Optimizing Environmental Hygiene: The Key to C. Difficile Control Philip C. Carling, M.D. Carney Hospital and Boston University School of Medicine

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Optimizing Environmental Hygiene The Key to C.
Difficile Control
Philip C. Carling, M.D.Carney Hospital
andBoston University School of Medicine

• Massachusetts CDI Preventative Collaboration
• June 24, 2010

Consultant Ecolab, Steris, ASHES Pending Patent
License - Ecolab
Pcarling_at_cchcs.org
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Presentation Objectives

1. Understand current issues related to the roe of
   the environment in CDI transmission
2. Understand the basis for suboptimal healthcare
   environmental cleaning
3. Appreciate the complexity of making practice
   recommendations without modern evidenced based
   studies

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Background EpidemiologyRisk Factors

• Antimicrobial exposure
• Acquisition of C. difficile
• Advanced age
• Underlying illness
• Immunosuppression
• Tube feeds
• ? Gastric acid suppression

Main modifiable risk factors
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How contaminated is the hospital environment?
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Contaminated Surfaces
VRE MRSA C. difficile

• Bed Rails
• Bed Table
• Door Knobs
• Doors
• Call Button
  
• Chair
• Tray Table
• Toilet Surface
  
• Sink Surface
  
• Bedpan Cleaner

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Surface Contamination of Near-patient
Environment23 Studies
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How does it get there?
Riggs M,etal. CID 200745592
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C. Difficile Environmental Contamination
Mutters R, etal. J Hosp Infect. 2009 71 43-48
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Can C. diff be transmitted from the environment
to patients?
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Increased acquisition risk from prior room
occupant 7 studies as of July 2010
Two additional studies showed very significant
risk without quantification Martinez (VRE) and
Wilks (Acinetobacter)
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C. difficile Transmission to Prior Room Occupants
Shaugnessey etal. Abstract K-4194 IDSA / ICAAC.
October 2008
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C. difficile Transmission to Prior Room Occupants
110 Increased risk
Shaugnessey etal. Abstract K-4194 IDSA / ICAAC.
October 2008
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Can better cleaning favorably impact
environmental contamination with C. diff ?
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Studies reporting a favorable impact of enhanced
environmental hygiene during a CDAD outbreak
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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
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Percentage of C. difficile-positive cultures
n9 rooms
Similar results found after ES cleaning
following interventions
Eckstein et al, BMC Infect Dis. 2007 Jun 21761.

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The impact of HP vapor on C. difficile
Boyce J etal. ICHE 2008
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The impact of HP vapor on C. difficile
Boyce J etal. ICHE 2008
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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
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Why is C. being transmitted to susceptible
patients in our hospitals ?
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Dont forget the Rutala Equation

• Product Practice

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Dont forget the Rutala Equation

• Product Practice

The other name for Hygienic Practice ?
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The other name for Hygienic Practice
The Missing Link
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The other name for Hygienic Practice
The Missing Link
Why?
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Thoroughness of Environmental Cleaning
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Thoroughness of Environmental Cleaning
gt65,000 Objects
Mean 34
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74
8 Reports
MRSA, VRE, CD,AB
10 Studies
40
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Why is environmental cleaning not being done
thoroughly ?
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Environmental Rounds to search for problems in
cleaning performanceor.
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The search fro the Nefarious Dust Bunny
What does this finding say about disinfection
cleaning at this hospital???
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Finding the Brown Spot
ES Director
IP
ES Supervisor
What does this finding say about disinfection
cleaning at this hospital???
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Finding the Brown Spot
How long has this been here?
ES Director
The nurses are right. ES at this hospital is
terrible
IP
ES Supervisor
What does this finding say about disinfection
cleaning at this hospital???
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Finding the Brown Spot
Who can I blame?
How long has this been here?
ES Director
The nurses are right. ES at this hospital is
terrible
IP
ES Supervisor
What does this finding say about disinfection
cleaning at this hospital???
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Finding the Brown Spot
Who can I blame?
I hate Environmental Rounds. Why doesnt this IP
get a life?
How long has this been here?
ES Director
The nurses are right. ES at this hospital is
terrible
IP
ES Supervisor
What does this finding say about disinfection
cleaning at this hospital???
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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

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Can the thoroughness of Hygienic Cleaning be
improved?
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RESULTS
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Targeting Solution (AKA Goo)
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Phase II A. Programmatic Analysis B.
Educational Interventions ES staff
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Baseline Environmental Evaluation of 36
Acute Care Hospitals
Mean 48.5
Hospitals
(20,056 Objects)
of Objects Cleaned
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Hospitals Environmental Hygiene Study Group36
Hospital Results
of Objects Cleaned
PRE INTERVENTION
POST INTERVENTION
P lt.0001
Resource Neutral
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74
40
11 Studies
82
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Are such results sustainable?
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Thoroughness of Terminal Room Environmental
Cleaning
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Was it a lot of work?
Chow S, Shao J, Wang H. Sample size calculations
in clinical research. 2ND ed. Chapman Hall
2007.
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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

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Improved Thoroughness of hygienic cleaning is a
worthy goal given the billions of dollars
involvedbut will it impact transmission of HAPs ?
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74
40
11 Studies
82
8 Reports
MRSA, VRE, CD, AB
68
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74
40
11 Studies
82
68
8 Reports
MRSA, VRE, CD, AB
MRSA, VRE
4 Studies
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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
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Cleaning House A New Metric in the Objective
Evaluation of Environmental Cleaning
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Approaches to Programmatic Environmental
Cleaning Monitoring

• Conventional Program
• Subjective visual assessment
• Deficiency oriented
• Episodic evaluation
• Problem detection feedback
• Open definition of correctable interventions

• Enhanced Program
• 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)
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AJIC Title Picture

• Am J Infect Control 201038S41-50 (June)

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Conclusion Where we are now
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Conclusion Where we can and need to go
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So what about the disinfectant?
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Dont forget the Rutala Equation

• Product Practice

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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?

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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

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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.

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A final thought about C. diff rates in hospitals
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With respect to environmental hygiene can C.
diff rates serve as the
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With respect to environmental hygiene can C.
diff rates serve as the
??
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Presentation Objectives

1. Understand current issues related to the roe of
   the environment in CDI transmission
2. Understand the basis for suboptimal healthcare
   environmental cleaning
3. Appreciate the complexity of making practice
   recommendations without modern evidenced based
   studies

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Thanks for inviting me
!!
Questions Comments?
pcarling_at_cchcs.org