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5/4/2012
2
Today’s Speaker
Philip C. Carling, M.D.Boston University School of Medicine
Consultant – Ecolab, Steris Pending Patent License - Ecolab
A 2012 Perspective
1990 – 2009
Shinier Floors
Disinfectant Efficacy
Next Decade
Providing a safer patient environment
Hygienic Practice(Technologic
Enhancements)
Healthcare Environmental Cleaning Goal
Near-Patient Surface Bio-burden Reduction
Developmental Emphasis
5/4/2012
3
A 2012 Perspective
1990 – 2009
Shinier Floors
Disinfectant Efficacy
Next Decade
Hygienic Practice(Technologic
Enhancements)
Healthcare Environmental Cleaning Goal
Near-Patient Surface Bio-burden Reduction
Developmental Emphasis
How is Environmental Cleaning being evaluated in this hospital ?
Are Shiny Floors Enough ??
5/4/2012
4
A 2012 Perspective
1990 – 2009
Shinier Floors
Disinfectant Efficacy
Next Decade
Providing a safer patient environment
Hygienic Practice(Technologic
Enhancements)
Healthcare Environmental Cleaning Goal
Near-Patient Surface Bio-burden Reduction
Developmental Emphasis
A 2012 Perspective
1990 – 2009
Shinier Floors
Disinfectant Efficacy
Next Decade
Providing a safer patient environment
Hygienic Practice(Technologic
Enhancements)
Healthcare Environmental Cleaning Goal
Near-Patient Surface Bio-burden Reduction
Developmental Emphasis
5/4/2012
5
A 2012 Perspective
1990 – 2009
Shinier Floors
Disinfectant Efficacy
Next Decade
Providing a safer patient environment
Hygienic Practice(Technologic
Enhancements)
Healthcare Environmental Cleaning Goal
Near-Patient Surface Bio-burden Reduction
Developmental Emphasis
Increased acquisition risk from prior room occupant
8 studies as of October 2010
Two additional studies showed very significant risk without quantification – Martinez (VRE) and Wilks (Acinetobacter)
0 100 200 300
Nseir
Nseir
Datta
Shaugnessy
Dress
Hardy
Huang
Increased Risk of Aquisition (%)
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6
Thoroughness of Environmental Cleaning
0
20
40
60
80
100
HEHSG HOSP
IOWA HOSP
OTHER HOSP
OPERATING ROOMS
NICUEMS VEHICLES
ICU DAILYAMB CHEMO
MD CLINIC
LONG TERM
DIALYSIS
%
DAILY CLEANING
TERMINAL CLEANING
Cle
aned
Mean = 32%
>110,000 Objects
Cleaned, emptyroom
identified
Room marked Room evaluated
Terminal cleaning after 1 or 2 patient cycles
Phase I: Covert Baseline Environmental Cleaning Evaluation
Phase II: A. Programmatic AnalysisB. Educational Interventions – ES staff
Cleaned, emptyroom
identified
Room marked Room evaluated
Terminal cleaning after 1 or 2 patient cycles
Phase III: Re-evaluation of Cleaning and feedback to ES
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RESULTS
40
50
60
70
80
Hospitals Environmental Hygiene Study Group36 Hospital Results
% o
f Obj
ects
Cle
aned
PRE INTERVENTION POST INTERVENTION
P = <.0001Resource Neutral
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8
Improving Disinfection Cleaning to Decrease Environmental Surface Contamination
0
50
100
% Relative Improvement from Baseline
Improvement in Cleaning Practice
Decrease in Environmental Pathogens
A A BB CC DD
80%
64%
References 1-4
Defining the Difference Between Cleaning and Cleanliness
Cleanliness Cleaning
Definition A measure of bacteriaon a surface
Measured by evaluating process
Defined Criteria No “Cleanliness Standard”
Compliance with existing cleaning policy
Improvement shown to decrease bacterial transmission (Published)
None Two 1,3
Impacted by Bioburden, thoroughness of recent cleaning, effectiveness of disinfectant, recent contamination or lack of
Thoroughness of evaluated cleaning practice
CDC endorsed to improve patient safety
No Yes 5
5/4/2012
9
CDC RecommendationsAcute Care Hospitals should implement a:
Level I Program:
Basic interventions to optimize disinfection cleaning policies, procedures and ES staff education and Practice. When completed move to Level II Program
Level II Program:All elements of Level I + Objective monitoring
Options for Evaluating Environmental Cleaning
October 2010
Reference 5.
We have all agreed for almost 200 years that a clean hospital is important to patient safety
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We know that these ORs are dirty…that’s easy
How have we traditionally evaluated how safe this OR is for the next patient?
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Environment of Care Rounds
Patient Safety
HCW Safety
Fire Safety
Equipment Safety
Identifying unsafe practices
Environmental Cleanliness
Conventional Monitoring of Healthcare Environmental Cleaning
“Infection Prevention
Environmental Rounds”
• Subjective visual assessment
“If something looks dirty, it means housekeeping has failed”
• Deficiency oriented
• Episodic evaluation
• Problem detection feedback
• Open definition of correctable intervention
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Approaches to Programmatic Environmental Cleaning Monitoring
Conventional Program
• Subjective visual assessment
• Deficiency oriented
• Episodic evaluation
• Problem detection feedback
• Open definition of correctable interventions
Enhanced Program
• Objective quantitative assessment
• Performance oriented
• Ongoing cyclic monitoring
• Objective performance feed back
• Goal oriented structured Process Improvement model
Reference 6.
