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Management of Surfaces, Air, Water and Waste in the Healthcare Environment

Richard A. Van Enk, Ph.D., CICDirector, Infection Prevention and Epidemiology,

Bronson Methodist Hospitalvanenkr@bronsonhg.org

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ObjectivesYou will be able to:

1. Recognize and be able to assess the risks to patients and staff posed by microorganisms in the healthcare environment

2. Avoid and manage situations that increase the risk of environmental contamination

3. Select the best approach to cleaning the healthcare environment and be able to measure the effectiveness of your procedures

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Introduction• The greatest infection risk to patients is their own

microorganisms• The second highest risk is through direct

contamination of the patient by the unwashed hands of the healthcare worker

• The third highest risk to the patient is microorganisms from the environment– Although it is not the highest risk, this risk is

controllable– There are standards for environmental cleanliness– Accrediting agencies are focusing on these risks

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Introduction

• The CDC publishes clear guidelines on environmental infection control (2003)

• This topic is typical for Infection Prevention; the infection preventionist is held responsible for the cleaning of the hospital but the job is done by other departments; Facilities Services, Maintenance, Environmental Services, so the work is collaborative

• Our job is monitoring and directing

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Basic concepts and definitions

• The basic question is; “how clean should things in the healthcare environment be to eliminate the risk of infection?”– We use the (Dr. E. H.) Spaulding classification

system (1957) to assess the risk of the healthcare environment and equipment

– Still used by the CDC, FDA, and most others– Three categories of risk; drives three levels of

cleaning/disinfection, relates to what you clean it with and how often it is cleaned

– This session will deal with noncritical

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Subdivisions of the Spaulding system

• Non-critical items include two groups;– Those that touch the patient (blood pressure cuffs,

bedpans, pulse oximeters, crutches)– These that do not directly touch the patient; (floors,

walls, furniture), also called housekeeping surfaces• Of the housekeeping surfaces, divided into low-

touch and high-touch surfaces (by staff)– High-touch; bed rails, bed surface, supply cart, overbed

table, IV pump– Others; doorknobs, light switches, edge of privacy

curtains– The more it is touched, the higher the risk

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Risk factors for environmental contamination

• Amount and frequency of contamination• Virulence of the microorganisms– Which organism– How long the organism survives outside the body

• Minutes; HIV virus• Hours to days; Gram negative bacteria• Weeks to months; mycobacteria, endospores (C. difficile)

• Susceptibility of the patient• Degree and route of patient exposure– Contamination of a central line versus intact skin

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Managing the risks of noncritical items and surfaces

• Work is done by the Environmental Services

• Cleaning intervals are standardized– Daily, on discharge

(“terminal”) and as needed

• Cleaning techniques are standardized– High to low, cleaner to

dirtier, clockwise…

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Managing the risks of noncritical items and surfaces

• Recommended agents are standardized– Detergents for cleaning– Disinfectants for disinfecting– Usually a quaternary ammonium

product (“quat”)– Disinfectants be registered by the

Environmental Protection Agency (EPA) for the intended use

• The most important thing for cleaning is to exactly follow the manufacturer’s instructions for use (IFU)– Staff must know them

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Some problem areas for environmental cleaning

• Not knowing or following the product instructions for use (dilution, age, labeling)

• Not using the proper wet time– Often 10 minutes

• Not using a fresh mop and cleaning cloth for every room

• Not using microfiber cloths• Not separating clean from dirty on the

cleaning cart

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Managing the risks of water

• Water is rarely the source of infection in hospitals• Hospital tap water is not sterile, but waterborne

microorganisms are limited– Pseudomonas aeruginosa, Acinetobacter, Stenotrophomonas,

Legionella, other Gram negative bacteria, Mycobacteria (not tuberculosis)

• We usually do not do direct microbial testing of water (what is normal?)

• We track respiratory infections caused by these organisms in immunocompromised patients as a surrogate measure of risk

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Managing the risks of water

• There are three areas of special concern1. Legionella2. Hydrotherapy tubs3. Dialysis

• All require mitigation plans and procedures, monitoring

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Managing the risks of water• Other potential water

contamination problems– Ice machines– Water features– Hands-free faucets– Faucet aerators

• Get rid of them or make sure they are well-maintained

• Engineering is important– No dead legs, proper

temperature, pressure

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Managing the risks of air

• Air is rarely a risk of infection in hospitals• Other than in the operating room (HEPA-

filtration of supply air), hospital air is not sterile but generally of low risk

• There are a few situations where contaminated air is a concern1. Patients with airborne infections2. Air during construction/demolition

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Managing the risks of air

• We generally don’t do air quality testing in hospitals except for very specific situations

