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Hi Barbara
Their are a number of companies that offer relatively cheap, easy to use and quick reading “kits” to measure chlorine concentrations in the air. (Drager being one example)
If you can demonstrate the levels of chlorine in the rooms being cleaned are below recommended safety levels then you should be able to satisfy OS&E and the cleaners.
However unless you gain buy in from the cleaners I suspect that you will be facing a loosing battle. Being able to quantify and demonstrate exposure levels will be one step towards doing that.
Kevin
Kevin Griffin
Bioquell Asia Pacific Pte Ltd+65 85113733
Sent using blackberry.
From: Barbara Elliott [mailto:Barbara.Elliott@SJOG.ORG.AU]
Sent: Tuesday, October 09, 2012 05:12 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Chlorine based cleaning implementationDoes anyone have any tips/ideas on how best to implement chlorine based cleaning products for one step cleaning? With the increase in C diff and MRO’s being identified we are keen to introduce chlorine based cleaning for routine cleaning.
We have had a trial here at our hospital with a product widely used in other hospital settings but have come against some resistance (excuse the pun!) from a number of cleaning staff who complain about the smell despite being given safety instructions for use and they have enlisted the OS&E department to fight the implementation of this.
Any thoughts/ suggestions gratefully received.
Thank you
BarbaraBarbara Elliott I Coordinator Infection Prevention & Control I St John of God Subiaco Hospital
Level 3, 12 Salvado Road SUBIACO WA 6008
P: 08 9382 6871 F: 08 9382 6785 M: 0413706384 E: barbara.elliott@sjog.org.au
[cid:NERBFBXVGTFF.IMAGE_15.jpg]IMPORTANT: This email and any attachments are for the sole use of the intended recipient. They may contain confidential or privileged information. This information may not necessarily be the view of St John of God Health Care Inc (SJGHC). SJGHC does not warrant, represent or guarantee the accuracy or completeness of the information. SJGHC does not accept liability for any loss or damage in connection with the information. If you are not the intended recipient then any use, reliance, interference with, disclosure, distribution or copying of this information by you is unauthorised and prohibited. If you have received this email in error then please notify the sender by return email and delete all copies. SJGHC does not waive any privilege.
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Hi Gerald
I certainly wouldn’t use a Sodium Hypochlorite solution or a caustic Soda for routine had washing.
Bleach can cause skin de-fatting, irritation and a number of other issues. Caustic soda will cause skin irritation.
Bleach is nasty stuff. We see every day the skin damage caused by some hand runs and frequent hand washing with products designed for skin use… Imagine how much worse bleach would make things.
Regards
Kevin
Thanks Kevin.
I’ve asked for the MSDS to have a look at the bleach concentrations churned out by this system as that’ll better guide our planning (from an OSH and IC perspective).
In terms of solely using the eWater for handwashing, has anyone encountered issues with this?
Would appreciate any feedback you’ve had from your catering staff.
Cheers,
Gerald
Gerald Chan
Coordinator Infection Control
St John of God Murdoch Hospital
100 Murdoch Drive
MURDOCH. WA 6150P: 9366 1552
M: 0405 495 906 (7804)
F: 9311 4685W: http://www.sjog.org.au/murdoch
Murdoch
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>>> Kevin Griffin 13/06/2012 2:38 PM >>>
Gerald
As you said the chemistry is pretty clear.
The resultant sodium Hypochlorite is basically that, normal Sodium Hypochlorite and should have stability and efficacy the same as that as a standard weak bleach solution.
Regards
Kevin
Kevin Griffin
Bioquell Asia Pacific Pte Ltd207 Henderson Road,#01-05
Singapore 159550
T: +65 6592 5145
F: +65 6227 5878
M: +65 8511 3733Dear all,
I’m keen to obtain feedback from hospitals currently using the eWater system and from anyone with a good grasp of electrolysed water.
Having seen a demo, I note that the system utilizes dissolved sodium chloride (stored in a separate container) which is then pumped into a wall mounted unit (eWater system), gets mixed with tap H2O which then goes through electrolysis… thus giving us 2 distinct byproducts comprising of sodium hypochlorite and sodium hydroxide (which the system spits out in 2 separate taps marketed as “sanitising” and “cleaning” solutions respectively).
