IPM in a Medical IPM in a Medical Treatment FacilityTreatment Facility
John D. Nelson, BCEJohn D. Nelson, BCE
EntomologistEntomologist
Tripler Army Medical CenterTripler Army Medical Center
ReferencesReferences
AR 40-5, Preventive MedicineAR 40-5, Preventive Medicine TB MED 561, Occupational and Environmental TB MED 561, Occupational and Environmental
Health Pest SurveillanceHealth Pest Surveillance AR 200-5, Environmental Quality, Pest Mgmt.AR 200-5, Environmental Quality, Pest Mgmt. DODI 4150.7, Pest Mgmt. Program.DODI 4150.7, Pest Mgmt. Program. TIM No. 20 - Pest Mgmt. Operations in a
Medical Treatment Facility TIM No. 29 - IPM Mgmt. In and Around BuildingsTIM No. 29 - IPM Mgmt. In and Around Buildings
OutlineOutline
TAMC – Pest Mgmt. Program SummaryTAMC – Pest Mgmt. Program Summary ““Urban” IPM in a Hospital Environment Urban” IPM in a Hospital Environment
(MTF)(MTF)MTF PestsMTF PestsPest Mgmt. ProcessPest Mgmt. Process IPM Program Elements IPM Program Elements Case Study – Crazy AntsCase Study – Crazy AntsOpportunities / IniaitivesOpportunities / Iniaitives
Tripler Army Medical CenterTripler Army Medical CenterPest Mgmt. AdministrationPest Mgmt. Administration
Pest Mgmt. services non-standardized in MTFs across Pest Mgmt. services non-standardized in MTFs across DA, DoDDA, DoD
Tenant of USAG-HI (installation)Tenant of USAG-HI (installation) USAG-HI Entomologist maintains PMP for entire USAG-HI Entomologist maintains PMP for entire
installation; TAMC has autonomous programinstallation; TAMC has autonomous program Pest Mgmt. activities transferred from DPW to TAMC in 1998 Pest Mgmt. activities transferred from DPW to TAMC in 1998
TAMC Entomologist administers the PMP, serves as TAMC Entomologist administers the PMP, serves as COR for pest control service contractsCOR for pest control service contracts
Responsible for pest control activities in CAC 500 bldgs. Responsible for pest control activities in CAC 500 bldgs. Subcontractors carry out pest mgmt. actions within TAMC Subcontractors carry out pest mgmt. actions within TAMC
(funded by logistics division)(funded by logistics division) MOA between Logistics Div. and Dept. Prev. Med.MOA between Logistics Div. and Dept. Prev. Med.
Funding: 20K LOG, 5K Dept. PV, 20K EPR fundsFunding: 20K LOG, 5K Dept. PV, 20K EPR funds
TAMC Pest Mgmt. PersonnelTAMC Pest Mgmt. Personnel
EntomologistEntomologistDept. of Prev. Med., Env. Health Section.Dept. of Prev. Med., Env. Health Section.Pest Mgmt. CoordinatorPest Mgmt. CoordinatorMedical EntomologistMedical EntomologistCurrently “one-man-show”Currently “one-man-show”
91S91SGS-9 TechnicianGS-9 TechnicianContractorsContractors
FacilityFacility
2,159,509 sq. ft.2,159,509 sq. ft.
