I gave a webinar last week for 3M (you can download my slides here) on “Your hospital room can make you sick: How improved cleaning and disinfection can help”. I asked the audience what they were doing to improve cleaning and disinfection, and thought I would share the findings. I don’t know the exact size of the audience (but it’s usually a couple of hundred mainly US based IPC folks), and the audience were allowed to choose any answers that applied to them for the second two questions.
Research from the Cleveland VA published in the ICHE special edition tells a fascinating story of sequential interventions to reduce environmental contamination with C. difficile. The research includes pretty much the whole battery of environmental interventions at our disposal: education of housekeepers, the introduction of a specially trained “A” team, ATP bioluminescence, fluorescent markers and UVC for “no-touch” disinfection. About the only thing missing is copper surfaces!
Before we get to the interventions, let’s just reflect on the fact that somewhere between 60-70% of rooms were contaminated with C. difficile after terminal disinfection in the baseline period. It’s little wonder that admission to a room previously occupied by a patient with C. difficile increased the chances of developing C. difficile infection! Related to this, there’s some interesting thoughts at the beginning of the discussion about whether there could be a “safe” level of C. difficile contamination. I discussed this in a previous blog post here.
The introduction of fluorescent marking with feedback did not eliminate the C. difficile environmental contamination, with 50-60% of cultures remaining contaminated. Similarly, the introduction of a UVC “no-touch” room disinfection system for terminal disinfection did not solve the problem, with 30-40% of cultures remaining contaminated. Only when daily disinfection was performed by a dedicated team and terminal disinfection was performed by EVS supervisors and/or the infection control team was the problem finally solved and C. difficile could no longer be cultured from surfaces. It’s disappointing that the intervention that worked in eliminating C. difficile room contamination comprised improvements in both daily and terminal cleaning, so it’s not possible to determine which was most important. It seems likely that a combination of the two did the trick.
Figure: sequential interventions to tackle environmental contamination with C. difficile.
The study used robust microbiology methods to sample the environment, comprising swabs plated directly onto selective agar, and gauze pads from the same surfaces cultured through broth enrichment. The % positive sites from the enriched gauzes was approximately double the swabs inoculated directly onto agar, demonstrating the value of broth enrichment for environmental sampling.
Another important study finding was that the effectiveness of room cleaning prior to UVC room disinfection was sub-optimal, indicating that the housekeepers were placing too much faith in the automated system, which is designed only to disinfect and not to clean.
So what does this odyssey mean? Firstly that a combination of interventions can be useful, and secondly, the extraordinary lengths required to eliminate C. difficile spores from the environment.
Sitzlar B, Deshpande A, Fertelli D, Kundrapu S, Sethi AK, Donskey CJ. An Environmental Disinfection Odyssey: Evaluation of Sequential Interventions to Improve Disinfection of Clostridium difficile Isolation Rooms. Infect Control Hosp Epidemiol 2013;34:459-465.
Long hours don’t necessarily correlate with productive output. A lifetime’s practice does not necessarily make a champion tennis player. An old boss once told me that “practice doesn’t make perfect; perfect practice makes perfect”. I think there’s something in this that goes some way to explaining the findings of a recent study examining the time taken to clean a hospital room and the thoroughness of cleaning.
You would expect that longer cleaning times would result in more thorough room cleaning. However, the authors used a fluorescent marker to evaluate the thoroughness of cleaning and found no correlation between the length of time cleaning a room and the thoroughness of cleaning.
Since this was an assessment of “terminal cleaning” (when the patient was discharged) you would hope that the rates of cleaning for the items in the room would be high. However, the marker was removed from less than half marked sites, and only 5% of monitors were cleaned in the 40 rooms assessed. Disappointingly, there was no correlation between completion of a room a cleaning checklist and removal of the markers.
So, the efficacy of cleaning remains low, even at patient discharge, so it is not surprising that admission to a room previously occupied by a patient with certain multidrug-resistant organisms increases the risk of acquisition!