The chemistry bit is rather clear, plain water with added salt, gets zapped and we get a weak bleach as well as caustic soda.
These mild solutions are ideal for sanitising fruits/veggies/meat in the catering industry… and that’s where they’re promoting its key use.
Aside from washing produce, the rep promoted the use of the supplied spray bottles which you then fill with eWater for disinfecting surfaces in the catering department.
They were keen on proving the effectiveness of eWater in this respect by doing swabs.
Obviously culture swabs taken before spraying the surface would yield a higher microbial count as we’re not just spraying plain water but a solution containing either bleach or caustic soda (that plus the rep was scrubbing the surfaces vigorously).
Where I start questioning this all is when the rep informs me that the eWater solution can be kept for >7 days in the spray bottles without losing its efficacy (these spray bottles get decanted each time).
Wouldn’t electrolyzed water lose its potency rather quickly? Or is it because we’ve added sodium chloride to the mix that we’ve now obtained a relatively stable bleach solution?
From the papers provided by the company, it is reported that eWater offers a higher sanitising efficiency due to its “significantly higher Oxidation-Reduction Potential (ORP)”.
This “significantly higher ORP” apparently offers a higher kill rate when compared to an un-electrolyzed comparable solution of bleach (with similar ppm counts).
They were also keen to promote the use of eWater as a replacement to handwashing with soap and water (in clinical areas as well!)… eWater does not contain emollients and with prolonged usage (fervent observance of the 5 Moments), IMO there would most definitely be reported skin issues relating to dryness. You can’t replace the effectiveness and convenience of ABHRs.
I recognise the potential of eWater in the kitchens (from a convenience perspective, space-saving, environmental, etc. compared to current processes) but do not see its use beyond that in a hospital setting.
Keen to hear the views from hospitals who’ve trialed this system… what’s your experience and has it been used out of the kitchen setting.
Thanks, all.
Regards,
Gerald
Gerald Chan
Coordinator Infection Control
St John of God Murdoch Hospital
100 Murdoch Drive
MURDOCH. WA 6150P: 9366 1552
M: 0405 495 906 (7804)
F: 9311 4685W: http://www.sjog.org.au/murdoch
Murdoch
facebook facebook.com/stjohnofgodmurdoch
twitter twitter.com/sjgh_murdoch
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Gerald
As you said the chemistry is pretty clear.
The resultant sodium Hypochlorite is basically that, normal Sodium Hypochlorite and should have stability and efficacy the same as that as a standard weak bleach solution.
Regards
Kevin
Kevin Griffin
Bioquell Asia Pacific Pte Ltd207 Henderson Road,#01-05
Singapore 159550
T: +65 6592 5145
F: +65 6227 5878
M: +65 8511 3733Dear all,
I’m keen to obtain feedback from hospitals currently using the eWater system and from anyone with a good grasp of electrolysed water.
Having seen a demo, I note that the system utilizes dissolved sodium chloride (stored in a separate container) which is then pumped into a wall mounted unit (eWater system), gets mixed with tap H2O which then goes through electrolysis… thus giving us 2 distinct byproducts comprising of sodium hypochlorite and sodium hydroxide (which the system spits out in 2 separate taps marketed as “sanitising” and “cleaning” solutions respectively).
The chemistry bit is rather clear, plain water with added salt, gets zapped and we get a weak bleach as well as caustic soda.
These mild solutions are ideal for sanitising fruits/veggies/meat in the catering industry… and that’s where they’re promoting its key use.
Aside from washing produce, the rep promoted the use of the supplied spray bottles which you then fill with eWater for disinfecting surfaces in the catering department.
They were keen on proving the effectiveness of eWater in this respect by doing swabs.
Obviously culture swabs taken before spraying the surface would yield a higher microbial count as we’re not just spraying plain water but a solution containing either bleach or caustic soda (that plus the rep was scrubbing the surfaces vigorously).
