Transcript Document 7212833

Optimizing Environmental Hygiene:
The Key to C. Difficile Control
Philip C. Carling, M.D.
Carney Hospital
and
Boston University School of Medicine
Massachusetts CDI Preventative
Collaboration
June 24, 2010
Consultant – Ecolab, Steris, ASHES
[email protected]
Pending Patent License - Ecolab
Presentation Objectives
A. Understand current issues related to
the roe of the environment in CDI
transmission
B. Understand the basis for suboptimal
healthcare environmental cleaning
C. Appreciate the complexity of making
practice recommendations without
modern evidenced based studies
Background: Epidemiology
Risk Factors
•
•
•
•
•
•
•
Antimicrobial exposure
Acquisition of C. difficile
Advanced age
Underlying illness
Immunosuppression
Tube feeds
? Gastric acid suppression
Main modifiable risk
factors
How contaminated is the hospital
environment?
Contaminated Surfaces
VRE
Bed Rails
+++++++
Bed Table
++++++
Door Knobs
++
Doors
+++
Call Button
+++
Chair
++
Tray Table
+++
Toilet Surface
+
Sink Surface
+
Bedpan Cleaner
MRSA
+
+
++
+
+
+
++
+
C. difficile
+++
+
++
++
++++
+++
+
Surface Contamination of Near-patient
Environment
23 Studies
100
% CONTAMINATED
80
60
40
20
0
C. DIFFICILE
VRE
MRSA
Skin Contamination %
How does it get there?
100
SKIN - ANY
80
60
64
CHEST/ABDOMEN
40
20
20
0
Patients with CDAD
Environmental Contamination %
GROIN
78
100
Asymptomatic
Carriers
ENVIRONMENT ANY
CALL BUTTON
BED RAIL
TABLE
TELEPHONE
80
78
60
Non carriers
60
40
30
20
0
Patients with CDAD
Asymptomatic
Carriers
Non carriers
Riggs M,etal. CID 2007;45:592
PCR COLONY COUNTS/10cm2
C. Difficile Environmental Contamination
6000
CDAD POS. PATIENT ROOMS
CDAD NEG. PATIENT ROOMS
3000
0
PT HANDS
NEAR
DISTANT
ENVIRONMENT ENVIRONMENT
HCW HANDS
Mutters R, etal. J Hosp Infect. 2009; 71: 43-48
Can C. diff be transmitted from the
environment to patients?
Increased acquisition risk from prior room occupant
7 studies as of July 2010
Huang
Hardy
Dress
Shaugnessy
Datta
0
60
120
180
Increased Risk of Aquisition (%)
Two additional studies showed very significant risk without quantification – Martinez
(VRE) and Wilks (Acinetobacter)
% RISK OF DEVELOPING CDAD
C. difficile Transmission to Prior
Room Occupants
20
10
0
FORMER CDAD
OCCUPANCY
NO PRIOR CDAD
OCCUPANCY
Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008
% RISK OF DEVELOPING CDAD
C. difficile Transmission to Prior
Room Occupants
20
110%
Increased
risk
10
0
FORMER CDAD
OCCUPANCY
NO PRIOR CDAD
OCCUPANCY
Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008
Can better cleaning favorably impact
environmental contamination with C.
diff ?
Studies reporting a favorable impact of enhanced
environmental hygiene during a CDAD outbreak
PUBLISHED REPORTS
4
3
2
1
0
<
1996
1996
1998
2000
2002
2004
2006
2008
June 2007
Methods:
Culture based evaluation - Pre-intervention;
- after routine terminal cleaning;
- after terminal cleaning by the research staff;
- following education of the ES staff and administrative interventions
Percentage of C. difficile-positive cultures
Percent positive
n=9 rooms
80
70
60
50
40
30
20
10
0
Bedrail
Bedside table
Phone
Call button
Toilet
Door handle
Before cleaning
*Similar results found after ES
cleaning following
interventions
After
After
housekeeping disinfection by
cleaning
research team*
Eckstein et al, BMC Infect Dis. 2007 Jun 21;7:61.
The impact of HP vapor on C. difficile
"ENVIRONMENTAL CONTAMINATION"
% SURFACES CONTAMINATED
30
25
"ENVIRONMENTAL
CONTAMINATION"
20
15
10
5
0
-5
Pre HPV
Post HPV
Boyce J etal. ICHE 2008
The impact of HP vapor on C. difficile
2
1.8
25
"ENVIRONMENTAL
CONTAMINATION"
"C. DIFF RATE"
20
1.6
1.4
1.2
15
1
10
0.8
0.6
5
C. DIFF RATE / 1000 PTD
% SURFACES CONTAMINATED
30
0.4
0
0.2
-5
0
Pre HPV
Post HPV
Boyce J etal. ICHE 2008
Does improving environmental hygiene
have a measurable Impact on
environmental contamination
with C. difficile?
