Measuring the effect of targeted cleaning

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Measuring the effect of targeted cleaning
Dr Stephanie Dancer, NHS Lanarkshire, Scotland
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The Scottish Express
The Herald
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Why the debate over MRSA and hospital cleaning?
There is no evidence cleaning has never been
regarded as an evidence-based science Aesthetic
considerations make cleaning difficult to
assess No way of measuring the cleaning process
or its impact on the environment Confounded by
fabric and maintenance deficits It costs money We
cannot see the enemy Cleaning has always
been taken for granted
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Survival of different strains of MRSA in
hospital dust
Wagenvoort JHT, J Hosp Infect 2000
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Where is MRSA in a hospital?
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C.difficile, VRE and MRSA are found on
hand-touch sites in the clinical environment
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It is almost as easy to pick up MRSA by touching
a patient's environment as it is by touching the
patient
MRSA and VRE in this room are picked up by
attendant staff and also by the next
patient Boyce et al, ICHE 1997 Huang et al, Arch
Intern Med 2006 Drees et al, ICHE 2008 Hayden
et al, ICHE 2008

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There is a heavy bioburden on all hand-touch
sites
Microbes can survive on surfaces for months. X
denotes tested surfaces

Hayden et al, SHEA 2004
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Whats so important about hand touch surfaces?
These are the places to find transmissible
microbes! Frequently used hand-touch surfaces
are high-risk surfaces The closer the surface is
to a patient, the more critical it is likely to
be
Biotrace, 2003

• Detection of pathogen transmission in neonatal
  nurseries using DNA markers as surrogate
  indicators
  Oelberg DG et al, Paediatrics 2000

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Are hand-touch sites routinely cleaned?
Routine cleaning practices were assessed by
applying a fluorescent solution to different
sites in side-rooms. These sites were evaluated
following patient discharge a site was
considered cleaned if the fluorescent material
was removed. Although 40 sites were cleaned
properly, they tended to be the more traditional
sites (toilets and sinks) whereas sites such as
telephones, doorknobs and other hand-touch
surfaces were scarcely cleaned at all.

Carling et al, Am J Infect Control,
2006
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So.. lets clean the near patient hand-touch
sites But how do we know if cleaning is
effective? How do we monitor cleanliness? What
is clean?
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How clean are hospital surfaces?
82-91 Visually clean
10-24 ATP clean
30-45 Microbiologically clean What is clean?
what an individual thinks it is We should
not define cleanliness without indicating
how we would assess it
Griffith CJ et al , J
Hosp Infect 2000
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Proposal for bacteriological standards for
surface level cleanliness in hospitals
5/cm2
45/cm2
Slide courtesy of Chris Griffith
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Microbiological standards for surface hygiene in
hospitals
There should be lt1cfu/cm2 specific organism in
the clinical environment Staphylococcus
aureus (including MRSA) Clostridium
difficile Vancomycin-resistant enterococci
Multiply-resistant Gram-negative bacilli

