Introduction to CDC’s “Guidelines for Environmental Infection

Control in Health-Care Facilities”Lynne Sehulster, PhD, M(ASCP)

Division of Healthcare Quality PromotionCenters for Disease Control and Prevention

Atlanta, GA 30333

Hosted by Paul Webber paul@webbertraining.com

Sponsored by 3M Canada www.3m.ca

Objectives of Today’s Presentation

After the completion of this session, the participant will:

Be familiar with the overall content of the EIC guidelines;

See how the guidance is applied to an airborne disease outbreak; and

Be familiar with performance measures and standards on environment of care

Target Audiences for the EIC Guidelines

Hospital epidemiologists Infection control practitioners Laboratorians Facility managers and engineers Housekeeping and laundry staff Administration

Where Can I Find the EIC Guidelines?

Part II Recommendations:– MMWR 2003; 52 (RR-10): 1-44– Errata: MMWR 2003; 52 (42): 1025-6

Full text version:– http://www.cdc.gov/ncidod/hip/enviro/

guide.htm Print version:

– ASHE will print in the near future

CDC Contributors to These Guidelines

Division of Healthcare Quality Promotion:– Lynne Sehulster, PhD; Matthew Arduino, DrPH; Joe

Carpenter, PE; Rodney Donlan, PhD Division of Bacterial and Mycotic Diseases:

– David Ashford, DVM, DSc, MPH; Richard Besser, MD; Barry Fields, PhD; Michael McNeil, MBBS, MPH; Cynthia Whitney, MD; Stephanie Wong, DVM, MPH

Division of Parasitic Diseases:– Dennis Juranek, DVM

Division of Oral Health:– Jennifer Cleveland, DDS, MPH

HICPAC Sponsor:– Raymond Chinn, MD, Sharp Memorial Hospital, San Diego

U.S. Organizations Whose Standards are Incorporated into

These Guidelines

American Institute of Architects (AIA) American Society of Heating,

Refrigeration, and Air-conditioning Engineers (ASHRAE)

Association for the Advancement of Medical Instrumentation (AAMI)

U.S. Federal Regulatory Agencies

Environmental Protection Agency (EPA) Department of Labor, Occupational Safety

and Health Administration (OSHA) Food and Drug Administration (FDA) Department of Agriculture (USDA) Department of Justice (DoJ)

Air Section

Air Section Subtopics

Airborne microorganisms HVAC components and function Construction Special care settings

– Airborne infection isolation (AII)– Protective environment– Operating rooms

Other aerosol hazards (infectious)

Ventilation Specifications

SpecificationsAirborne Infection

Isolation (AII)Protective

Environment (PE)

Air pressure Negative Positive

Room air changes

> 6 ACH for existing areas; > 12 ACH for new construction or

renovation

> 12 ACH

Sealed Yes Yes

Filtration on supply air 90% (dust-spot testing) 99.97% (HEPA)

Recirculation No Yes

Ventilation Specifications

SpecificationsCritical Care

RoomOperating Room

Air pressurePositive, negative,

or neutralPositive

Room air changes > 6 ACH > 15 ACH

Sealed No Yes

Supply air filtration> 90% (dust-spot

testing)90% (dust-spot

testing)

Recirculation Yes Yes

Ventilation Specifications

Specifications Isolation Anteroom

Air pressure Positive or negative

Room air changes > 10 ACH

Sealed Yes

Supply air filtration > 90% (dust-spot testing)

Recirculation No

Construction Issues

Multidisciplinary team Risk assessment prior to project start External construction – keep dust out! Internal construction – contain the dust! Barriers Surveillance and air sampling

External Construction

Keep the facility air pressure positive to the outside

Ensure that roughing filters are changed frequently

Seal and caulk windows, especially in PE Keep doors closed as much as possible Wet dust surfaces Protect immunocompromised patients from

dust during transfers

Internal Construction

Dust containment, removal and moisture control– Educate construction workers and staff– Prepare the site– Notify staff, visitors, patients re: precautions– Relocate patients and move staff as needed– Monitor for adherence to infection control– HVAC system maintenance; water system– Daily clean-up and removal of debris

Particle Sampling

Simple to perform, immediate results Verify HVAC system performance:

– Filtration efficiency– Rank order from “dirty” to “clean”

Verify infection control measures during construction:– Construction barrier and dust

containment

Aspergillosis Outbreak

Impact of Aspergillosis, 1996

10,190 hospitalizations; average length of stay = 17.3 days

1970 deaths; mortality rate = 19.3% Economic burden in health care = $633.1 million Conditions associated with secondary diagnosis of

aspergillosis:– pneumonia, other respiratory infections, cancer or

leukemia, HIV infection

Dasbach EJ, Davies GM, Teutsch SM. Clin Infect Dis 2000; 31: 1524-1528

Impact of Aspergillosis, 1996

When there is a secondary diagnosis of aspergillosis in cancer or leukemia patients:– 26 more hospital days– $115,262 in additional costs– 4 times the mortality rate compared to

similar patients without aspergillosis

Dasbach EJ, Davies GM, Teutsch SM. Clin Infect Dis 2000; 31: 1524-1528.

