Introduction to CDC s Guidelines for Environmental Infection Control

Introduction to CDC’s “Guidelines for Environmental Infection Control in Health-Care Facilities” Lynne Sehulster, Ph. D, M(ASCP) Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Atlanta, GA 30333 Hosted by Paul Webber paul@webbertraining. com Sponsored by 3 M Canada www. 3 m. ca

Objectives of Today’s Presentation After the completion of this session, the participant will: n Be familiar with the overall content of the EIC guidelines; n See how the guidance is applied to an airborne disease outbreak; and n Be familiar with performance measures and standards on environment of care

Target Audiences for the EIC Guidelines n n n Hospital epidemiologists Infection control practitioners Laboratorians Facility managers and engineers Housekeeping and laundry staff Administration

Where Can I Find the EIC Guidelines? n Part II Recommendations: – – n MMWR 2003; 52 (RR-10): 1 -44 Errata: MMWR 2003; 52 (42): 1025 -6 Full text version: http: //www. cdc. gov/ncidod/hip/enviro/ guide. htm – n Print version: – ASHE will print in the near future

CDC Contributors to These Guidelines n Division of Healthcare Quality Promotion: – n Division of Bacterial and Mycotic Diseases: – n Dennis Juranek, DVM Division of Oral Health: – n David Ashford, DVM, DSc, MPH; Richard Besser, MD; Barry Fields, Ph. D; Michael Mc. Neil, MBBS, MPH; Cynthia Whitney, MD; Stephanie Wong, DVM, MPH Division of Parasitic Diseases: – n Lynne Sehulster, Ph. D; Matthew Arduino, Dr. PH; Joe Carpenter, PE; Rodney Donlan, Ph. D Jennifer Cleveland, DDS, MPH HICPAC Sponsor: – Raymond Chinn, MD, Sharp Memorial Hospital, San Diego

U. S. Organizations Whose Standards are Incorporated into These Guidelines n n n American Institute of Architects (AIA) American Society of Heating, Refrigeration, and Air-conditioning Engineers (ASHRAE) Association for the Advancement of Medical Instrumentation (AAMI)

U. S. Federal Regulatory Agencies n n n Environmental Protection Agency (EPA) Department of Labor, Occupational Safety and Health Administration (OSHA) Food and Drug Administration (FDA) Department of Agriculture (USDA) Department of Justice (Do. J)

Air Section

Air Section Subtopics n n Airborne microorganisms HVAC components and function Construction Special care settings – – – n Airborne infection isolation (AII) Protective environment Operating rooms Other aerosol hazards (infectious)

Ventilation Specifications Airborne Infection Isolation (AII) Protective Environment (PE) Air pressure Negative Positive Room air changes > 6 ACH for existing areas; > 12 ACH for new construction or renovation > 12 ACH Sealed Yes Filtration on supply air 90% (dust-spot testing) 99. 97% (HEPA) Recirculation No Yes

Ventilation Specifications Critical Care Room Operating Room Air pressure Positive, negative, or neutral Positive Room air changes > 6 ACH > 15 ACH Sealed No Yes Supply air filtration > 90% (dust-spot testing) Recirculation Yes

Ventilation Specifications Isolation Anteroom Air pressure Positive or negative Room air changes > 10 ACH Sealed Yes Supply air filtration > 90% (dust-spot testing) Recirculation No

Construction Issues n n n Multidisciplinary team Risk assessment prior to project start External construction – keep dust out! Internal construction – contain the dust! Barriers Surveillance and air sampling

External Construction n n n Keep the facility air pressure positive to the outside Ensure that roughing filters are changed frequently Seal and caulk windows, especially in PE Keep doors closed as much as possible Wet dust surfaces Protect immunocompromised patients from dust during transfers

Internal Construction n Dust containment, removal and moisture control – Educate construction workers and staff – Prepare the site – Notify staff, visitors, patients re: precautions – Relocate patients and move staff as needed – Monitor for adherence to infection control – HVAC system maintenance; water system – Daily clean-up and removal of debris

Particle Sampling n n n Simple to perform, immediate results Verify HVAC system performance: – Filtration efficiency – Rank order from “dirty” to “clean” Verify infection control measures during construction: – Construction barrier and dust containment

Aspergillosis Outbreak

Impact of Aspergillosis, 1996 n n 10, 190 hospitalizations; average length of stay = 17. 3 days 1970 deaths; mortality rate = 19. 3% Economic burden in health care = $633. 1 million Conditions associated with secondary diagnosis of aspergillosis: – pneumonia, other respiratory infections, cancer or leukemia, HIV infection Dasbach EJ, Davies GM, Teutsch SM. Clin Infect Dis 2000; 31: 1524 -1528

Impact of Aspergillosis, 1996 When there is a secondary diagnosis of aspergillosis in cancer or leukemia patients: – – – 26 more hospital days $115, 262 in additional costs 4 times the mortality rate compared to similar patients without aspergillosis Dasbach EJ, Davies GM, Teutsch SM. Clin Infect Dis 2000; 31: 1524 -1528.