Where I start questioning this all is when the rep informs me that the eWater solution can be kept for >7 days in the spray bottles without losing its efficacy (these spray bottles get decanted each time).
Wouldn’t electrolyzed water lose its potency rather quickly? Or is it because we’ve added sodium chloride to the mix that we’ve now obtained a relatively stable bleach solution?
From the papers provided by the company, it is reported that eWater offers a higher sanitising efficiency due to its “significantly higher Oxidation-Reduction Potential (ORP)”.
This “significantly higher ORP” apparently offers a higher kill rate when compared to an un-electrolyzed comparable solution of bleach (with similar ppm counts).
They were also keen to promote the use of eWater as a replacement to handwashing with soap and water (in clinical areas as well!)… eWater does not contain emollients and with prolonged usage (fervent observance of the 5 Moments), IMO there would most definitely be reported skin issues relating to dryness. You can’t replace the effectiveness and convenience of ABHRs.
I recognise the potential of eWater in the kitchens (from a convenience perspective, space-saving, environmental, etc. compared to current processes) but do not see its use beyond that in a hospital setting.
Keen to hear the views from hospitals who’ve trialed this system… what’s your experience and has it been used out of the kitchen setting.
Thanks, all.
Regards,
Gerald
Gerald Chan
Coordinator Infection Control
St John of God Murdoch Hospital
100 Murdoch Drive
MURDOCH. WA 6150P: 9366 1552
M: 0405 495 906 (7804)
F: 9311 4685W: http://www.sjog.org.au/murdoch
Murdoch
facebook facebook.com/stjohnofgodmurdoch
twitter twitter.com/sjgh_murdoch
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Hi Fiona
I’m glad to hear that you are checking levels.
There have been a couple of papers recently looking at post cycle concentration of Hydrogen Peroxide. (Fu TY, Gent P, Kumar V. Efficacy, efficiency and safety aspects of hydrogen peroxide vapour and aerosolized hydrogen peroxide room disinfection systems. J Hosp Infect 2012; 80: 199-205.)
So many factors play a role (temperature, humidity, loading and presence of porous objects) that just waiting a set time isn’t sufficient to ensure peroxide concentrations are within safe levels. The conclusion appears to be that a independent low level electromechanical sensor must be used to confirm levels after each cycle even when forced catalytic aeration is used.
Regards
Kevin
Kevin Griffin
Bioquell Asia Pacific Pte Ltd207 Henderson Road,#01-05
Singapore 159550
T: +65 6592 5145
F: +65 6227 5878
M: +65 8511 3733Hi Kevin,
We have been guided by the manufacturer in relation to wait times prior to rooms being available for occupancy. These have been verified with the use of a hydrogen peroxide meter that records as low as 1ppm.
Kind Regards,
Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
185 Fox Valley Road, Wahroonga, NSW, 2076
_____
Fiona
How are you monitoring Hydrogen Peroxide levels in the room after disinfection ?
In Europe
The SWL (Safe Working Limit) for Hydrogen peroxide is 1ppm for a (TWA) Time Weighted Average 8 hour exposure over a 24 hour period.
The STEL (Short Term Exposure Limit) is 2ppm for 15 minutes with a maximum of 4 exposures in a 24 hour period.
The Safe Work Australia standards (http://www.safeworkaustralia.gov.au/sites/SWA/AboutSafeWorkAustralia/WhatWeDo/Publications/Documents/237/AdoptedNationalExposureStandardsAtmosphericContaminants_NOHSC1003-1995_PDF.pdf)
Have set the TWA limit at 1ppm with no STEL established
As Hydrogen Peroxide is odourless and colourless it is extremely difficult to detect at lower concentration levels ( < 5ppm) which would be well above the SWL or even the European STEL. This is especially important in rooms with porous surfaces which will outgas for some time and particularly so as patients are in these rooms for 24 hours a day.