• We do use surrogate measures to assess airborne infection risk

1. Tuberculosis– Annual TB skin testing of staff – Daily monitoring of air pressure

2. Construction mold risk– Monitor Aspergillus and other fungal pathogens in

respiratory cultures of patients

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Managing the risks of air

• Patients with airborne infections

• There are several infections that are spread through suspension in air– Most common is tuberculosis

• We use airborne precautions to eliminate the risk– Private room, negative airflow

with monitoring, entry through anteroom, personal protective equipment for staff

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The special case of construction, demolition, and renovation

• Anytime the hospital building is disturbed, there is risk

• Construction risk is in both air and water, mostly air

• The area inside wall cavities and above suspended ceilings is considered contaminated

• The risk of construction is almost all in the dust, which contains mold spores

• Control of risk in construction is control of dust

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The Infection Control Risk Assessment Process

• The ICRA process begins as soon as the first draft of the project plans are ready

• The ICRA team meets to review the plans– IP, construction manager,

Facilities, Safety, Planning

• The IP grades the project based on risk, that drives the mitigation steps

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The Infection Control Risk Assessment Process

• The IP risk factors include:– Extent, duration, degree of dust,

types of barriers, risk of water, and type of people exposed

• The ICRA plan is signed by everyone; a contract to follow the plan

• IP regularly visits the site to make sure the plan is followed and see if anything changed

• The ICRA team meets pre-construction, midpoint and at completion to do a walk-through

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Ways to do construction safely

• The most important thing to do construction in a hospital safely is to establish a complete airtight envelope around the construction area with negative airflow to the outside– Plastic or hard walls– Air handlers with

pressure monitors

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Evaluation of infection risk for the hospital environment

• Visual inspection; doesn’t work

• Culture for bacteria; takes too long and not useful; don’t do it unless you have a very specific reason

• New; surrogate measures– Fluorescent markers– ATP bioluminescence

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New strategies to reduce microorganisms on the hospital environment

• Antimicrobial surfaces– Chemicals or metal ions

(silver or copper)

• Fogs, hydrogen peroxide vapor or peracetic acid– Takes longer, but more

effective?– BioQuell, Sanosil, Ultra-D,

Vaprosure, Glosaire

• UV Radiation– Shorter (15 minutes) but

problems with shadowing– Xenex, Optimum-UV, TRU-D,

Surfacide,

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Managing hospital waste

• Hospitals generate various types of waste– General , biohazardous,

recyclable, drugs, sharps

• IP is concerned with biohazardous waste and sharps (“regulated waste”)

• Waste segregation and safe disposal is our responsibility– Includes responsibility for

the regulated waste company

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Managing hospital linen

• We are responsible for clean and soiled hospital linen

• Keep separately• Keep covered• Staff handling soiled linen

must wear full PPE (gloves, gowns, masks, eye protection)

• Hospital linen must be processed to hospital standards– The Healthcare Laundry

Accreditation Council

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References

• Boyce, J. M. 2014. The Inanimate Environment, Chapter 19. In: W. R. Jarvis, ed. Bennett & Brachman’s Hospital Infections, sixth edition. Lippincott Williams & Wilkins, Philadelphia PA.

• Chou, T. 2014. Environmental Services, Chapter 107. In: APIC Text of Infection Control and Epidemiology, 4th Edition. APIC, Washington, DC.

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References, links• The Association for the Healthcare Environment– http://www.ahe.org/– Offers guidelines, training and certification

• OSHA guidelines on working safely in the healthcare environment– https://

www.osha.gov/SLTC/etools/hospital/housekeeping/housekeeping.html

• Association for the Advancement of Medical Instrumentation– http://www.aami.org/

• The Healthcare Laundry Accreditation Council– http://www.hlacnet.org/

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References, links

• Infection Control Risk Assessment Matrix of Precautions for Construction & Renovation. 2009. ECRE.– www.ashe.org/advocacy/organizations/CDC/pdfs/

assessment_icra.pdf• Michigan regulated waste regulations– http://www.michigan.gov/deq/0,4561,7-135-3312

_4123_4119---,00.html

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CDC Guidelines

• 2003 Guidelines for Environmental Infection Control in Health-Care Facilities– http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf

• CDC toolkit for evaluating hospital environmental services– http://

www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf

• Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005– http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf

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APIC resources• All APIC resources

– http://apic.org/Resources/Topic-specific-infection-prevention/Environmental-services

• Vogel, R. 2015. Infection Prevention Manual for Construction & Renovation. APIC, Washington, D.C.

• Bartley, J. M. APIC State-of-the-Art Report: The role of infection control during construction in health care facilities– http://apic.org/Resource_/

TinyMceFileManager/Education/EPI-201-resources/EPI201_2012_resource_Construction_and_Renovation.pdf