Healthcare-Associated Outbreaks of IPA n n n Activities that cause increases in counts of airborne Aspergillus spores Building demolition, construction, renovation, repair Bird droppings in air ducts supplying highrisk patient care areas Contaminated fireproofing material Damp wood, sheet rock

Aspergillosis Outbreak Hospital A n n n February, March 1996; September 1996 940 bed facility; Oncology Center is a 3 story building connected to the hospital Pressure differentials, HVAC system checked monthly Construction immediately adjacent to the Oncology Center A. flavus emerges, previously A. fumigatus

Investigative Findings: 1996 n n 21/29 surveillance-identified patients met case definition of “definite” or “probable” Housekeeping procedures inadequate; clean “wet” Univariate analysis: location near the stairwell Large volume samplers detected A. flavus, while small volume samples were negative

Thio CL, Smith D, Merz WG, et al. Infect Control Hosp Epidemiol 2000; 21: 18 -23

Investigative Findings: 1996 n Pressure differentials – – – 25 PE rooms, 3 of which were negative relative to the corridor (-0. 35 to – 3. 2 Pa) Air pressure in the central stairwell was positive relative to the corridor of the unit Oncology Center was neutral – negative compared to the adjacent hospital

Environmental Control Measures: Spring 1996 n n Reviewed the function of the HVAC system Doors engineered to close automatically; kept closed at all times Wet dusted and cleaned surfaces Sealed windows, exterior walls

Environmental Control Measures: Spring 1996 n n Closed nearby entrance; redirected pedestrian traffic Construction policy Air sampling for fungal spores N 95 respirators for high-risk patients

Environmental Control Measures: Fall 1996 n n n Closed the stairwell between the HSCT and leukemia units Conducted case-control studies Additional environmental cultures Reviewed housekeeping procedures Large volume air sampling Supplemental HEPA filtration when structural modification not feasible

Water Section

Water Section Subtopics n n n n Waterborne microorganisms Facility water systems Strategies for controlling Legionella spp. Cooling towers Hemodialysis and water quality Ice machines Hydrotherapy AERs and dental unit water lines (DUWLs)

Modes of Transmission of Microorganisms in Water n n n Direct contact (hydrotherapy) Ingestion of water (drinking water, ice) Indirect contact (improperly reprocessed medical device) Inhalation of aerosols (showers) Aspiration of contaminated water

Updates on Air and Water n Updated recommendations for air and water infection control measures: Guidelines for Preventing Health-Care. Associated Pneumonia, 2003 Available at: http: //www. cdc. gov/ncidod/hip/pneumonia/ default. htm

Environmental Services Section

Environmental Services Section Subtopics n n n Principles of cleaning and disinfection Cleaning spills of blood/body substance Carpeting, cloth furniture Flowers and plants Pest control Special pathogen concerns and cleaning

Should Environmental Sampling Be Done? n n NO, not routinely Environmental sampling may be useful: – – – To verify the effectiveness of a new cleaning and disinfecting process To identify environmental reservoirs during outbreak situations Coordinate sampling with the laboratory

Environmental Sampling Section

Environmental Sampling Section Subtopics n n Principles of environmental sampling Air sampling Water sampling Environmental surface sampling

Laundry and Bedding Section

Laundry and Bedding Section Subtopics n n n Epidemiology Collecting and sorting soiled linens Laundry processes Antimicrobial-impregnated articles Pillows, mattresses Air-fluidized beds

Animals in Healthcare Facilities Section

Animals in Healthcare Facilities Section Subtopics n n Animal-assisted activities, animalassisted therapy, resident animals Service animals Animals as patients in healthcare facilities Research animals in healthcare facilities

Regulated Medical Waste Section

Regulated Medical Waste Section Subtopics n n n Epidemiology Categories of medical waste Management of waste Treatment of waste Discharge of blood, body fluids to the sanitary sewer CJD issues

EIC Guidelines Performance Measures n n n Document infection control professionals’ involvement in all phases of construction Monitor and document airflow for AII and PE, especially when occupied Monitor water in hemodialysis settings monthly for endotoxin and bacteria Determine source(s) of NTM Identify and respond to water damage

JCAHO – 2004 Standards for the Management of the Environment of Care n Planning and Implementation Activities – – EC 1. 10 – EC 1. 30: safety risks, smoking policy, safe environment EC 2. 10: security risk management EC 3. 10: hazardous materials and wastes EC 4. 10 – EC 4. 20: emergency management

JCAHO – 2004 Standards for the Management of the Environment of Care n Planning and Implementation Activities – – EC 5. 10 – EC 5. 50: Code® issues EC 6. 10 – EC 6. 20: EC 7. 10 – EC 7. 50: EC 8. 10 – EC 8. 30: management fire safety and Life Safety medical equipment utilities management environmental

JCAHO – 2004 Standards for the Management of the Environment of Care n Measuring and Improving Activities – EC 9. 10 – EC 9. 30: monitoring and analyzing environmental conditions; implementing recommendations to improve the environment of care

JCAHO – 2004 Standards for the Management of the Environment of Care n Standard – n Rationale – n Performance expectation Background, justification Elements of Performance – Steps needed to achieve the standard

Thank You! Protect patients, protect healthcare personnel, and promote safety, quality, and value in the healthcare delivery system

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