Regards
Kevin
Kevin Griffin
Bioquell Asia Pacific Pte Ltd207 Henderson Road,#01-05
Singapore 159550
T: +65 6592 5145
F: +65 6227 5878
M: +65 8511 3733Hi Nicky,
We use a combination of disinfectants for isolation patients depending on why the patient is in isolation, what sort of clean (daily or terminal) and what sort of room it is they are in.
Where possible we use a hydrogen peroxide disinfectant for terminal cleans of infectious patient rooms, if not (e.g. an open room) it is either bleach or triclosan. I have had reports from our Cleaning Manager the staff are really on board with hydrogen peroxide disinfection as their chemical exposure has been reduced.
Kind Regards,
Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
185 Fox Valley Road, Wahroonga, NSW, 2076
_____
Hi All,
We currently follow the Australian Guidelines for the Prevention and Control of Infection in Healthcare Guidelines regarding cleaning schedules, using a detergent for most surfaces and a TGA – registered disinfectant with label claims specifying its effectiveness against specific infectious organisms for isolation rooms.
My question is the hospital is wishing to switch to a bleach product for the purposes of isolation rooms can anyone offer any evidence for or against a bleach product to assist me in my discussions, one of my concerns is the aspect of OH&S when using bleach regularly.
Thank you for your responses in advance.
Kind Regards
Nicky Swindells CNC
Infection Control Coordinator/Wound Management
Mater Hospitals Central Queensland
Rockhampton Yeppoon Gladstone
07 49313420
This email does not necessarily constitute an official representation of Mercy Health and Aged Care Central Queensland Limited. Any unauthorised use of the email or contents is strictly prohibited. Emails may be interfered with, may contain computer viruses or other defects and may not be successfully replicated on other systems. It is your responsibility to scan this message and any attachments for computer viruses or other defects and Mercy Health and Aged Care Central Queensland Limited gives no warranties in relation to these matters.
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Fiona
How are you monitoring Hydrogen Peroxide levels in the room after disinfection ?
In Europe
The SWL (Safe Working Limit) for Hydrogen peroxide is 1ppm for a (TWA) Time Weighted Average 8 hour exposure over a 24 hour period.
The STEL (Short Term Exposure Limit) is 2ppm for 15 minutes with a maximum of 4 exposures in a 24 hour period.
The Safe Work Australia standards (http://www.safeworkaustralia.gov.au/sites/SWA/AboutSafeWorkAustralia/WhatWeDo/Publications/Documents/237/AdoptedNationalExposureStandardsAtmosphericContaminants_NOHSC1003-1995_PDF.pdf)
Have set the TWA limit at 1ppm with no STEL established
As Hydrogen Peroxide is odourless and colourless it is extremely difficult to detect at lower concentration levels ( < 5ppm) which would be well above the SWL or even the European STEL. This is especially important in rooms with porous surfaces which will outgas for some time and particularly so as patients are in these rooms for 24 hours a day.
Regards
Kevin
Kevin Griffin
Bioquell Asia Pacific Pte Ltd207 Henderson Road,#01-05
Singapore 159550
T: +65 6592 5145
F: +65 6227 5878
M: +65 8511 3733Hi Nicky,
We use a combination of disinfectants for isolation patients depending on why the patient is in isolation, what sort of clean (daily or terminal) and what sort of room it is they are in.
Where possible we use a hydrogen peroxide disinfectant for terminal cleans of infectious patient rooms, if not (e.g. an open room) it is either bleach or triclosan. I have had reports from our Cleaning Manager the staff are really on board with hydrogen peroxide disinfection as their chemical exposure has been reduced.
Kind Regards,
Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
185 Fox Valley Road, Wahroonga, NSW, 2076
_____
Hi All,
We currently follow the Australian Guidelines for the Prevention and Control of Infection in Healthcare Guidelines regarding cleaning schedules, using a detergent for most surfaces and a TGA – registered disinfectant with label claims specifying its effectiveness against specific infectious organisms for isolation rooms.
My question is the hospital is wishing to switch to a bleach product for the purposes of isolation rooms can anyone offer any evidence for or against a bleach product to assist me in my discussions, one of my concerns is the aspect of OH&S when using bleach regularly.
Thank you for your responses in advance.