Dancer S, J Hosp Infect,
2004
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Microbiological standards for surface hygiene in
hospitals
The Aerobic Colony Count (ACC) from a hand
contact surface should be lt2.5-5 cfu/cm2 This
standard is based upon food industry counts as
applied to food preparation surfaces but could be
utilised for frequent hand touch surfaces in
hospitals.
Dancer S, J Hosp
Infect, 2004
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Bed rail
Overbed table
Bedside locker
We screened ten hand-touch sites on two surgical
wards for one year, using the proposed standards
Dancer et al, IntJEHR 2008
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Staphylococcal reservoirs on two surgical wards
We found S.aureus MRSA on lockers, overbed
tables and beds Finding these pathogens at
any site was significantly associated with
higher microbial growth levels from that site
(p0.001) Total microbial growth levels each
week were significantly associated with
weekly bed occupancies gt95 (p0.0004) Conclusion
s Microbial dirt on hand-touch sites
reflects weekly bed occupancies and indicates a
risk for S.aureus MRSA Both of these
pathogens were more likely to be recovered from
near-patient sites on the ward
Dancer SJ et al, Int J Env Health Res, 2008
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White et al, AmJIC, 2008
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What is the evidence that cleaning reduces the
risk of MRSA acquisition?
Rampling et al, J Hosp Infect, 2001
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MRSA in hospital clinical specimens
Successful interventions (ECCMID 06 P1333
ECCMID 07 O23)
Environmental swabbing (p0.03)
Bleach (p0.002)
Hand Gel (p0.03)
MRSA in Clinical Specimens
Admission Screen (plt0.01)
Stop Bleach (p0.03)
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Southern General Hospital, Glasgow
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What is the evidence for cleaning as a viable
control mechanism for hospital-acquired infection?
We introduced one extra cleaner into two matched
wards from Monday to Friday, with each ward
receiving extra detergent-based cleaning for six
months in a cross-over design Ten hand-touch
sites on both wards were screened weekly using
the standards and patients were monitored for
MRSA infection throughout the year-long study
Patient and environmental MRSA isolates were
characterized using DNA finger- printing
Dancer et al, BMC Med, 2009
BBC website, 2008
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Screening sites
Hand-touch sites at bedside areas (patient
lockers, overbed tables and bed
frames) Clinical equipment (patient hoist,
infusion pump and blood pressure stand) Sites
at the nurses work station (computer keyboard,
desk and patient notes) A side-room door
handle NB. Patient curtains were not included
hand-touch sites were sampled from one ward
hoist, BP stand and computer keyboard but from
different sites representing the remaining items
throughout the ward, excluding those in the
isolation rooms
Dancer et al, BMC Med, 2009
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Dancer et al, BMC Infect Dis, 2008
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Dancer et al, BMC Medicine, 2009
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Where were S.aureus and MRSA?

• Sites more frequently contaminated with
  S.aureus and MRSA were
• bedside locker (17 isolates)
• overbed table (13 isolates)
• bed frame (12 isolates)
• These are all near-patient sites

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Table to show the molecular relationships between
patient and environmental strains of MRSA on one
surgical ward over a one year period
Dancer et al, BMC Med 2009
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• Results
• One extra cleaner was responsible for a 33
  reduction in
• levels of microbial dirt on hand-touch sites and
  a 27
• reduction in new MRSA infections, despite busier
  wards and
• more MRSA patient-days
• Adjusting for MRSA patient-days and based upon 9
  new
• MRSA infections found during routine cleaning, we
  
• expected 13 new infections with the extra
  cleaning rather
• than the four that actually occurred
• DNA fingerprinting confirmed indistinguishable
  strains from
• both hand-touch sites and patients some of these
  were
• isolated months apart

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DYNAMIC TRANSMISSION CYCLE
OF HOSPITAL PATHOGENS
Patients (infected and/or colonised)
Antibiotic Pressures Berntsen et al, NEJM
1960 Cheng et al, JHI 2008
Environment including air
Hands (whose?)
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Could patients hands constitute a missing link?
Banfield Kerr, J Hosp Infect 2005
What is the impact of systematic patient hand
disinfection on MRSA infection rates in a
hospital?
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Staff will not clean their hands!
. overall compliance for hand disinfection
was 22 from nearly 600 opportunities for hand
hygiene Kim PW et al, AJIC 2003
Staff are too busy! Dancer et
al, AmJIC, 2007 Harbarth et al, Crit Care
Med, 2007 Introducing alcohol hand
antiseptic does not necessarily reduce infection
Lai et al, 1CHE, 2006 Larson et al, Behav
Med 2000 Rupp et al, ICHE, 2008 Any
benefits from hand hygiene are eroded if the
environment is heavily contaminated with MRSA

Farr et al, LI D, 2001
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The Hand-Touch equation

Hand
Hand-touch site
WHY is all the emphasis on cleaning hands and
not on cleaning the things that they touch?
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Conclusion

• MRSA acquisition and inadequate hospital cleaning
  are linked
• High risk sites are near-patient hand-touch sites
• We know which sites need cleaning, but not
  necessarily how often we should clean them
• Find the evidence for soap and water first,
  before powerful disinfectants destroy our
  environment
• Hands are important because they touch
  patients, objects and surfaceswe need clean
  hands AND clean surfaces

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Acknowledgements

• Michael Coyne and Lisa White
• Karen Jennings and colleagues at UNISON
• Kirsty Girvan
• Jim Lamb
• Professor Chris Robertson
• Microbiology, Southern General Hospital
• Janssen Cilag
• Beth Anderson

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