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1
'Environmental Cleaning & Disinfection to Eliminate
Persistent Resistant Micro Organisms
in the Healthcare Setting'
Marilyn Leadsom (Presenter)
Infection Prevention Practitioner
Maletje Griesel (Acknowledgment)
Senior Pharmacist
Netcare Ltd
A ‘Birds Eye View ‘of the
maze we must navigate!
2
Hygiene in healthcare is nothing new… but the
challenges have taken on a new significance!
Florence Nightingale was a pioneer in establishing the importance of sanitation in hospitals
From 1858 she meticulously gathered data relating death tolls in hospitals to cleanliness, and,
because of her novel methods of communicating this data, she was also dubbed a pioneer in applied
statistics, through the use of the Rose Diagrams.
Nightingale noted that 10 times more soldiers died of the so-called filth diseases, such as cholera,
dysentery, typhoid etc. than those who succumbed to bullets and cannon balls.
She determined the cause to be related to the overcrowding, paltry latrines, sewer facilities &
inadequate ventilation.
So here we are 159 years later faced with a similar problem … no antibiotics then & the end of the
antibiotic era upon us.
We do however have all the expertise & support systems needed, but we should understand
healthcare hygiene ,needs to be taken to a higher level of importance.
1858-2017
From the pre to post antibiotic
era
3
Environmental hygiene in healthcare facilities is important on a
number of fronts…………..
‘the patients perspective’’- we are judged on how clean our premises appear to be
- they need to be aesthetically impressive
- patients have an increased awareness of how hygiene affects infection rates
- the patient has a right to feel safe & expect results in line with healthcare costs
- patients may wonder if we cant keep our hospital clean how will we cope with the complicated work?
- will they feel confident? Will they recommend our hospital?
Its still not good
enough is it?
4
Patient Feedback
‘during your hospital stay, how often was
your room & bathroom kept clean’?
5
Our journey of improvement began in 2011, continues until
this present time & has evolved into the ‘Stop The Superbug
Bundle’, which still requires upscaling.
In 2011 we were unexpectedly faced with the onset of cases of Carbapenem-resistant Enterobacteriaceae
(CRE) (Klebsiella pneumoniae 0XA 181 & 48)
It was 72 days before the offending enzyme could be identified by the laboratory & by this time 21 positive
in-patients were identified by tracking & tracing throughout the hospital.
We were dealing with a situation we didn’t fully understand, was causing fear amongst the workforce from
whom there were more questions than we had answers.
The antibiotic stewardship committee was in its embryonic phase & this galvanised us into action.
There cant be too many people sitting here today who have not faced similar challenges
in the last five years & whom continue to battle with sudden increases in cases on a regular basis.
6
Why is cleaning & disinfection more important now than at any other
time in recent history?
• Resistant micro-organisms have become increasingly difficult to treat in patients & eradicate from the
healthcare environment.
• The age of untreatable infections has arrived and England’s chief medical officer has recently warned
of a ‘post–antibiotic apocalypse’ & states that this will spell ‘the end of modern medicine’
• Any outbreak has a significant impact on the daily operational activities in any healthcare institution.
But without antibiotics to fight infections, common medical interventions such as caesarean sections,
transplants, hip replacements & cancer treatments would become incredibly risky, if not imponderable
as per the recent suspension of the BMT program in Italy.
• Patients do & will continue to suffer disruption to their lives at many levels. Their length of stay,
morbidity and mortality rates do increase when faced with any infection but the devastation caused by
those that are untreatable cannot be underestimated.
• We will all have concerns about our work & the health & well being of our families
7
Questions & Suggestions at the ABS committee
The questions posed were:
‘how do we & can we put the cat back in the bag’?
‘how do we reduce the number of antibiotic resistant
micro-organisms, antibiotic usage & infection rates?
We began to formulate & roll out a plan to eliminate CRE
A sensible suggestion:
• In early 2012 Dr Adrian Brink arrived in Cape Town to gather epidemiological data as the cases
continued to rumble on & gave me the following advice.
• He said ‘M you will never ‘search & destroy’.