Kind Regards
Nicky Swindells CNC
Infection Control Coordinator/Wound Management
Mater Hospitals Central Queensland
Rockhampton Yeppoon Gladstone
07 49313420
This email does not necessarily constitute an official representation of Mercy Health and Aged Care Central Queensland Limited. Any unauthorised use of the email or contents is strictly prohibited. Emails may be interfered with, may contain computer viruses or other defects and may not be successfully replicated on other systems. It is your responsibility to scan this message and any attachments for computer viruses or other defects and Mercy Health and Aged Care Central Queensland Limited gives no warranties in relation to these matters.
If you are not the intended recipient you are hereby notified that any dissemination, distribution or reproduction of this message
is prohibited. If you have received this message in error please notify the sender immediately, then destroy the original message.
Any views expressed in this message are solely those of the individual sender, except where the sender is specifically authorised
by Sydney Adventist Hospital to state that they are the views of Sydney Adventist Hospital.
_____________________________________________________________________
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Dear Fiona
The use of UV for water decontamination and air decontamination has been around for quite some time. However its use as a surface disinfectant is relatively new particularly in the healthcare sector.
To my knowledge there are currently 3 studies looking at the use of UV in Healthcare.
Nerandzic et al (Nerandzic MM, Cadnum JL, Pultz MJ, Donskey CJ. Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms. BMC Infect Dis 2010;10:197.)
Demonstrated that UV results in a 2-3 log reduction for MRSA, Similar results for C.diff and a 3 – 4 log reduction for VRE.
Rutala et al (Rutala WA, Gergen MF, Weber DJ. Room decontamination with UV radiation. Infect Control Hosp Epidemiol 2010;31:1025-1029.)
Demonstrated a 3-4 log reduction for MRSA and VRE and a 2-3 log reduction for C.diff
Boyce et al. (Infect Control Hosp Epidemiol 2011;32(8):000-000)
Demonstrated a 1.7 to 2.9 log reduction on Cdiff spores (depending on location) using single cycle process and a 1.4 – 3.2 log reduction using a 2 stage cycle (run one cycle, love the machine and then run a second cycle) Cycle times for the single cycle varied from 34.2 to 100.1 minutes and for the multicycle process varied from 72.1 to 146.3 minutes for a single room with en-suite.
Interestingly all the studies reported that location of the surface tested relevant to the position of the machine had a big impact on findings. Much higher reductions within line of sight while far lower reduction in shadowed areas.
All the studies also reported that while UV did result in reduced frequency of MRSA, VRE and C,diff on frequently touched surfaces complete eradication of organisms was not achieved. Other Data (Owens et al. Appl Biosaf. 2005) also shows that the presence of organic matter greatly reduces efficacy.
The other issue that you may need to be aware of is material compatibility. Andersen et al. Infect Control Hosp Epidemiol. 2006.27: 729-34. And Mkinen et al. Finnish Institute of Occupational Health. 2003. Both demonstrated the possibility of rapid aging of plastics and fading of coloured paints, fabrics and textiles following repeated exposure to UV.
There are a number of non touch automated decontamination technologies on the market, all have some form of efficacy data, some with many years of peer reviewed published in use efficacy studies, some with varies degrees of clinical data in outbreak situations and even some data on clinical impact in endemic situations.
While I have no personal experience with UV the challenges (as with any other non touch decontamination technology) are the same. Implementation, ease of use, efficacy, how to verify cycles, eradication V’s reduction in environmental pathogens, material compatibility, safety, capital and running costs. It’s also worth noting that efficacy and clinical data from one UV based technology may not be replicated by another anymore than the efficacy and clinical data from one Hydrogen Peroxide based technology can be replicated by another or efficacy of all alcohol hand rubs is equal.
Before deciding on one technology I would review all the factors, look at published peer reviewed efficacy and actual in use data, look for clinical data, reference sites, published reports on use of the technology and then arrange a demonstration where you can test the equipment against a biological challenge in your own particular setting, view it in operation and get a feel for the equipment, how it would impact on your facility etc.
