Massachusetts CDI Preventative Collaboration June 24, 2010

Optimizing Environmental Hygiene: The Key to C. Difficile Control

Philip C. Carling, M.D.

Carney Hospital and

Boston University School of MedicineMassachusetts CDI Preventative

Collaboration

June 24, 2010

Consultant – Ecolab, Steris, ASHES

Pending Patent License - [email protected]

Presentation Objectives

A. Understand current issues related to the roe of the environment in CDI transmission

B. Understand the basis for suboptimal healthcare environmental cleaning

C. Appreciate the complexity of making practice recommendations without modern evidenced based studies

Background: Epidemiology

Risk Factors

• Antimicrobial exposure

• Acquisition of C. difficile

• Advanced age

• Underlying illness

• Immunosuppression

• Tube feeds

• ? Gastric acid suppression

Main modifiable risk factors

How contaminated is the hospital environment?

Contaminated Surfaces

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

VRE MRSA C. difficile

Surface Contamination of Near-patient Environment

23 Studies

0

20

40

60

80

100

C. DIFFICILE VRE MRSA

% C

ON

TAM

INA

TED

How does it get there?

78

60

30

0

20

40

60

80

100

Patients with CDAD AsymptomaticCarriers

Non carriers

En

vir

on

me

nta

l C

on

tam

ina

tio

n %

ENVIRONMENT ANY

CALL BUTTONBED RAIL

TABLETELEPHONE

78

64

20

0

20

40

60

80

100

Patients with CDAD AsymptomaticCarriers

Non carriers

Sk

in C

on

tam

ina

tio

n %

SKIN - ANY

GROIN

CHEST/ABDOMEN

Riggs M,etal. CID 2007;45:592

C. Difficile Environmental Contamination

0

3000

6000

PT HANDS NEARENVIRONMENT

DISTANTENVIRONMENT

HCW HANDS

PCR

COLO

NY C

OUN

TS/1

0cm

2

CDAD POS. PATIENT ROOMS

CDAD NEG. PATIENT ROOMS

Mutters R, etal. J Hosp Infect. 2009; 71: 43-48

Can C. diff be transmitted from the environment to patients?

Increased acquisition risk from prior room occupant

7 studies as of July 2010

0 60 120 180

Datta

Shaugnessy

Dress

Hardy

Huang

Increased Risk of Aquisition (%)

Two additional studies showed very significant risk without quantification – Martinez (VRE) and Wilks (Acinetobacter)

C. difficile Transmission to Prior Room Occupants

0

10

20

FORMER CDADOCCUPANCY

NO PRIOR CDADOCCUPANCY

% R

ISK

OF

DEVE

LOPI

NG C

DAD

Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

C. difficile Transmission to Prior Room Occupants

0

10

20

FORMER CDADOCCUPANCY

NO PRIOR CDADOCCUPANCY

% R

ISK

OF

DEVE

LOPI

NG C

DAD

Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

110% Increased risk

Can better cleaning favorably impact environmental contamination with C.

diff ?

Studies reporting a favorable impact of enhanced environmental hygiene during a CDAD outbreak

0

1

2

3

4

<1996

1996 1998 2000 2002 2004 2006 2008

PU

BL

ISH

ED

RE

PO

RT

S

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

Percentage of C. difficile-positive cultures n=9 rooms

80

706050

4030

2010

0

Pe

rce

nt

po

sit

ive

Before cleaning Afterhousekeeping

cleaning

Afterdisinfection byresearch team*

BedrailBedside tablePhoneCall buttonToiletDoor handle

Eckstein et al, BMC Infect Dis. 2007 Jun 21;7:61.

*Similar results found after ES cleaning following

interventions

The impact of HP vapor on C. difficile"ENVIRONMENTAL CONTAMINATION"

-5

0

5

10

15

20

25

30

Pre HPV Post HPV

% S

UR

FAC

ES

CO

NTA

MIN

ATE

D

"ENVIRONMENTALCONTAMINATION"

Boyce J etal. ICHE 2008

The impact of HP vapor on C. difficile

-5

0

5

10

15

20

25

30

Pre HPV Post HPV

% S

UR

FA

CE

S C

ON

TA

MIN

AT

ED

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

C. D

IFF

RA

TE

/ 10

00 P

TD

"ENVIRONMENTALCONTAMINATION"

"C. DIFF RATE"

Boyce J etal. ICHE 2008

Does improving environmental hygiene have a measurable Impact on

environmental contamination with C. difficile?

Eckstein – 2007Boyce – 2008

Impact on Transmission?

Quasi-experimental support – Substantial but limited by study design and evaluation in outbreak settings

Why is C. being transmitted to susceptible patients in our

hospitals ?

Don’t forget the Rutala Equation

Product + Practice

Don’t forget the Rutala Equation

Product + Practice

The other name for Hygienic Practice ?

The other name for Hygienic Practice

The Missing Link

The other name for Hygienic Practice

The Missing Link

Why?

Thoroughness of Environmental Cleaning

0

20

40

60

80

100

%

DAILY CLEANING

TERMINAL CLEANING

Cle

aned

Thoroughness of Environmental Cleaning

0

20

40

60

80

100

%

DAILY CLEANING

TERMINAL CLEANING

Cle

aned

Mean = 34%

>65,000 Objects

0 20 40 60 80 100

Baseline Thoroughness of Cleaning

Increased risk of prior roomoccupant transmission

%

10 Studies

8 ReportsMRSA, VRE, CD,AB

40%

74%

Why is environmental cleaning not being done thoroughly ?

