Cleaning and Disinfection Practices

Cleaning and Disinfection Practices Dr. Michelle J. Alfa, FCCM Medical Director Clinical Microbiology Discipline, Diagnostic Services of Manitoba Disclaimers: Sponsored to give invited presentations at various National and International conferences by; STERIS, 3M, J&J, Healthmark, APIC, CACMID, Virox, Medisafe, Ontario Hospital Association, CHICA, and multiple conference associations. The University of Manitoba has licensed Dr. Alfa s patent for Artificial Test Soil to Healthmark. Opinion Leader Panel participation or Consulting Services for: 3M, J&J, STERIS, Olympus, biomerieux, Serim, Borden Ladner Gervais LLP, various Canadian Healthcare facilities. Research projects for: 3M, STERIS, J&J, Novaflux, Virox, Olympus, Medisafe, Case Medical, Province of Manitoba, Public Health Agency of Canada (NOTE: no funds from these research projects comes to Dr. Alfa all funds handled by the St. Boniface Research Centre). Overview: Cleaning & Disinfection of the Healthcare Environment What is environmental cleaning and disinfection anyway?? Healthcare Environment is it a Reservoir? - public versus patient-care areas Cleaning monitoring: -UV marker -ATP -Bioburden 3

Best Practices for Environmental Cleaning for Prevention and Control of Infections: In All Health Care Settings PIDAC: Provincial Infectious Diseases Advisory Committee, Dec 8, 2009 Queens Printer for Ontario Toronto, Canada ISBN: 978-1-4249-9727-5 4 What is Environmental Cleaning Anyway? Cleaning: detergent & physical action Removal of debris, organic material (e.g. patient secretions) and microorganisms Disinfection: killing action Exposure to agent that kills microorganisms chemical (liquid,vapour,gas) UV light, steam 5 Health Care: Cleaning & Disinfection (PIDAC 2009) Non-patient care areas: - cleaning Patient-care areas: - cleaning & disinfection - high-touch surfaces - frequency: risk stratification - compliance monitoring 6

Hospital grade Disinfectants: (DIN from Health Canada) Alcohols (60-95% ethyl or isopropyl) -USE: some equipment; - no rinse needed Chlorine: 1:10 or 1:100 use-dilution -USE: Hydrotherapy equipment, blood spills - rinse needed for 1:10 use-dilution -toxic fumes workplace safety issues - PPE needed Phenolics (not in nurseries or food contact surfaces) -USE: floors, walls, furnishing, IV poles - one-step commercial formulations PIDAC 2009 Appendix E 7 Hospital grade Disinfectants: (DIN from Health Canada) Quaternary Ammonium compounds (QUATs ) - USE: floors, walls, furnishing - narrow microbicidal spectrum Iodophors (not antiseptic formulations) -USE: hydrotherapy tanks, hard surfaces, & equipment that doesn t touch mucous membranes PIDAC 2009 Appendix E 8 Hospital grade Disinfectants: (DIN from Health Canada) Accelerated Hydrogen Peroxide (AHP) not antiseptic formulations 0.5% (1:16 dil of 7% stock): some kill -USE: surfaces in patient rooms - No rinse needed 0.5% (ready to use, TB claim): excellent kill -USE: surfaces in patient rooms - No rinse needed 4.5% (ready to use, thickened): -USE: toilet bowls, sinks, commodes ONLY - Rinse needed, PPE needed 3% (ready to use): -USE:floors, walls, furnishings - PPE needed PIDAC 2009 Appendix E 9

DISINFECTANT ISSUES: BEWARE!!! Contact time: Liquid on a surface will dry in ~ 3mins must be re-applied if recommended contact time is longer than 3 mins Rinse off residuals: Some disinfectants must be rinsed off after contact time due to irritation to patient skin (e.g. bleach 5000 ppm) PPE: Some disinfectants require PPE 10 Microfiber cloths for cleaning Rutala et al 2007: - String mops not as effective as microfiber mops for microbial removal - Microfiber effective without disinfectant Moore et al 2006: - Microfiber cloths vary in efficiency - Some microfiber cloths transfer organisms and re-contaminate surface during cleaning 11 Newest Aid for Healthcare?? Along with hospital-issue gown patients will get microfiber slippers!! Available in Safeway!! 12