Eckstein – 2007
Boyce – 2008
Impact on Transmission?
Quasi-experimental support –
Substantial but limited by study
design and evaluation in outbreak
settings
Why is C. being transmitted to
susceptible patients in our
hospitals ?
Don’t forget the Rutala Equation
Product + Practice
Don’t forget the Rutala Equation
Product + Practice
The other name for Hygienic Practice ?
The other name for Hygienic Practice
The Missing
Link
The other name for Hygienic Practice
The Missing
Link
Why?
Thoroughness of Environmental Cleaning
100
DAILY CLEANING
% Cleaned
80
TERMINAL CLEANING
60
40
20
0
HEH
S
DIA
IOW
OTH
OP
NIC
EM
ICU
AM
MD
LON
E
LYS
S
B
U
C
A
D
E
G
R
VEH
CH
LIN
A IL
RH
GH
ATI
HO
T
IS
E
E
IC
Y
RM
NG
OSP
IC L
SP
OS
MO
P
ES
RO
OM
S
Thoroughness of Environmental Cleaning
100
DAILY CLEANING
% Cleaned
80
TERMINAL CLEANING
>65,000
Objects
60
40
20
Mean = 34%
0
HEH
S
DIA
IOW
OTH
OP
NIC
EM
ICU
AM
MD
LON
E
LYS
S
B
U
C
A
D
E
G
R
VEH
CH
LIN
A IL
RH
GH
ATI
HO
T
IS
E
E
IC
Y
RM
NG
OSP
IC L
SP
OS
MO
P
ES
RO
OM
S
Increased risk of prior room
occupant transmission
MRSA, VRE, CD,AB
0
20
8 Reports
10 Studies
40%
Baseline Thoroughness of Cleaning
74%
40
60
%
80
100
Why is environmental cleaning
not being done thoroughly ?
“Environmental Rounds” to
search for problems in cleaning
performance
or….
The search fro the Nefarious
Dust Bunny
What does this finding say about
disinfection cleaning at this hospital???
Finding the “Brown Spot”
ES Director
IP
ES Supervisor
What does this finding say about
disinfection cleaning at this hospital???
Finding the “Brown Spot”
How long has this
been here?
ES Director
ES Supervisor
The nurses are right.
ES atIP
this hospital is
terrible
What does this finding say about
disinfection cleaning at this hospital???
Finding the “Brown Spot”
Who can I blame?
How long has this
been here?
ES Director
ES Supervisor
The nurses are right.
ES atIP
this hospital is
terrible
What does this finding say about
disinfection cleaning at this hospital???
Finding the “Brown Spot”
Who can I blame?
I hate Environmental
Rounds…. Why
doesn’t this IP get
a life?
How long has this
been here?
ES Director
ES Supervisor
The nurses are right.
ES atIP
this hospital is
terrible
What does this finding say about
disinfection cleaning at this hospital???
Conventional monitoring of health care
environmental cleaning
“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
Can the thoroughness of
Hygienic Cleaning be improved?
RESULTS
Targeting Solution (AKA – Goo)
Phase I: Covert Baseline Environmental Cleaning Evaluation
Terminal cleaning after 1 or 2 patient cycles
Cleaned, empty
room
identified
Phase II:
Room marked
Room evaluated
A. Programmatic Analysis
B. Educational Interventions – ES staff
Phase III: Re-evaluation of Cleaning and feedback to ES
Terminal cleaning after 1 or 2 patient cycles
Cleaned, empty
room
identified
Room marked
Room evaluated
Baseline Environmental Evaluation of
36 Acute Care Hospitals
8
Hospitals
Mean = 48.5 %
6
4
(20,056 Objects)
2
0
1-5%
1115%
2125%
3135%
4145%
5155%
6165%
% of Objects Cleaned
7175%
8185%
9195%
% of Objects Cleaned
Hospitals Environmental Hygiene Study Group
36 Hospital Results
80
70
60
50
40
PRE INTERVENTION
Resource Neutral
POST INTERVENTION
P = <.0001
Increased risk of prior room occupant
transmission
74%
40%
Baseline Thoroughness of Cleaning
11 Studies
Thoroughness of cleaning following
structured interventions
82%
0
20
40
60
%
80
100
Are such results sustainable?