• ‘search & contain’ is your only hope!
• And so began our journey into the unknown!
We were trying to put the ‘cat back in the bag’ and were informed ‘the horse had already bolted’!
This conundrum set the scene of everything we have sought to implement since!
8
The IPP & Clinical Pharmacist proposed the following theory
• Increased infection rates lead to an increase in antibiotic usage
• The latter increases the likelihood of antibiotic resistance developing
• Infections become more difficult & expensive to treat
• Infections and resistance to antibiotics increase the risk of morbidity and mortality
Conversely…………aims
• If infections are reduced
• Less antibiotics will be needed
• Resistance is less likely to develop
• Infections become more easily treatable
• Morbidity and mortality rates are reduced
• Patient outcomes are improved
Context
9
M & M’s Model – we can choose the A Virtuous upward Circle or
suffer the consequences of A Vicious downward Spiral
• Increased Resistance
• Increased Patient M&M
• Increased Use of Antibiotics
• Increased Infection Rates
Decreased
Infection Rates
Decreased Use of
Antibiotics
Decreased Resistance
Decrease In Patient
M&M
10
In order to co-ordinate preventative processes to achieve the aims we
DEVELOPED A BUNDLE OF BUILDING BLOCKS (concentrating on 6
basic areas) which when applied rigorously & consistently can & do
improve patient outcomes
Improved Patient
Outcome
Early Detection
Isolation Precautions
Hand Hygiene
Enhanced Environment
al Hygiene
Best Care Always
Antibiotic Stewardship
ABS & HH get
maximum
coverage in the
press but EEH not
so much.
As the antibiotic
armamentarium
dwindles we will
become more
intent in
eliminating micro-
organisms from
the healthcare
environment to
limit exposure &
spread.
11
Role of environmental surfaces in the
transmission of healthcare related pathogens
Environmental surfaces were once thought to play a negligible
role in the endemic transmission of healthcare related pathogens.
(Weber DJ, et al. The role of the surface environment in healthcare-associated infections. 2013)
However, recent data indicates that contaminated surfaces & equipment act as reservoirs, are transmitted
by hands & play an important role in both endemic and epidemic transmission of certain
pathogens that cause HAI. Biofilms not fully understood until recently, urgently need disrupting!
CDI, MRSA, VRE, CRE, Norovirus, but to name a few pathogens share the ability to be shed from
infected or colonised patients, have the ability to survive on dry surfaces for extended periods, and are
difficult to eradicate by routine cleaning and disinfection.
It is well documented that pathogens are left behind by prior occupants in patient care areas despite
cleaning having occurred.
(Huang, et al 2006)
The continued emergence of antimicrobial resistance demands collaboration between the
environmental services team & that they be included in the healthcare delivery team
.
.
12
• The Infectious Disease Society of America has highlighted a clique of micro-organisms –
acronymically termed the ESKAPE pathogens – capable of ‘escaping’ the biocidal action of
antibiotics & sometimes disinfectants. They collectively represent new paradigms in
pathogenesis, transmission and resistance.
• Urgent focus on preventing these dangerous pathogens plus detecting, containing and
eliminating them should now be regarded as routine.
• The ‘stop the superbug bundle’ is central to the infection prevention strategy, which will serve
to eliminate the ESKAPED pathogens below
• E Enterococcus faecium (VRE) 5 days to 46 mnths
• S Staphylococcus aureus (MRSA) 7 days to 12 mnths
• K Klebsiella pneumoniae (ESBL) 2 hrs to 30 mnths
• A Acinetobacter baumannii (MDR/CRAB) 3 days to 11 mnths
• P Pseudomonas aeruginosa (MDR/CRPA) 6 hrs to 16 mnths
• E Enterobacter spp
• D Clostridium Difficile (CDI) > 5 mnths
Ref: BMC Infectious Diseases 20016 & adapted from
Kramer et al
One of many references each varies slightly
Norovirus
8 hrs to 2
months
CAURIS
13
The IPC should consider
• the service level agreement. Are there sufficient staff & how are absences dealt with?