The Healthcare Cleaning Dance: Do you do the watoosey or the two-step?? Cleaning & Disinfection: - Two-step: detergent to clean surface followed by application of disinfectant; no rinsing - One-step: cleaning agent that also disinfects; no rinsing - Watoosey?: detergent to clean surface followed by application of disinfectant; must be removed by rinsing 13 Other Novel Methods for Environment Disinfection: Fogging: -VHP, -Ozone gas, -super-oxidized water, UV irradiation: Steam: CleanRoomTechnology website Lightclean Website Stambio website 14 Room Fogging: VHP vapour Works but rapidly re-contaminated (both MRSA and other bacteria) Hardy K et al Rapid recontamination with MRSA of the environment of an intensive care unit after decontamination with hydrogen peroxide vapour. J Hosp Infect 2007;66:360-368 15

Infection Transmission: Environmental role A culture report should not dictate the practice of Standard Precautions (Bartley et al 2008) A culture report should not dictate the practice of Hospital Cleaning/Disinfection (opinion: M.Alfa 2011) Ensure ROUTINE cleaning/disinfection is done well the highest risk of transmission is just prior to the diagnosis of the patient having an ARO 16 Healthcare Challenge: Bum to Toilet Ratio!! Shared toilets - Multiple patients in same room - Two rooms; one toilet Inadequate cleaning of one toilet facility may affect many patients! VRE, MRSA, ESBLs, C.difficile, Acinetobacter spp Improvements in cleaning; reduce all AROs 17 HEALTHCARE ENVIRONMENT IS IT A RESERVOIR?? 18

Is it Clean Enough??? Visual assessment: crude measure Bedpan sprayers: phased out NEED TO ENSURE SURFACES ARE CLEANED EVEN IF THEY DON T LOOK VISIBLY DIRTY: YOU CAN T SEE THE MICROBES 19 Microbial survival on surfaces 60 Survives Years Days of survival 50 40 30 20 10 ** ** 0 MRSA VRE ESBL Spores C.difficile Acinetobacter Organism **Prolonged survival when suspended in dust/organic debris of up to six months to a year has been reported (Dancer 2007, Hardy 2007) 20 Environmental detection: MRSA in Stool of patient with diarrhea Bedside rails: 100% Blood pressure cuff: 88% Television remote: 75% Bedside Table: 63% Toilets: 63% High-touch sites If MRSA (+) but not in stool; ~ 30% environmental contamination Boyce J Hosp Infect 2007;65:50-54, Dancer Infection.thelancet 2007 21

Do caregivers acquire MRSA from environment? 42% of 12 nurses contaminated gloves with MRSA by touching objects in room of patients with MRSA in wound or urine WITHOUT ANY PATIENT CONTACT! Boyce J Environmental contamination makes an important contribution to hospital infection J Hosp Infect 2007;65:50-54. 22 Evidence of Infection Transmission PIDAC 2009 has excellent literature review MRSA: - Patients in ICU who acquired MRSA had same strain as found in the ICU environment (Hardy et al Infect Control Hosp Epidemiol 2006) MRSA & VRE: - Patients admitted to room previously occupied by patient with MRSA or VRE have significantly higher risk of acquiring these AROs (Drees et al Clin Infect Dis 2008, Huang et al Arch Int Med 2006) 23 How to Break the Chain of Transmission? ENSURE: - Environmental cleaning/disinfection -Hand hygiene Sounds Easy!! Why isn t it working??? 24