Approaches to Programmatic Environmental Cleaning Monitoring
Conventional Program Advantages
An established model
Enhanced Program Advantages
Direct evaluation of practiceUses a standardized, consistent, objective
and uniform system of monitoringProvides regular and ongoing performance
results to ES staffFacilitates the monitoring of many data
points to optimize performance analysisProvides positive practice based feedback
to ES staffAllows for objective remedial interventionsEasily adaptable to existing PI modalitiesFacilitates compliance with CMS and
JCAHO standardsExternal benchmarking, reporting and
recognition feasible
Reference 6.
5/4/2012
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Approaches to Programmatic Environmental Cleaning Monitoring
Conventional Program Limitations
Limited generalizability of findingsPoor specificity and low sensitivityIntrinsically subjective with a high
potential for observer bias
Only evaluates daily HP
Limited ability to support JCAHO standard EC.04.01.03.EP2
Limited ability to demonstrate compliance with CMS CoP 482.42
Benchmarking not feasible
Enhanced Program Limitations
Requires a new program implementation
Ongoing administrative support critical to success
Potential resistance to objective monitoring and reporting
While useful, the covert baseline evaluation may be difficult to implement effectively
Monitoring tool differences
Reference 6.
Approaches to Programmatic Environmental Cleaning Monitoring
Conventional Program Limitations
Inability to evaluate actual practice
Based only on negative outcome analysis
Limited generalizability of findings
Poor specificity and low sensitivity
Subjectivity with a high potential for observer bias
Poor programmatic specificity
Potential for observer bias
Only evaluates daily HP
Unable to support JCAHO standard EC.04.01.03.EP2
Limited ability to demonstrate compliance with CMS CoP 482.42
Benchmarking not feasible
Enhanced Program Limitations
Requires a new program implementation
Ongoing administrative support critical to success
Potential resistance to objective monitoring and reporting
While useful, the covert baseline evaluation may be difficult to implement effectively
Potential monitoring tool issues
Carling PC, Bartley JM. AJIC 2010
5/4/2012
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Objective Approaches to Monitoring Environmental Hygiene
Understanding the Tools
Evaluating Patient Zone Environmental Cleaning
Method
Covert Practice
Observation
Swab cultures
Agar slide cultures
Fluorescent gel
ATP system
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Evaluating Patient Zone Environmental Cleaning
Method Ease of Use
Identifies Pathogens
Useful for Individual Teaching
Directly Evaluates Cleaning
Published Use in
Programmatic Improvement
Covert Practice
Observation
Swab cultures
Agar slide cultures
Fluorescent gel
ATP system
Evaluating Patient Zone Environmental Cleaning
Method Ease of Use
Identifies Pathogens
Useful for Individual Teaching
Directly Evaluates Cleaning
Published Use in
Programmatic Improvement
Covert Practice Low No Yes Yes 1 Hospital
Observation
Swab cultures
Agar slide cultures
Fluorescent gel
ATP system
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Evaluating Patient Zone Environmental Cleaning
Method Ease of Use
Identifies Pathogens
Useful for Individual Teaching
Directly Evaluates Cleaning
Published Use in
Programmatic Improvement
Covert Practice Low No Yes Yes 1 Hospital
Observation
Swab cultures High Yes Not Studied No 1 Hospital
Agar slide cultures
Fluorescent gel
ATP system
Evaluating Patient Zone Environmental Cleaning
Method Ease of Use
Identifies Pathogens
Useful for Individual Teaching
Directly Evaluates Cleaning
Published Use in
Programmatic Improvement
Covert Practice Low No Yes Yes 1 Hospital
Observation
Swab cultures High Yes Not Studied No 1 Hospital
Agar slide cultures
Fluorescent gel
ATP system
5/4/2012
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Evaluating Patient Zone Environmental Cleaning
Method Ease of Use
Identifies Pathogens
Useful for Individual Teaching
Directly Evaluates Cleaning
Published Use in
Programmatic Improvement
Covert Practice Low No Yes Yes 1 Hospital
Observation
Swab cultures High Yes Not Studied No 1 Hospital
Agar slide cultures Good Limited Not Studied No 1 Hospital
Fluorescent gel
ATP system
Evaluating Patient Zone Environmental Cleaning
Method Ease of Use
Identifies Pathogens
Useful for Individual Teaching
Directly Evaluates Cleaning
Published Use in
Programmatic Improvement
Covert Practice Low No Yes Yes 1 Hospital
Observation
Swab cultures High Yes Not Studied No 1 Hospital
Agar slide cultures Good Limited Not Studied No 1 Hospital
Fluorescent gel
ATP system
5/4/2012
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Evaluating Patient Zone Environmental Cleaning
Method Ease of Use
Identifies Pathogens
Useful for Individual Teaching
Directly Evaluates Cleaning
Published Use in
Programmatic Improvement
Covert Practice Low No Yes Yes 1 Hospital
Observation
Swab cultures High Yes Not Studied No 1 Hospital
Agar slide cultures Good Limited Not Studied No 1 Hospital
Fluorescent gel High No Yes Yes 49 Hospitals
ATP system
Surface evaluation using ATP bioluminescence
Swab surface luciferace tagging of ATP Hand held luminometer
Used in the commercial food preparation industry to evaluate surface cleaning before reuse and as an educational tool for more than 30 years.