“Environmental Rounds” to search for problems in cleaning

performanceor….

The search fro the Nefarious Dust Bunny

What does this finding say about disinfection cleaning at this hospital???

Finding the “Brown Spot”

What does this finding say about disinfection cleaning at this hospital???

ES Director

IPES Supervisor

Finding the “Brown Spot”

What does this finding say about disinfection cleaning at this hospital???

ES Director

IPES Supervisor

How long has this been here?

The nurses are right. ES at this hospital is terrible

Finding the “Brown Spot”

What does this finding say about disinfection cleaning at this hospital???

ES Director

IPES Supervisor

Who can I blame?

How long has this been here?

The nurses are right. ES at this hospital is terrible

Finding the “Brown Spot”

What does this finding say about disinfection cleaning at this hospital???

ES Director

IPES Supervisor

Who can I blame?

How long has this been here?

The nurses are right. ES at this hospital is terrible

I hate Environmental Rounds…. Why doesn’t this IP get a life?

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

Can the thoroughness of Hygienic Cleaning be improved?

RESULTS

Targeting Solution (AKA – Goo)

Cleaned, empty room

identified

Room marked Room evaluated

Terminal cleaning after 1 or 2 patient cycles

Phase I: Covert Baseline Environmental Cleaning Evaluation

Phase II: A. Programmatic AnalysisB. Educational Interventions – ES staff

Cleaned, empty room

identified

Room marked Room evaluated

Terminal cleaning after 1 or 2 patient cycles

Phase III: Re-evaluation of Cleaning and feedback to ES

0

2

4

6

8

1-5% 11-15%

21-25%

31-35%

41-45%

51-55%

61-65%

71-75%

81-85%

91-95%

Baseline Environmental Evaluation of 36 Acute Care Hospitals

% of Objects Cleaned

Hos

pita

ls

Mean = 48.5 %

(20,056 Objects)

40

50

60

70

80

Hospitals Environmental Hygiene Study Group36 Hospital Results

% o

f O

bjec

ts C

lean

ed

PRE INTERVENTION POST INTERVENTION

P = <.0001Resource Neutral

0 20 40 60 80 100

Thoroughness of cleaning followingstructured interventions

Baseline Thoroughness of Cleaning

Increased risk of prior room occupanttransmission

%

11 Studies

40%

74%

82%

Are such results sustainable?

Thoroughness of Terminal Room Environmental Cleaning

0

20

40

60

80

100

PRE PHASE II PHASE III

%

90% GOAL

CLEAN

Was it a lot of work?

Sample Size Required to Monitor Cleaning Practice

0

100

200

300

400

500

600

20% 30% 40% 50% 60% 70% 80%

Thoroughness of Cleaning

Num

ber

of O

bjec

ts to

be

Mon

itore

d

Chow S, Shao J, Wang H. Sample size calculations in clinical research. 2ND ed. Chapman & Hall; 2007.

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 ApproachSenior leadership support

ES buy in

Transparency

Blameless Benchmarking

Problems Solutions open cooperation

Recognition of success at all levels

Improved Thoroughness of hygienic cleaning is a worthy goal given the billions of dollars involved…but will it impact transmission of HAPs ?

0 20 40 60 80 100

Programmatic decrease in environmentalcontamination

Thoroughness of cleaning following structuredinterventions

Baseline thoroughness of Cleaning

Increased risk of prior room occupanttransmission

%

11 Studies

8 ReportsMRSA, VRE, CD, AB

40%

74%

82%

68%

0 20 40 60 80 100

Programmatic decrease in aquisition

Programmatic decrease inenvironmental contamination

Thoroughness of cleaning followingstructured interventions

Baseline thoroughness of Cleaning

Increased risk of prior room occupanttransmission

%

11 Studies

8 Reports

4 StudiesMRSA, VRE

40%

74%

82%

68%MRSA, VRE, CD, AB

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

Cleaning House: A New Metric in the Objective Evaluation of

Environmental Cleaning

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)

AJIC Title Picture

Am J Infect Control 2010;38:S41-50 (June)

Conclusion – Where we are now

Terminal Cleaning Efficiency Vs. Thoroughness

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80

Minutes

Th

oro

ug

ne

ss

(%

Cle

an

ed

)

"SINGLE CLEANING"

Conclusion – Where we can and need to go

Terminal Cleaning Efficiency Vs. Thoroughness

0

20

40

60

80

100

0 10 20 30 40 50 60

Minutes

Th

oro

ug

ness (

% C

lean

ed

)

So what about the disinfectant?

Don’t forget the Rutala Equation

Product + Practice

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?

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

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.

A final thought about C. diff rates in hospitals

With respect to environmental hygiene …

can C. diff rates serve as the

With respect to environmental hygiene …

can C. diff rates serve as the

??

Presentation Objectives

A. Understand current issues related to the roe of the environment in CDI transmission

B. Understand the basis for suboptimal healthcare environmental cleaning

C. Appreciate the complexity of making practice recommendations without modern evidenced based studies

Thanks for inviting me !!

Questions – Comments? [email protected]