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Optimizing Environmental Hygiene: The Key to C. Difficile Control Philip C. Carling, M. D. Optimizing Environmental Hygiene: The Key to C. Difficile Control Philip C. Carling, M. D. Carney Hospital and Boston University School of Medicine Massachusetts CDI Preventative Collaboration June 24, 2010 Consultant – Ecolab, Steris, ASHES Pcarling@cchcs. org Pending Patent License - Ecolab

Presentation Objectives A. Understand current issues related to the roe of the environment in 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 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? How contaminated is the hospital environment?

Contaminated Surfaces VRE Bed Rails +++++++ Bed Table ++++++ Door Knobs ++ Doors +++ Contaminated Surfaces VRE Bed Rails +++++++ Bed Table ++++++ Door Knobs ++ Doors +++ Call Button +++ Chair ++ Tray Table +++ Toilet Surface + Sink Surface + Bedpan Cleaner MRSA + + ++ + C. difficile +++ ++ +++ +

Surface Contamination of Near-patient Environment 23 Studies Surface Contamination of Near-patient Environment 23 Studies

How does it get there? Riggs M, etal. CID 2007; 45: 592 How does it get there? Riggs M, etal. CID 2007; 45: 592

C. Difficile Environmental Contamination Mutters R, etal. J Hosp Infect. 2009; 71: 43 -48 C. Difficile Environmental Contamination Mutters R, etal. J Hosp Infect. 2009; 71: 43 -48

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

Increased acquisition risk from prior room occupant 7 studies as of July 2010 Two 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)

C. difficile Transmission to Prior Room Occupants Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. C. difficile Transmission to Prior Room Occupants Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

C. difficile Transmission to Prior Room Occupants 110% Increased risk Shaugnessey etal. Abstract K-4194 C. difficile Transmission to Prior Room Occupants 110% Increased risk Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

Can better cleaning favorably impact environmental contamination with C. diff ? Can better cleaning favorably impact environmental contamination with C. diff ?

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

June 2007 Methods: Culture based evaluation - Pre-intervention; - after routine terminal cleaning; - 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 Percent positive n=9 rooms 80 70 60 50 40 Percentage of C. difficile-positive cultures Percent positive n=9 rooms 80 70 60 50 40 30 20 10 0 Bedrail Bedside table Phone Call button Toilet Door handle Before cleaning *Similar results found after ES cleaning following interventions After housekeeping disinfection by cleaning research team* Eckstein et al, BMC Infect Dis. 2007 Jun 21; 7: 61.

The impact of HP vapor on C. difficile Boyce J etal. ICHE 2008 The impact of HP vapor on C. difficile Boyce J etal. ICHE 2008

The impact of HP vapor on C. difficile Boyce J etal. ICHE 2008 The impact of HP vapor on C. difficile Boyce J etal. ICHE 2008

Does improving environmental hygiene have a measurable Impact on environmental contamination with C. difficile? 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

Why is C. being transmitted to susceptible patients in our hospitals ? 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

Don’t forget the Rutala Equation Product + Practice The other name for Hygienic 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

The other name for Hygienic Practice The Missing Link Why? The other name for Hygienic Practice The Missing Link Why?

Thoroughness of Environmental Cleaning Thoroughness of Environmental Cleaning

Thoroughness of Environmental Cleaning >65, 000 Objects Mean = 34% Thoroughness of Environmental Cleaning >65, 000 Objects Mean = 34%

MRSA, VRE, CD, AB 40% 74% 10 Studies 8 Reports MRSA, VRE, CD, AB 40% 74% 10 Studies 8 Reports

Why is environmental cleaning not being done thoroughly ? Why is environmental cleaning not being done thoroughly ?

“Environmental Rounds” to search for problems in cleaning performance or…. “Environmental Rounds” to search for problems in cleaning performance or….

The search fro the Nefarious Dust Bunny What does this finding say about disinfection The search fro the Nefarious Dust Bunny What does this finding say about disinfection cleaning at this hospital? ? ?

