Transcript hiv care for the internist part i - Massachusetts Coalition for the

Improving Environmental Cleaning and
Disinfection in Healthcare Settings
A New Metric for an old Job
Massachusetts Coalition
for the
Prevention of Medical Errors
March 26, 2008
Philip C. Carling, M.D.
Director of Infectious Diseases and Hospital
Epidemiology at Carney Hospital
and Faculty of Boston University School of Medicine
How Important is Environmental
Contamination in Hospitals?
Contaminated Surfaces
VRE
Bed Rails
+++++++
Bed Table
++++++
Door Knobs
++
Doors
+++
Call Button
+++
Chair
++
Tray Table
+++
Toilet Surface
+
Sink Surface
+
Bedpan Cleaner
MRSA
+
+
++
+
+
+
++
+
C. difficile
+++
+
++
++
++++
+++
+
P. Carling, M.D. 3/08
Surface Contamination of Near-patient
Environment
23 Studies
100
% CONTAMINATED
80
60
40
20
0
C. DIFFICILE
VRE
MRSA
P. Carling, M.D. 3/08
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
How Well Do Environmental
Disinfectants Work ?
How Well Does Environmental
Disinfecting Work ?
• Phenolic
Compounds
• Quartinary
Amonium
Compounds
• Chloride
Disinfectants
• Formaldehyde
ALL
Kill a wide range
of microbial
pathogens
Work Rapidly
Work effectively
in clinical
settings
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?
CMS
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
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
How Well Does Environmental
Cleaning Work ?
GOAL OF THE PROJECT
To develop a surrogate marking
system to evaluate the effectiveness of
environmental cleaning/disinfection of
the near-patient environment
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
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
Preliminary Results – Three Hospitals
100
92
% OBJECTSCLEANED
86
82
80
56
60
45
42
40
20
0
HOSPITAL A
P. Carling, M.D. 3/08
HOSPITAL B
HOSPITAL C
Clinical Infectious Diseases – February 2006
The Healthcare Environmental
Hygiene Study Group
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
Baseline Environmental Evaluation of
35 Acute Care Hospitals
8
Hospitals
Mean = 48.5 %
6
4
2
0
1-5%
1115%
2125%
3135%
4145%
5155%
6165%
% of Objects Cleaned
7175%
8185%
9195%
P. Carling, M.D. 3/08
PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN
ACUTE CARE HOSPITALS
20
%
P. Carling, M.D. 3/08
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
Hospitals Environmental Hygiene Study Group
Hospital Results
% of Objects Cleaned
80
70
60
50
40
PRE INTERVENTION
POST INTERVENTION
P. Carling, M.D. 3/08
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
Does it make a difference?
Studies in which have evaluated the relevance and
epidemiology of environmental HAPs
9
8
ENHANCED CLEANING = DECREASED INFECTION
ENVIRONMENTAL PATHOGENS TO HCW HANDS
PUBLISHED REPORTS
7
ENVIRONMENTAL PATHOGENS TO PATIENTS
6
5
4
3
2
1
0
1994
1996
1998
2000
2002
2004
2006
2008
P. Carling, M.D. 3/08
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: [email protected]
P. Carling, M.D. 3/08