Healthcare-Associated Outbreaks of IPA

Activities that cause increases in counts of airborne Aspergillus spores

Building demolition, construction, renovation, repair

Bird droppings in air ducts supplying high-risk patient care areas

Contaminated fireproofing material Damp wood, sheet rock

Aspergillosis Outbreak Hospital A

February, March 1996; September 1996 940 bed facility; Oncology Center is a 3-

story building connected to the hospital Pressure differentials, HVAC system

checked monthly Construction immediately adjacent to the

Oncology Center A. flavus emerges, previously A. fumigatus

Investigative Findings: 1996

21/29 surveillance-identified patients met case definition of “definite” or “probable”

Housekeeping procedures inadequate; clean “wet”

Univariate analysis: location near the stairwell

Large volume samplers detected A. flavus, while small volume samples were negative

Thio CL, Smith D, Merz WG, et al. Infect Control Hosp Epidemiol 2000; 21: 18-23

Investigative Findings: 1996

Pressure differentials– 25 PE rooms, 3 of which were negative

relative to the corridor (-0.35 to –3.2 Pa)– Air pressure in the central stairwell was

positive relative to the corridor of the unit– Oncology Center was neutral – negative

compared to the adjacent hospital

Environmental Control Measures: Spring 1996

Reviewed the function of the HVAC system Doors engineered to close automatically; kept

closed at all times Wet dusted and cleaned surfaces Sealed windows, exterior walls

Environmental Control Measures: Spring 1996

Closed nearby entrance; redirected pedestrian traffic

Construction policy Air sampling for fungal spores N95 respirators for high-risk patients

Environmental Control Measures: Fall 1996

Closed the stairwell between the HSCT and leukemia units

Conducted case-control studies Additional environmental cultures Reviewed housekeeping procedures Large volume air sampling Supplemental HEPA filtration when

structural modification not feasible

Water Section

Water Section Subtopics

Waterborne microorganisms Facility water systems Strategies for controlling Legionella spp. Cooling towers Hemodialysis and water quality Ice machines Hydrotherapy AERs and dental unit water lines (DUWLs)

Modes of Transmission of Microorganisms in Water

Direct contact (hydrotherapy) Ingestion of water (drinking water, ice) Indirect contact (improperly reprocessed

medical device) Inhalation of aerosols (showers) Aspiration of contaminated water

Updates on Air and Water

Updated recommendations for air and water infection control measures:

Guidelines for Preventing Health-Care-Associated Pneumonia, 2003

Available at: http://www.cdc.gov/ncidod/hip/pneumonia/ default.htm

Environmental Services Section

Environmental Services Section Subtopics

Principles of cleaning and disinfection Cleaning spills of blood/body substance Carpeting, cloth furniture Flowers and plants Pest control Special pathogen concerns and cleaning

Should Environmental Sampling Be Done?

NO, not routinely Environmental sampling may be useful:

– To verify the effectiveness of a new cleaning and disinfecting process

– To identify environmental reservoirs during outbreak situations

– Coordinate sampling with the laboratory

Environmental Sampling Section

Environmental Sampling Section Subtopics

Principles of environmental sampling

Air sampling Water sampling Environmental surface sampling

Laundry and Bedding Section

Laundry and Bedding Section Subtopics

Epidemiology Collecting and sorting soiled

linens Laundry processes Antimicrobial-impregnated

articles Pillows, mattresses Air-fluidized beds

Animals in Healthcare

Facilities Section

Animals in Healthcare Facilities Section Subtopics

Animal-assisted activities, animal-assisted therapy, resident animals

Service animals Animals as patients in healthcare

facilities Research animals in healthcare

facilities

Regulated Medical Waste

Section

Regulated Medical Waste Section Subtopics

Epidemiology Categories of medical

waste Management of waste Treatment of waste Discharge of blood, body

fluids to the sanitary sewer CJD issues

EIC Guidelines Performance Measures

Document infection control professionals’ involvement in all phases of construction

Monitor and document airflow for AII and PE, especially when occupied

Monitor water in hemodialysis settings monthly for endotoxin and bacteria

Determine source(s) of NTM Identify and respond to water damage

JCAHO – 2004 Standards for the Management of the Environment

of Care

Planning and Implementation Activities– EC 1.10 – EC 1.30: safety risks, smoking

policy, safe environment– EC 2.10: security risk management– EC 3.10: hazardous materials and wastes– EC 4.10 – EC 4.20: emergency management

JCAHO – 2004 Standards for the Management of the Environment

of Care

Planning and Implementation Activities– EC 5.10 – EC 5.50: fire safety and Life Safety

Code® issues– EC 6.10 – EC 6.20: medical equipment– EC 7.10 – EC 7.50: utilities management – EC 8.10 – EC 8.30: environmental

management

JCAHO – 2004 Standards for the Management of the Environment of Care

Measuring and Improving Activities– EC 9.10 – EC 9.30: monitoring and analyzing

environmental conditions; implementing recommendations to improve the environment of care

JCAHO – 2004 Standards for the Management of the Environment of Care

Standard– Performance expectation

Rationale– Background, justification

Elements of Performance– Steps needed to achieve the standard

Thank You!

Protect patients, protect healthcare personnel, and promote safety, quality, and

value in the healthcare delivery system

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