• how much time is allocated to routine work & how will non routine work be accommodated
without other areas falling behind?
• the role of surface selection (hard & soft surfaces) – new technologies
• training of housekeeping, nursing & paraprofessional staff
• behavioural change through education, understanding & involvement
• designated housekeeping technicians (internal & external pre VHF)
• methods of cleaning: who does what, with what, to what, how & when
• which disinfectants to use & when. Who mixes them & how
• knowledge of all areas to be cleaned (MRI, portable x-ray, dialysis machines)
• methods of evaluating cleaning, using which comprehensive tools both during &
afterwards?
• on the spot visual checks, detailed inspections/hygiene audits (internal & external)
14
The Ten & Twelve Do’s Of
Destruction
2011-2013
“The Twelve D’s of Destruction” (Search & Destroy/Control)
•Detect (screen on arrival and every 3rd day)•Dedicated (staff/restrict staff movement)•Divert (close the unit)•De-clutter (all unnecessary items to be removed from patient areas as a preventative measure)
•Deep & detailed cleaning ( meticulous & vigorous physical cleaning with detergent)•Decontaminate (terminal disinfection)•Destroy (anything that cannot be disinfected)•Decorate (painting if required preferably with anti-microbial paint)•Discharge (as soon as possible directly from the source unit)•Discourage dissemination (isolate, do not move patients unless essential)•Drains (replace old ‘u’ bends and taps. Treat drains regularly & after affected patients)•Disinfect (with dry mist vaporised hydrogen peroxide)
Preventative &
Curative Measures
shown in Italics
15
Declutter - miss one spot? You miss the lot!
Scrutinise the environment & move out
any non essential items
Keep organised
Reduce contamination & therefore
cleaning & dissemination
16
Declutter & utilise Dust Cover
17
High Touch Points – Bio Fluorescence Technology
Measuring the effectiveness of cleaning
10 or more high touch
points are checked by
housekeeping
& a further 10 by
nursing staff
(utilising a checklist
which calculates the
score)
We use this
-randomly for routine
cleaning
-specifically in isolation
areas
-deep cleaning blitzes
18
Environmental Cleaning Technicians
‘The Glitterbug Kit’
With kind permission
of Thelma Dyantyi
19
Decontaminate….. is the equipment clean & well
maintained? Who cleans it, when with what etc.
How often do we inspect it?
20
Think of the waterless world with no antibiotics.
Wipes are available & more hygienic!
Patient Wash Wipes?
Environmental Cleaning Wipes?
21
Preventative or Curative Cleaning & Disinfection?
• We should not base our
methodology on actually identifying
an isolate
• Many micro organisms go
undetected
• Because if no action is taken, it has
been estimated that drug resistant
infections will kill 10 million people a
year by 2050
With kind permission of Ndileka
Ngxambuza
An Environmental Cleaning Technician
(with permission)
22
Destroy anything that cannot be
cleaned & disinfected
Sticky Stuff.Sellotape is like Sushi for Serratia
• Line ends of tape in a drawer
• Half empty tubes
• Tape dangling from equipment
• Prestik
• Cardboard Boxes
False
Economy
23
Destruction – when in doubt throw it out!
Toilet rolls
Paper Towels
Contaminated
Disinfectants
24
Preparation & attention to detail is the key to success
25
All surfaces must be
exposed to the fog
Mattress & pillows are
checked & discarded if
torn or perished
Pre packed items on
bed frame can be
fogged as can
paperwork
A drying rack for wet
laundry is useful for the
paperwork!
26
Those ‘hard to reach nooks & crannies’
(nightmare on wire street)
A solid reason for using fogging or other similar
technologies
A bed being cleaned & disinfected ready
for VHP between patients in UK
27
Drains can be death traps?
Splashback of Biofilm.
Ref: Applied and Environmental Microbiology, 2017
Basins
Baths
Toilets
Sluices
Macerators
Design of
reticulation
system & hand
washing basin
Drain cleaning after
ESKAPED organisms
& regularly routinely
28
Is your facility ‘super clean’?