Installation Description
Hospital SettingHospital SettingImportant IssuesImportant Issues
Little to no threshold toleranceLittle to no threshold tolerance Nosocomial infectious agents (mechanical Nosocomial infectious agents (mechanical
transmission)transmission) Sensitive environments – pests may affect Sensitive environments – pests may affect
sterility of supplies and equipmentsterility of supplies and equipment Immunocompromised individualsImmunocompromised individuals Infants/childrenInfants/children Anxiety – pests may interfere with patient Anxiety – pests may interfere with patient
comfort or recoverycomfort or recovery High liability potential – if pests implicated in High liability potential – if pests implicated in
compromising quality of patient carecompromising quality of patient care
Hospital EnvironmentsHospital Environments Sensitive environmentsSensitive environments
Surgical suitesSurgical suites Sterile facilitiesSterile facilities ICUsICUs Patient wards/roomsPatient wards/rooms Waiting areasWaiting areas
Food handling / service establishmentsFood handling / service establishments Food areasFood areas Nonfood areasNonfood areas
Admin, Maintenance, & Utility areasAdmin, Maintenance, & Utility areas Lounges / Break-rooms Waiting roomsWaiting rooms Locker rooms Locker rooms OfficesOffices
MTF DemographicsMTF Demographics
Generals / senior officersGenerals / senior officersSurgeonsSurgeonsOther physiciansOther physiciansNursesNursesSenior / junior enlistedSenior / junior enlistedCiviliansCiviliansPatients (AD & Beneficiaries)Patients (AD & Beneficiaries)ContractorsContractors
Agricultural vs. Urban IPMAgricultural vs. Urban IPM
Field EnvironmentField Environment MonitoringMonitoring Multiple strategiesMultiple strategies Economic thresholdsEconomic thresholds Some insects tolerated Some insects tolerated Minimal human Minimal human
interaction interaction
Human EnvironmentHuman Environment MonitoringMonitoring Multiple strategiesMultiple strategies Aesthetic thresholdsAesthetic thresholds Very few insects Very few insects
toleratedtolerated Constant human Constant human
interactioninteraction
Urban environmentUrban environment
Manmade environmentManmade environmentConditions suitable/comfortable for Conditions suitable/comfortable for
humans & pestshumans & pestsConsistent world wideConsistent world wideSpecific assemblage of pestsSpecific assemblage of pests
Urban IPM ComponentsUrban IPM Components
InspectionInspection Education - clients and techniciansEducation - clients and technicians Analyzing pest problemAnalyzing pest problem Taking short term corrective actionsTaking short term corrective actions Implement long-term, preventive actionImplement long-term, preventive action
Sanitation / ExclusionSanitation / Exclusion
Monitoring, documenting, and evaluating resultsMonitoring, documenting, and evaluating results Follow-upFollow-up
Measurement of customer satisfaction criticalMeasurement of customer satisfaction critical
Essential Program ElementsEssential Program Elements(keys for success)(keys for success)
IPM treatment strategies - varietyIPM treatment strategies - variety Knowledgeable coordinatorKnowledgeable coordinator
Pest idPest id Treatment recommendationsTreatment recommendations ReevaluationReevaluation Long-term solutionsLong-term solutions
Comprehensive planComprehensive plan Decision modelsDecision models Paper trail/record keepingPaper trail/record keeping Public relationsPublic relations Contractor relationsContractor relations
PestsPests
AntsAnts RoachesRoaches RodentsRodents BirdsBirds TermitesTermites ArachnidsArachnids EctoparasitesEctoparasites FliesFlies Wasps / BeesWasps / Bees
Pest Management ProcessPest Management Process
Complaint
Inspection/Consultation
Sanitation/Education
Structural modification
Treatment
Monitoring
1) Complaint1) Complaint
AvenuesAvenues TelephoneTelephone EmailEmail Website – Sharepoint (internal)Website – Sharepoint (internal) Direct – “Hey you…”Direct – “Hey you…” PMC Inspection – routine and randomPMC Inspection – routine and random
Priority assignmentPriority assignmentFY 06’ Avg. response time FY 06’ Avg. response time ≤ 48 hrs.≤ 48 hrs.
Pest Complaint PercentagesPest Complaint Percentagesn=275 FY 06’n=275 FY 06’
ANTS
BEES/WASPS
FLIES
OTHER INVERTSOTHER VERTS
RODENTS
COCKROACHES
2) Inspection / Consultation2) Inspection / Consultation
Talk to POCTalk to POCHistory of problemHistory of problemPest speciesPest speciesSource of problemSource of problemFood / waterFood / waterOther concerns or issuesOther concerns or issuesDD Form 1532-1 (or equivalent) DD Form 1532-1 (or equivalent)
3) Education3) Education
Food / water sourcesFood / water sources Important speciesImportant speciesControl methods usedControl methods usedConcerns warranted?Concerns warranted?Attainable expectations?Attainable expectations?Listen & communicateListen & communicateTraining opportunity / EmpowermentTraining opportunity / Empowerment
Pests in Paradise PrimerPests in Paradise Primer
4) Structural Modification & 4) Structural Modification & SanitationSanitation
ElementsElements Door / windowsDoor / windows Cracks / crevicesCracks / crevices WaterWater
LandscapeLandscape PlantsPlants Water containersWater containers Garbage / recycle cansGarbage / recycle cans HarborageHarborage
Pest RequirementsPest Requirements
FOOD
WATER SHELTER
5) Treatment5) Treatment
Physical, biological, and or chemical controlPhysical, biological, and or chemical controlPesticides, baits (must be labeled for hospital Pesticides, baits (must be labeled for hospital
use)use)No preventive treatments allowed by regsNo preventive treatments allowed by regsCoordinator or Contractor as PCO?Coordinator or Contractor as PCO?