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The ATP tool in context
Industrial Use• Developed in the 1970s for commercial food preparation • Used when very clean surfaces are important• High-grade disinfectants + Rinsing• Testing immediately after cleaning and just before use is
the standard
Healthcare Use• Griffiths – JHI studies – Effectively used cultures and
ATP to debunk the “visibly clean ” standard• He and later Dancer showed that most surfaces had
both high bacterial and ATP counts (89% of surfaces “Failed”) (many appeared dirty!)
• The Hygienic standard is proposed
Limitations of ATP evaluation of cleanliness in healthcare settings
Three studies of ATP sensitivity and specificity clarify the limits of the ATP “Cleanliness Standard” as it was proposed several years ago
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Reference 7.
2007
Study # 1.
Correlation between ATP bioluminescence (RLU/Swab) and aerobic colony count (cfu/swab)
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Correlation between ATP bioluminescence (RLU/Swab) and aerobic colony count (cfu/swab)
Satisfactory by RLUs but Unsatisfactory by #
CFU
Bioluminescence PPV = 63% NPV= 71%
Study # 2. Correlation between RLU & Microbial Contamination. Mulvey D, et al. J Hosp Infect 2011
5/4/2012
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Study # 2. Lack of Correlation between RLU & Microbial Contamination.
“Routine cleaning with detergent can reduce concentration of microbes & organic matter by RLU. The effect is not large, with many sites exhibiting similar values after cleaning as they did before. …Further work is required to refine practical sampling strategy and choice of benchmarks.”
GOOD
Dr. John Boyce’s Conclusion
ICHE December 2011
Study # 3.
5/4/2012
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The major reason using ATP to spot check cleanliness has
not worked…..
Basic cleanliness* of healthcare surfaces
0
20
40
60
80
100
%
* No aerobic growth or < 2.5 CFU/cm2
Nine Published studies 2006 - 2011
5/4/2012
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Use of Cultures to Evaluate Cleaning Performance
AdvantagesCan be pathogen specificTouch slide procedure can easily confirm heavy
contamination or sterility
DisadvantagesPathogen Specific:
Very costlySeveral research methodologies used
Touch Slides:“Hygienic Standards” suggested but not validatedLogistical issues – Timing of monitoring
– Labor intensive– Does light growth mean low contamination or
relatively good cleaning?
Despite their limitations, can dip slide cultures or ATP be theoretically used to
evaluate cleaning practice?
The CDC Guidance says yes……But
5/4/2012
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Using tools that measure cleanliness to systematically evaluate cleaning process
But then you will need to deal with the other implication
of…..
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Basic cleanliness* of healthcare surfaces
0
20
40
60
80
100
%
* No aerobic growth or < 2.5 CFU/cm2
Nine Published studies 2006 - 2011
5/4/2012
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New TJC ES Leadership Requirement
February 2009
New TJC ES Leadership Requirement
February 2009
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The Environmental Hygiene Imperative
EVS Leadership and IPs,
Optimize current practice
The Environmental Hygiene Imperative
EVS Leadership and IPs,
Optimize current practice
Innovation – Demand evidence based support
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ES Management Bottom Line
Optimized Measurement
=
Optimized Management
Conclusions
• It is very likely that surfaces in the Patient Zone are of relevance in the transmission of Healthcare Associated Pathogens.
• While optimizing hand hygiene and isolation practice is clearly important there is no reason why the effectiveness and thoroughness of environmental hygienic cleaning should not also be optimized, particularly since such an intervention can be essentially resource neutral.
5/4/2012
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References
1. Hayden MK, etal. Clin Infect Disease2006;42:11,1552-60.
2. Hota B, etal. J Hosp Infect. 2009 Feb;71(2):123-31.
3. Datta R, etal Arch Intern Med. 2011 Mar 28;171(6):491-4.
4. Munoz-Price etal. Inf Control Hosp Epid. 2012 (in-press)
5. Options for Evaluating Environmental Cleaning October 2010. Found at :
6. Carling P, Bartlet J. Am J Infect Control. 2010 Jun;38(5 Suppl 1):S41-50
7. National Health Service. Link 195.92.246.148/knowledge_network/documents/Bioluminescence_20070620104921.pdf
8. Mulvey D, et al. J Hosp Infect 2011
9. Boyce J, etal. Infect Control Hosp Epidemiol. 2011. 32: 1187-93
10. Options for Evaluating Environmental Cleaning,October 2010http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html
Thanks for inviting me !!
Questions – Comments? [email protected]