Efficacy of Bleach (5,000 ppm) in presence of organic material [killing of C.difficile spores] Spray agent on surface and leave unwiped 7.000 Recovery (log 10 cfu/ml) 6.000 5.000 4.000 3.000 2.000 Spray agent on surface and wipe 1.000 0.000 Inoculum PerDiem Optim 33B 500 ppm NaOCl 1000 ppm 5000 ppm NaOCl NaOCl 500 ppm NaOCl 1000 ppm 5000 ppm NaOCl NaOCl The Physical Action of Cleaning is critical NO MATTER WHAT AGENT is used for cleaning/disinfecting 25 Monitoring Cleaning Compliance Quality Program: - audit cleaning compliance - provide weekly feedback to staff - part of yearly performance appraisal 26 Audit: Cleaning Compliance Audit tools; recommended by PIDAC 1. UV Marker: [shows surface was wiped] - Carling et al 2008: 49% of surfaces clean after terminal cleaning - Alfa et al 2008: 20 50% of toilets clean after routine cleaning - Carling et al 2008: 57.1% ICU surfaces clean after patient discharge - Alfa et al 2010: UVM useful to assess clinical cleaning intervention 2. ATP: [measure of organic & microbe level] - Cooper et al 2007: < 500 RLU /cm 2 - Griffith et al 2007: 0 14% of surfaces clean after routine cleaning - Mulvey et al 2011: environment cleaning < 100 RLU/cm 2 3. Viable count: [measure of microbe level] - Dancer et al 2004: < 5 cfu/cm 2 - Griffith et al 2007: 50 90% of surfaces clean after routine cleaning 27

Environmental Cleaning: UV Marker Visibly Clean: NOT ADEQUATE UV marker to audit cleaning UVM Score: (3) (0) % Tests Non-isolation rooms 100 90 80 70 60 50 40 30 20 10 0 0 1 2 3 UV Marker Score (Avg) www.brevis.com Ward 1 Ward 2 Ward 3 Alfa et al BMC-Infectious Diseases 2008 28 Percentage of cleaning compliance UV Marker Audit Arm 1 A7 %of bathroom sites cleaned 100.0 90.0 80.0 70.0 62.5 64.1 65.6 65.6 55.0 57.5 60.0 50.0 46.9 40.0 30.0 20.0 10.0 0.0 0 1 2 3 4 5 6 Time (weeks) Twelve patient rooms Tested Mon Fri Four sites per bathroom - toilet, sink, door knob, soap dispenser 192 sites tested per week - Staff aware of study but do not get any feedback Issues: - Dedicated ward staff pulled for discharge cleaning - Cleaning compliance person specific - Visibly clean may be thought to not need cleaning - Visitors disrupt ability to clean room Data from Adriana Tratjman s M.Sc. thesis 29 UV Marker Audits: Impact of Feedback on Compliance Cleaning of selected sites in the washrooms Arm 1 New Staff Training: Ensure Trainers meet compliance targets 110.0 100.0 Percentage of cleaning compliance 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 Target of 90% 0.0 week 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Feedback Data from Adriana Tratjman s M.Sc. thesis 30

Use of Oxivir TB (Accelerated Hydrogen Peroxide) as a bleach alternative Alfa et al 2010; BMC Infectious Diseases [www.biomedcentral.com] C.difficile (% samples) 45 40 35 30 25 20 15 10 5 0 Arm 1 Arm 2 Arm 3 Arm 1: 50 patients, 133 samples CDAD, twice daily cleaning, Oxivir TB Arm 2: 68 patients, 254 samples CDAD, twice daily cleaning, PerDiem Arm 3: 68 patients, 179 samples Diarrhea, once daily cleaning, PerDiem 31 ATP monitoring of Environmental Cleaning ATP is present in living cells: both human and bacterial cells ATP measured by assay that detects relative light units or RLUs Human White cell Bacteria Low level of RLUs High level of RLUs Pictures from Google Images 32 ATP Assay Is not a linear correlation with microbial numbers [~10 3 cfu/sample to be detected] Reflects total human cellular and bacterial cellular residuals Protein, carbohydrate in pure form (i.e. not in a living cell) will NOT show any RLUs when tested by the ATP assay. Rapid test Pictures from Google Images 33