Kevin Griffin
Bioquell Asia Pacific Pte LtdT: +65 6592 5145
F: +65 6227 5878
M: +65 8511 3733Hi All,
I have been asked to consider the use of a UV light disinfection system in patient care areas. Does anyone use this technology? If so I would like to speak with you about what you use it for and the issues / benefits you have with it.
Kind Regards,
Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
185 Fox Valley Road, Wahroonga, NSW, 2076
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Glenys
Perhaps “routine” was a bad choice of words. What I am talking about is a standardised, more sensitive sampling technique. I dont think that anyone would argue that four or five swabs of 1cm2 gives an accurate representation of the level of biological contamination within a patient room or bed space.
Without am accurate picture it’s impossible to tell how successful any intervention has been. If you look at the various studies that do look at the level of environmental contamination there are hugely different findings as to the level of contamination before and after interventions. I have a hard time believing that such a variation is totally down to the cleaning techniques employed in the different hospitals especially when you look closely and realise that the studies reporting the higher level of contamination tend to use either more sensitive sampling techniques or perform high number of surface swabs.
Regarding “is the environment supposed to be sterile”. I think thats the debate we are having.
Firstly, I am talking about discharge cleaning and disinfection when a patient has vacated the room. Daily cleaning and disinfection is a separate issue. The standard should be different for various room categories. For example, a room vacated by a patient with Cdiff will require more attention than a room vacated by a patient who was not known to carry a pathogen. While “sterile” may be an unobtainable goal we should certainly be aiming for pathogen free. All the data show that even low levels of environmental contamination in a room increase the risk of acquisition to the next patient being admitted to that room. I would argue that if our aim is to reduce acquisition rates, and minimise risk to patients then “pathogen-free” is what we should be aiming for.
The level of environmental contamination that creates a risk is unknown but what we do know is that the risk of transmission is directly proportional to the level of contamination in the environment (Lawley et al. 2010 and Datta et al. 2011). Lawley also demonstrated that for C.diff that 1cfu cm2 of environmental contamination was sufficient to cause infection in mice. We also know that the infectious dose for some pathogens is extremely low, For noro virus 1 to 10 virus particles are sufficient to cause infection (Yezli and Otter 2011).
At the very least I think we should set a target, a maximum level of bio contamination, within a room that is acceptable (in 2004 Dancer proposed a level of < 1cfucm2) and then we need to find a way or technique that can achieve this goal, repeatedly and reliably.
I also suspect that this target will be location specific. What I mean is high risk locations such ICU, Organ transplant or Oncology will have lower maximum levels (perhaps <1cfu per cm2 as suggested by Dancer) than "lower risk" areas such as a general medical ward.
The alternative is to set a "target" decontamination challenge, say a 6 log sporicidal reduction similar to the that already implemented in for autoclaves.
I would argue that any of the data I have seen (see papers referenced in my previous reply) would suggest that traditional "cleaning" techniques cannot achieve this goal. I think that Farrin Manian's research goes the furthest to show that even enhanced environmental cleaning cannot eliminate environmental contamination and that going that extra step does have a significant impact on acquisition rates, even in an non outbreak situation. Passaretti's data demonstrate that eliminating environmental contamination significantly reduced the risk of acquisition to the patient being admitted to the room, again in a non outbreak situation.
Even if we accept this and agree that one of the new technologies are required to achieve this new standard that does not negate the need for cleaning. These technologies will only be used on a subset of rooms vacated by patients with pathogens. Also, any of the technologies you mention are adversely affected by the presence of organic matter. It goes right back to what we learnt over 100 years ago, first you clean then you disinfect.
That is why I think this debate is so important. If we accept that elimination of environmental pathogens is the goal then it will require a fundamental change in how environmental decontamination, or cleaning, is viewed and require a complete rethink of how we implement and monitor the environment in Hospitals. For that to happen then debates such as this are a vital part of achieving the consensus required.
