. Rhinoviruses – Several hours Hepatitis A – > 4 hours Parainfluenza viruses – 10 hours P. Carling, M.D. 3/08

6. How Well Do Environmental Disinfectants Work ?

7. How Well Does Environmental Disinfecting Work ? Phenolic Compounds Quartinary Amonium Compounds Chloride Disinfectants Formaldehyde Kill a wide range of microbial pathogens Work Rapidly Work effectively in clinical settings ALL

8. Since surfaces in the “patient zone” are contaminated with environmentally resilient transmissible pathogens such as C. difficile, etc., What guidelines are there to direct our disinfection cleaning practice to mitigating the problem?

9. The hospital must provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases… The infection prevention and control program must include appropriate monitoring of housekeeping… activities to ensure that the hospital maintains a sanitary environment. §482.42 Condition of Participation: Infection Control Interpretive Guidelines §482.42 November 21, 2007 CMS

10. A hospital with a comprehensive hospital-wide infection control program should have and implement ….provisions to monitor compliance with all policies, procedures and protocols… §482.42 Condition of Participation: Infection Control Interpretive Guidelines §482.42 November 21, 2007 CMS

11. How Well Does Environmental Cleaning Work ?

12. GOAL OF THE PROJECT To develop a surrogate marking system to evaluate the effectiveness of environmental cleaning/disinfection of the near-patient environment

13. The Targeting Solution A mixture of several glues, soaps and a targeting dye which: Dries rapidly Environmentally stable Readily wetted by spray disinfectants Easily removed with light abrasion Inconspicuous P. Carling, M.D. 3/08

14. Targeting Patient Rooms Targets were chosen by considering sites A. A patient was most likely to contaminate and B. A care givers may touch with their hands Between 8 -10 Targets marked in each room after terminal cleaning Targets were evaluated after one to two patients had cycled through the room P. Carling, M.D. 3/08

15. Preliminary Results – Three Hospitals Clinical Infectious Diseases – February 2006 P. Carling, M.D. 3/08

16. On the basis of our preliminary results and presentations at SHEA, APIC and ICAAC conferences we have gathered together a group of hospitals to further evaluate the tool and process improvement programs The Healthcare Environmental Hygiene Study Group

17. Baseline Environmental Evaluation of 35 Acute Care Hospitals % of Objects Cleaned Hospitals Mean = 48.5 % P. Carling, M.D. 3/08

18. PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS % P. Carling, M.D. 3/08

19. The Program Phase I – Covert Baseline Environmental Evaluation Phase II A. Educational Interventions – ES Staff B. Feedback to the ES – Staff P. Carling, M.D. 3/08

20. Hospitals Environmental Hygiene Study Group Hospital Results % of Objects Cleaned PRE INTERVENTION POST INTERVENTION P. Carling, M.D. 3/08

21. Healthcare Environmental Hygiene Study Group Current Projects Hospital Post Discharge Cleaning Project – Beta sites OR Terminal Cleaning Project – 16 sites NICU Discharge Cleaning Project – 15 sites ICU daily Cleaning Project – 12 sites Skilled Nursing Facility Daily Cleaning Project – 5 Sites Iowa Statewide MRSA Control Project – About 100 sites Chemotherapy Suite Daily Cleaning Project – 10 sites Canadian Consortium – 6 Major Medical Centers P. Carling, M.D. 3/08

22. Does it make a difference?

23. Studies in which have evaluated the relevance and epidemiology of environmental HAPs P. Carling, M.D. 3/08

24. Thanks for your interest! Carling PC, Briggs JL, Perkins, J and Highlander D. Improved cleaning of patient rooms using a new target method. Clinical Infectious Diseases 2006;42:385-8. Carling PC, Parry ML, SM Von Beheren; for the Healthcare Environmental Hygiene Study Group. Identifying Opportunities to Enhance Environmental Cleaning in 23 Acute Care Hospitals. Infect Control Hosp Epidemiol 2008;29:1-7. Questions / Comments: pcarling@cchcs.org P. Carling, M.D. 3/08