ATP Monitoring of Healthcare Environmental surfaces Validation for Healthcare? - what RLU to target? < 500 RLUs/cm 2, < 100 RLUs/cm 2 34 ATP Benchmark: Hospital clean [Mulvey et al 2011 J Hosp Infect] Detergent based cleaning: reduced ATP by 32% Cleaning did not always eliminate MRSA or MSSA Limited correlation between cfu/cm 2 and ATP level Recommended 100 RLU as benchmark for adequate cleaning [Hygiena ATP assay] After cleaning with detergent 22% of high touch sites failed [i.e. >100 RLU] 35 Environmental Monitoring UV Marker reliably shows if surface wiped; inexpensive, easy to do ATP reflects viable organisms and patient secretions; easy to do, validation for appropriate healthcare benchmark still needs to be established Use validated cutoff (manufacturer recommended or literature) Establish accepted % compliance e.g. 90% Baseline of ~ 1 month with feed back: develop action plan if <90% 36

Agent used for cleaning & disinfection PIDAC: recommends routine cleaning & disinfection of high risk health care areas [frequency based on risk-assessment] Detergents (many) at their use-dilution and usual contact times have little to no microbial killing ability Transfer/recontamination of surfaces during cleaning is reduced if agent has killing ability Focus on optimizing routine cleaning: risk highest is prior to implementation of isolation precautions 37 Environmental cleaning: Re-contamination from patient etc occurs rapidly; need ongoing & effective environmental cleaning process Whatever product used AUDIT to ensure cleaning is done properly Focus cleaning on High-touch areas for greatest impact in reducing spread of AROs 38 BATTLEFRONT: INFECTION HOUSEKEEPING IS THE FRONT LINE IN THE BATTLE OF THE BUGS! BE SURE YOU HAVE OPTIMIZED YOUR DEFENCES! Housekeeper 007 TRAINING OPTIMAL KILLING AGENT FEEDBACK ON COMPLIANCE Infectious Disease Picture from Google Images 39

References 1. Rutala et al Microbiologic evaluation of microfiber mops for surface disinfection AJIC 2007:35:569-73. 2. Moore G et al A laboratory evaluation of the decontamination properties of microfibre cloths J Hosp Infect 2006;64:379-385 3. Bartley et al Reservoirs of pathogens causing health care associated infections in the 21 st centurey: is renewed attention to inanimate surfaces warranted? Clin Micro Newletter 2 8;30:113-117 4. Dancer et al MRSA acquisition in an intensive care unit. AJIC 2006;34:10-17 5. Boyce Environmental contamination makes an important contribution to hospital infection J Hosp Infect 2007;65:50-54 6. Carling et al Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals ICHE 2008:29:1-7 7. Carling et al Intensive care unit environmental cleaning: an evaluation of sicteen hospitals using a novel assessment tool J Hosp Infect 2008;68:39-44 8. Cooper et al Monitoring the effectiveness of cleaning in four British hospitals AJIC 2007;35:338-41 9. Dancer Importance of the environment in MRSA acquisition: the case for hospital cleaning 10. Hardy et al Rapid recontamination with MRSA of environment of an ICU after decontamination with hydrogen peroxide vapour. J Hosp Infect 2007;66:360-68 11. Griffith et al The effectiveness of existing and modified cleaning regimens in a Welsh hospital J Hosp Infect 2007;66:352-359 12. Fohnston B.L, E Bryce Hosptial infection control strategies for VRE, MRSA and C.difficile. CMAJ 2009:180:627-631 13. Alfa MJ, Dueck C, Olson N, DeGagne P, Papetti S. Wald A, Lo E, Harding G. UV-visible marker confirms that environmental persistence of Clostridium difficile spores in toilets of patients with C. difficile-assoc 14. iated diarrhea is associated with lack of compliance with cleaning protocol.e. BMC Infect Dis. 2008 May 12; 8:64. 15. Mulvey D, P Redding, C Robertson, C Woodall, P Kingsmore, D Bedwell, SJ Dancer Finding a benchmark for monitoring hospital cleanliness J Hosp Infect 2011;77:25-30. 40