Common Sense RuleCommon Sense Rule Work order generationWork order generation On-call priority designationsOn-call priority designations
Control OptionsControl Options
SanitationSanitationEducation Education MonitoringMonitoringExclusionExclusionTrappingTrappingBaitingBaitingPesticide applicationPesticide application
Problem AreasProblem Areas
LockersLockersBreak roomsBreak roomsPlumbingPlumbingRestaurantsRestaurantsOffice goodiesOffice goodiesPatient waiting roomsPatient waiting rooms
6) Monitoring6) Monitoring Pesticides should only be applied with Pesticides should only be applied with
supportive monitoring datasupportive monitoring data Population estimationPopulation estimation Decision levelsDecision levels Baseline informationBaseline information Conducted regularly (fixed traps, customer Conducted regularly (fixed traps, customer
survey, or pest log) survey, or pest log)
Pest Control Contract ProblemsPest Control Contract Problems
No direct controlNo direct controlControl optionsControl optionsQuality of workQuality of work
Liability of environmental regulationsLiability of environmental regulationsNo vested interest in organizationNo vested interest in organizationDifficult to terminateDifficult to terminateMore difficult to rehire new companyMore difficult to rehire new company
Contract RelationsContract Relations
Recruiting quality companiesRecruiting quality companiesCommunicationCommunicationQuality ControlQuality Control
ProfessionalismProfessionalism Client satisfactionClient satisfaction EfficacyEfficacy TimelinessTimeliness SafetySafety Compliance with laws / regsCompliance with laws / regs
Pest Ants of HIPest Ants of HI
big-headedbig-headedcrazycrazyglaberglaberpharaohpharaoh long-leggedlong-leggedcarpentercarpenterghostghostargentineargentine
Ant RequirementsAnt Requirements
Food Food proteinprotein fatfat sugarsugar
WaterWater
Shelter (harborage) - Shelter (harborage) - sometimessometimes carpenter antscarpenter ants glaber antsglaber ants
Ant Food Preferences Ant Food Preferences & Colony Structure& Colony Structure
Species Sweet Protein Oil Insect Queen
Crazy X X X MGlaber X SPharaoh X X X X MLong-legged X X SCarpenter X X M
Big-headed X X X M
Ant IPM - BaitingAnt IPM - Baiting
Low toxicityLow toxicityFeeding preferenceFeeding preferencePre-baitingPre-baitingClosest to sourceClosest to sourceNONO insecticide use insecticide useBait acceptanceBait acceptanceRe-inspection / refresh baitsRe-inspection / refresh baits
Ant IPM - Bait TypesAnt IPM - Bait Types
Stations - various Stations - various
Gels – variousGels – various
Liquids - sugar/boric acid Liquids - sugar/boric acid
Custom mixturesCustom mixtures
Start
Pest Complaint
Inspection / identification
Education/Sanitation/ Environmental modification
Interior/exteriorBaiting
Ant Aesthetic Threshold:
A/D = Ants per day
(+) A/D > 10 (Complaint) (-) A/D < or = 10 (Satisfaction)
(+)
(+)
(+)
1-month follow-up inspection
(+)
(-)
(-)
(-)
Seek and destroy colonies (outside)
Group A Group B
Ant IPMAnt IPM
Ant IPMAnt IPM
Group A SpeciesGroup A Species Glaber AntsGlaber Ants Long-leggedLong-legged ArgentineArgentine Carpenter Carpenter Big-headedBig-headed
Group B SpeciesGroup B Species Crazy Crazy PharaohPharaoh GhostGhost
Pathogens Associated with Pathogens Associated with Pharaoh Ants in HospitalsPharaoh Ants in Hospitals
Pseudomonas aeroginosaPseudomonas aeroginosaStaphlococcus spp.Staphlococcus spp.Steptococcus pyogenesSteptococcus pyogenesSalmonella spp.Salmonella spp.Clostridium spp.Clostridium spp.Many others...Many others...
Paratrechina longicornis (Latr.)