Regards
Kevin Griffin
Director Healthcare Solutions
Bioquell Asia Pacific Pte LtdT: +65 6592 5145
F: +65 6227 5878
M: +65 8511 3733
E: Kevin.Griffin@bioquell.com
W: http://www.bioquell.com—–Original Message—–
From: AICA Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Glenys Harrington
Sent: 16 September 2011 20:30
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Environmental hygiene and disinfection as part of Standard Precautions modelKevin,
Perhaps the answer is not to look for a "defined routine sampling technique to determine a minimum standard for environmental contamination" as there will always be problems with interpreting what the results mean given the environment is not meant to be "sterile".
It would be more useful to determine what are the minimum, standardised, "reliable and repeatable" environmental decontamination procedure/s (i.e. cleaning and the use of florescent markers/cleaning and the use of microfiber/cleaning and chemical disinfection/cleaning and new technologies [HPV, UV, steam, other]) that can be shown to be linked to a sustainable reduction in infection and/or colonisation in patients in non-outbreak settings.
Regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426—–Original Message—–
From: AICA Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Friday, 16 September 2011 7:12 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: [AICA_Infexion_Connexion] Environmental hygiene and disinfection as part of Standard Precautions model[Moderator note: this message has been discussed with the original poster of this thread, and agreed that the content is not product specific and is worth consideration as part of this discussion.]
John
I read your post with great interest and think its a fantastic topic (and badly needed) for discussion.
I was going to reply to the list but to be honest I am coming from a slightly biased perspective and really do not want to the list to degenerate into another marketing tool (or for that matter to get into trouble with the people who manage the list.) so here is my (for what its worth) feelings on the topic. Any feedback appreciated and if you feel its not going to be taken or seen incorrectly then I am happy to reply to everyone.
Unfortunately while opinion is changing (and changing rather quickly) there is still debate in some circles as to the role of the environment in the spread of HCAIs. History tells us that the medical profession takes a while to change its mind (look at Semmelweis or John Snow)!
The historical belief that pathogens dont survive long in the hospital environment has been proven to be completely wrong with evidence that the many bacteria can survive weeks, months or even years in the environment. The feeling that the patient contaminated the environment but that the a contaminated environment was not a risk to a patient has been reassessed and found to be incorrect in some circumstances. The question is not now whether a contaminated environment makes an important contribution to transmission but how much of a contribution does it make. Related to this, what level of cleaning and disinfection is required? Is cleaning enough? Do we need disinfection? To what level?
What is exacerbating the problem is the lack of data on the actual level of contamination that exists in hospitals pre and post cleaning. Taking two or three swabs, even on a routine basis just isnt sensitive enough to give us that kind of data. How can sampling 2cm2 out of the entire surface area (even out of the high hand touch surfaces) even give us an indicative result on the level of contamination in a room? There is even some doubt as to the sensitivity of standard swabbing. If you look at a letter in AJIC in 2009, (Otter JA et al. Am J Infect Control
2009;37:517-8) standard swabbing found 2% of surfaces contaminated with C.diff but moving to the newer pre moistened cellulose sponges swabbing
1m2 found that 28% of surfaces were contaminated. This goes to show how inaccurate or lacking sensitivity our environmental testing, even when it done routinely.We all know that the environment contaminates healthcare workers hands, particularly the near patient environment. There are multiple studies that show this but the one that to me stands out is Hayden et al. Infect Control Hosp Epidemiol 2008;29:149-154 which showed that VRE touching that surface was posed the same risk of contaminating a HCW hands as touching the patient !!!
The most convincing evidence that contaminated surfaces are important in transmission comes from the fact that there is an increased risk to a patient of acquiring a MDRO if the previous patient in that room had a MDRO:
Martinez et al. Arch Intern Med 2003; 163: 1905-12 showed if VRE was cultured within the room the risk to the next patient increased by a factor of 2.6, Huang et al. Arch Intern Med 2006; 166: 1945-51 showed that if the prior room occupant had VRE the risk increased by a factor of 1.6 and for MRSA it was 1.3 Drees et al. Clin Infect Dis 2008; 46:
678-85. demonstrated that if VRE was cultured within the room that the risk increased by a factor of 1.9. prior room occupancy risk increased by a factor of 2.2 and more worryingly even with all the cleaning that if the previous room occupant at any tome in the previous 2 weeks had VRE the risk still increased by a factor of 2.