An external objective auditor with the
authority not to continue if not clean
(fogging technician) is appointed
Clear instructions with name of chemical
and dose & time of opening on the sealed
door.
Maximise on the occasion as it is not
cheap! Add in other items that need super
cleaning.
Nurses are very inventive
29
Cleaning Run Chart – Housekeeping – A Story Board
If you cant measure it you cant manage it!
92,5
98
93
95
98
99,5
93,2
91,3
94,6
86,9
90,5
97,5
96,4
97,5
80,0
82,0
84,0
86,0
88,0
90,0
92,0
94,0
96,0
98,0
100,0
Compliance %
Median 1
Not enough
staff for size &
high tech
surfaces
Low morale as
news of
changes
Started training
Morale
restored.
Extra Staff
Shiny New
Hospital
30
What quality assurance can we give our patients?
What evidence do we have to support the provision of safe clean
environment?
How much are we prepared to pay to ensure the above?
Cost the 2011 outbreak was estimated as R750,000
Cost of 2017 outbreaks in London & Manchester cost the NHS 10 million
GBP
Medico-legal risk & compensation?
The full extent of the ESCAPED organisms is not known, reporting is not
mandatory & healthcare institutions do not publish cases even locally so we
can put alert systems in place
‘Lets face it nobody should get sick whilst trying to
get well’!
31
Processes Demonstrated & Now Outcomes
The infection rate has been reduced from
• 5/1000 patient days in 2012
• 1/1000 patient days in 2017
32
CRE cases between 2012 & 2017
0
50
100
150
200
250
300
03-Dec-11 03-Dec-12 03-Dec-13 03-Dec-14 03-Dec-15 03-Dec-16
Da
ys
Be
twee
n
DaysBetween()
SICU & CCU
Closures
21 cases Dec 2011 to Dec 2012
4 cases in 2013
4 cases in 2014
5 cases in 2015
2 cases in 2016
SICU & CCU
Closures
21 cases Dec 2011 to Dec 2012
4 cases in 2013
4 cases in 2014
5 cases in 2015
4 cases in 2016
4 cases in 2017
10 D's 12 D's SSBBBuidling Blocks
33
Hand Hygiene
Compliance
October 2016 –
September 2017
5023 HH Interventions Measured
Compliance 87.22
34
Oct/14
No
v/1
4
De
c/1
4
Jan/1
5
Fe
b/1
5
Ma
r/15
Apr/
15
Ma
y/1
5
Jun/1
5
Jul/15
Aug/1
5
Sep/1
5
Oct/15
No
v/1
5
De
c/1
5
Jan/1
6
Feb
/16
Ma
r/16
Apr/
16
Ma
y/1
6
Jun/1
6
Jul/16
Aug/1
6
Sep/1
6
Oct/16
No
v/1
6
De
c/1
6
Jan/1
7
Feb
/17
Ma
r/17
Apr/
17
Ma
y/1
7
Jun/1
7
Jul/17
Aug/1
7
Sep/1
7
Hospital Antibiotics Utilization - DDD per 100 Bed Days
Netcare CBMH
Median
DDD/100 bed day run chart (Oct 2014-Sept 2017)
* DDD – Define Daily Dose (WHO)
March 2012: ABS
prescription
implemented
March 2013:
Collaboration between
IPP & Senior
PharmacistOct 2015: Building Blocks
implemented
Feb 2015: Electronic ABS and
IPP modules launched
Oct 2013:12 D’s of destructionDec 2016: Hospital move
2017: Enhanced
Environment Cleaning
2017: ABS improve clinician
collaboration
Improvement
shown –
reduction of
DDD’s in last 6
months
10%
reduction in
DDD’s in
last 3 years
35
Conclusion…………interconnectedness ….a
world view
An interconnected system in the workplace is the process of linking
manpower, technological resources & other items of capital together.
Typically it will improve efficiency, effectiveness & accountability
throughout the organisation
If these three key disciplines are aligned then
‘#superbugswillfall’
Reduction of
Persistent Resistant
Micro-organisms
ABS
EEHHH