Crazy Ant Case Study
Crazy Ant ComplaintsCrazy Ant Complaints
Several urgent complaints from A-wing, 2Several urgent complaints from A-wing, 2ndnd floorfloor
Party Friday - Department of SurgeryParty Friday - Department of SurgeryRefreshments left out over the weekend – Refreshments left out over the weekend –
covered with antscovered with antsAnts now in exam rooms and doc officesAnts now in exam rooms and doc officesOrigin – perimeter of hospitalOrigin – perimeter of hospital
Crazy Ants Crazy Ants Contract PCO ManagedContract PCO Managed
Boric acid sugar-based gel baitBoric acid sugar-based gel bait Perimeter treatment Perimeter treatment
Cyfluthrin (Tempo WP)Cyfluthrin (Tempo WP) Cypermethrin (Demon WP)Cypermethrin (Demon WP)
Re-infestation- one monthRe-infestation- one month Re-treatment with same strategy Re-treatment with same strategy Infestation continuing and spreading to other Infestation continuing and spreading to other
areasareas
Crazy Ant BiologyCrazy Ant Biology
Large coloniesLarge coloniesMultiple queens – colonies split readilyMultiple queens – colonies split readilyShifting food preferences – difficult to baitShifting food preferences – difficult to baitVery mobile – invades quicklyVery mobile – invades quicklyAssociated with nectar producing plantsAssociated with nectar producing plantsTends aphids/scale insectsTends aphids/scale insects
Crazy Ants Crazy Ants Coordinator ManagedCoordinator Managed
Reevaluation of infestation Reevaluation of infestation Boric acid & Hydromethylnon baits insideBoric acid & Hydromethylnon baits inside
Rapid control - no re-infestationsRapid control - no re-infestationsContinual sporadic infestationsContinual sporadic infestationsPerimeter treatmentsPerimeter treatmentsExclusionExclusionEducate staffEducate staff
Crazy Ants Crazy Ants Perimeter ProgramPerimeter Program
Vegetation managementVegetation management Monthly monitoringMonthly monitoring ExclusionExclusion Perimeter treatmentsPerimeter treatments
Borate baits (Terro II)Borate baits (Terro II) Hydromethylnon baits (Amdro, Maxforce granules)Hydromethylnon baits (Amdro, Maxforce granules) Bifenthrin (Talstar granules)Bifenthrin (Talstar granules)
Follow-up treatments as necessaryFollow-up treatments as necessary
Crazy Ant ComplaintsCrazy Ant Complaints
0
2
4
6
8
10
12
A-wing
B-wing
C-wing
D-wing
PCO Coordinator
Perimeter Program
Crazy Ant ControlCrazy Ant ControlKeys to Successful ManagementKeys to Successful Management
Manage exterior populationsManage exterior populations ExclusionExclusion Vegetation ManagementVegetation Management
Eliminate nectar producersEliminate nectar producers Control aphids/scale insectsControl aphids/scale insects
Bait aggressively – be flexibleBait aggressively – be flexible Granular pesticideGranular pesticide Client EducationClient Education
Underlying Issues - PeopleUnderlying Issues - People
Perimeter vegetationPerimeter vegetation
Personal sanitation – food / shelter / waterPersonal sanitation – food / shelter / water
Trash management Trash management
Underlying Issues - Contractors Underlying Issues - Contractors
Do:Do:Apply treatmentsApply treatmentsTreat a single point (in time)Treat a single point (in time)
Don’t DoDon’t DoPreventionPreventionSanitationSanitationEducationEducationSolve long-term problemsSolve long-term problems
Crazy Ants Crazy Ants Coordinator ManagedCoordinator Managed
Rapid feedback and reevaluation/re-treatmentRapid feedback and reevaluation/re-treatment
Rapid control inside - no re-infestationsRapid control inside - no re-infestations
Continual sporadic infestationsContinual sporadic infestations
Definitive ID of pest and sourceDefinitive ID of pest and source
Precise application of appropriate treatmentPrecise application of appropriate treatment
Historical perspectiveHistorical perspective
Centralized solution – for entire facility not just a given pointCentralized solution – for entire facility not just a given point
Long-term solutionsLong-term solutions
Initiatives / OpportunitiesInitiatives / Opportunities
GPS geo-referencing & Bar-codingGPS geo-referencing & Bar-coding Research projectsResearch projects
Pesticide resistance studiesPesticide resistance studies Bait preference studiesBait preference studies
Establish self-help pest management programEstablish self-help pest management program Waste water / Sewer line treatmentsWaste water / Sewer line treatments Enforce designated staff eating areasEnforce designated staff eating areas Steam-clean or cold store carts, tray racks, and Steam-clean or cold store carts, tray racks, and
other portable itemsother portable items
Aloha!