Shaughnessy. Infect Control Hosp Epidemiol 2011;32:201-206 showed that if the prior room occupant had C.diff that the risk to the next patient admitted increased by a factor of 2.4.
Nseir et al. Clin Microbiol Infect 2010 looked at the MDR Gram Negatives and showed that prior room occupancy was also a significant risk factor.
For Acinetobacter you risk increased by a factor of 3.8 and for Pseudomonas the risk factor increased by 2.1.So, having established that the environment contributes to transmission, the question is, what is the best way to reduce the contamination to a safe level?
We also know that cleaning and disinfection, even with the best technique will not reliably eradicate this environmental contamination.
As far back as 2004 Garry French French et al. J Hosp Infect
2004;57:31-37 showed that manual cleaning failed to eradicate environmental contamination from MRSA. Byers et al. Infect Control Hosp Epidemiol 1998;19:261-264 showed that it took an average of 2.8 disinfections to eradicate VRE from a room, Boyce et al. Infect Control Hosp 2008;29:723-729 showed that bleach leaning failed to eradicate C.diff (using the more sensitive Sponge testing 25% of surfaces remained contaminated after bleach cleaning).Similarly, Farrin Manian demonstrated at SHEA in 2010 (and since part published Manian et al. Infect Control Hosp Epidemiol
2011;32(7):667-672) that even with 2 daily bleach cleans and 4 repeat bleach cleans on patient discharge that 26.6% of rooms remained contaminated by MDR Acinetobacter or MRSA !!!!! 4 repeat bleach cleans
How many hospitals currently or will ever go to that standard ??In the same study as above, Farrin Manian showed that Hydrogen Peroxide Vapour (HPV) was more effective than the four rounds of cleaning and bleach disinfection. Furthermore he demonstrated (again in SHEA 2010 but not yet published) that by eradicating this contamination (using Hydrogen Peroxide Vapour) that there was a 54% reduction of patient acquisition rates for MDR Acinetobacter, 42% reduction on C.diff, 50% reduction in VRE and a 24% reduction in MRSA !!
Two other studies also suggest that eradicating environmental contamination reduces the acquisition of pathogens. John Boyce showed at SHEA in 2006 and since published, Boyce et al. Infect Control Hosp
2008;29:723-729 that eradicating C.diff from the environment (again using HPV) reduced patient acquisition rates for C. diff by 54%. In another study of HPV decontamination in 2008, Passaretti presented data at SHEA (still to be published and again using HPV) demonstrating that by eradicating environmental contamination from a room where the previous room occupant had a MDRO that the risk of acquisition to the next patient dropped substantially. From VRE there was a 77% reduction, for MRSA a 54% reduction for C.diff a 65% reduction and for Gram negative rods a 38% reduction. Over all the eradication of environmental contamination on patient discharge reduced the risk of acquiring a MDRO by 66%…..So, yes, routine cleaning and disinfection of the rooms of patients on MRO precautions should be done but more may need to be done a patient discharge to eradicate pathogens for the safety of the next patient.
Regarding terminology, I tend to use environmental decontamination to encompass both cleaning and disinfection, but standardisation would be helpful here.
I think we need to define a routine sampling technique and a minimum standard for environmental contamination that must be achieved before a patient can be admitted to a room or bed-space. (I suspect different standards can be set for different areas depending on risk, for example in Oncology, ICU and Organ transplant the standard may be <1 CFU per CM2 for general medical ward it could be <2CFU per cm2.) There are some proposed guidelines (J Hosp Infect 2004; 56: 10-15 but these have not been adopted widely). We need to find a reliable and repeatable method of achieving this standard and it needs to be implemented and monitored.
And there needs to be a budget made available for this.Regards
Kevin Griffin
Director Healthcare Solutions
Bioquell Asia Pacific Pte LtdT: +65 6592 5145
F: +65 6227 5878
M: +65 8511 3733
E: Kevin.Griffin@bioquell.com
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