Thoroughness of Terminal Room
Environmental Cleaning
10 0
90%
GOAL
80
60
%
CLEAN
40
20
0
PRE
PHASE II PHASE III
Was it a lot of work?
Number of Objects to be Monitored
Sample Size Required to Monitor Cleaning Practice
600
500
400
300
200
100
0
20%
30%
40%
50%
60%
70%
80%
Thoroughness of Cleaning
Chow S, Shao J, Wang H. Sample size calculations in clinical research. 2ND ed. Chapman & Hall; 2007.
These results suggest that substantial
improvements in environmental cleaning are
achievable and sustainable
Leadership
Enid K. Eck, RN, MPH
Regional Director, Infection
Prevention and Control
Kaiser Permanente,
Dedicated, Energetic,
Supportive and Optimistic!
Programmatic Approach
Senior leadership support
ES buy in
Transparency
Blameless Benchmarking
Problems
Solutions
open cooperation
Recognition of success
at all levels
Improved Thoroughness of hygienic
cleaning is a worthy goal given the
billions of dollars involved…but will it
impact transmission of HAPs ?
Increased risk of prior room occupant
transmission
74%
40%
Baseline thoroughness of Cleaning
11 Studies
Thoroughness of cleaning following structured
interventions
82%
Programmatic decrease in environmental
contamination
MRSA, VRE, CD, AB
0
20
68%
40
60
%
8 Reports
80
100
Increased risk of prior room occupant
transmission
74%
40%
Baseline thoroughness of Cleaning
11 Studies
Thoroughness of cleaning following
structured interventions
Programmatic decrease in
environmental contamination
Programmatic decrease in aquisition
82%
MRSA, VRE, CD, AB
MRSA, VRE
0
20
68%
8 Reports
4 Studies
40
60
%
80
100
Given these results and in the context of
the economic issues involved we need to
seriously consider moving beyond
Conventional Monitoring of health care
environmental cleaning
Cleaning House: A New Metric in the
Objective Evaluation of
Environmental Cleaning
Approaches to Programmatic
Environmental Cleaning Monitoring
Conventional Program
Enhanced Program
• Subjective visual
assessment
• Deficiency oriented
• Episodic evaluation
• Problem detection
feedback
• Open definition of
correctable interventions
• Objective quantitative
assessment
• Performance oriented
• Ongoing cyclic monitoring
• Objective performance
feed back
• Goal oriented structured
Process Improvement
model
Carling PC, Bartley JM. AJIC (In-press)
AJIC Title Picture
Am J Infect Control 2010;38:S41-50 (June)
Conclusion – Where we are now
Terminal Cleaning Efficiency Vs. Thoroughness
100
"SINGLE CLEANING"
Thorougness (% Cleaned)
80
60
40
20
0
0
10
20
30
40
Minutes
50
60
70
80
Conclusion – Where we can and need to go
Terminal Cleaning Efficiency Vs. Thoroughness
Thorougness (% Cleaned)
100
80
60
40
20
0
0
10
20
30
Minutes
40
50
60
So what about the
disinfectant?
Don’t forget the Rutala Equation
Product + Practice
Issues with disinfectants, detergents, cloths, etc.
• What is the true role of bleach in
disinfection cleaning?
• How effective will new green
disinfectants be?
• When is it okay to use detergents?
• Where are we going with dwell
time?
• Where does microfibre fit in?
• If effective killing with bleach takes
many minutes, what is the clinical
efficacy of bleach wipes?
• What is the correct amount of
quat?
• Are disinfectants being mixed
accurately?
Now is the time to carefully evaluate
the role of product in the clinical setting
Old assumptions and new claims of
effectiveness of all tools, chemicals and
technological interventions must:
- be quantitatively evaluated clinically
- while objectively analyzing the
thoroughness of cleaning practice
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.
A final thought about C. diff
rates in hospitals
With respect to environmental hygiene
…can C. diff rates serve as the
With respect to environmental hygiene
…can C. diff rates serve as the
??
Presentation Objectives
A. Understand current issues related to
the roe of the environment in CDI
transmission
B. Understand the basis for suboptimal
healthcare environmental cleaning
C. Appreciate the complexity of making
practice recommendations without
modern evidenced based studies
Thanks for inviting me !!
Questions – Comments?
[email protected]