Finding the “Brown Spot” ES Director ES Supervisor IP What does this finding say Finding the “Brown Spot” ES Director ES Supervisor IP What does this finding say about disinfection cleaning at this hospital? ? ?

Finding the “Brown Spot” How long has this been here? ES Director ES Supervisor Finding the “Brown Spot” How long has this been here? ES Director ES Supervisor The nurses are right. ES at. IP hospital is this terrible What does this finding say about disinfection cleaning at this hospital? ? ?

Finding the “Brown Spot” Who can I blame? How long has this been here? Finding the “Brown Spot” Who can I blame? How long has this been here? ES Director ES Supervisor The nurses are right. ES at. IP hospital is this terrible What does this finding say about disinfection cleaning at this hospital? ? ?

Finding the “Brown Spot” Who can I blame? I hate Environmental Rounds…. Why doesn’t Finding the “Brown Spot” Who can I blame? I hate Environmental Rounds…. Why doesn’t this IP get a life? How long has this been here? ES Director ES Supervisor The nurses are right. ES at. IP hospital is this terrible What does this finding say about disinfection cleaning at this hospital? ? ?

Conventional monitoring of health care environmental cleaning “Environmental Rounds” • Subjective visual assessment “If 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? Can the thoroughness of Hygienic Cleaning be improved?

RESULTS RESULTS

Targeting Solution (AKA – Goo) Targeting Solution (AKA – Goo)

Phase I: Covert Baseline Environmental Cleaning Eva Terminal cleaning after 1 or 2 patient Phase I: Covert Baseline Environmental Cleaning Eva Terminal cleaning after 1 or 2 patient cycles Cleaned, empty room identified Room marked Room evaluated Phase II: A. Programmatic Analysis B. Educational Interventions – ES staff Phase III: Re-evaluation of Cleaning and feedback to Terminal cleaning after 1 or 2 patient cycles Cleaned, empty room identified Room marked Room evaluated

Baseline Environmental Evaluation of 36 Acute Care Hospitals Mean = 48. 5 % (20, Baseline Environmental Evaluation of 36 Acute Care Hospitals Mean = 48. 5 % (20, 056 Objects) % of Objects Cleaned

% of Objects Cleaned Hospitals Environmental Hygiene Study Group 36 Hospital Results PRE INTERVENTION % of Objects Cleaned Hospitals Environmental Hygiene Study Group 36 Hospital Results PRE INTERVENTION Resource Neutral POST INTERVENTION P = <. 0001

74% 40% 11 Studies 82% 74% 40% 11 Studies 82%

Are such results sustainable? Are such results sustainable?

Thoroughness of Terminal Room Environmental Cleaning Thoroughness of Terminal Room Environmental Cleaning

Was it a lot of work? Chow S, Shao J, Wang H. Sample size Was it a lot of work? Chow S, Shao J, Wang H. Sample size calculations in clinical research. 2 ND ed. Chapman & Hall; 2007.

These results suggest that substantial improvements in environmental cleaning are achievable and sustainable Leadership 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

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

74% 40% 11 Studies 82% MRSA, VRE, CD, AB 68% 8 Reports 74% 40% 11 Studies 82% MRSA, VRE, CD, AB 68% 8 Reports

74% 40% 11 Studies 82% MRSA, VRE, CD, AB MRSA, VRE 68% 4 Studies 74% 40% 11 Studies 82% MRSA, VRE, CD, AB MRSA, VRE 68% 4 Studies 8 Reports

Given these results and in the context of the economic issues involved we need 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 Cleaning House: A New Metric in the Objective Evaluation of Environmental Cleaning

Approaches to Programmatic Environmental Cleaning Monitoring Conventional Program Enhanced Program • Subjective visual assessment Approaches to Programmatic Environmental Cleaning Monitoring Conventional Program Enhanced Program • Subjective visual assessment • Deficiency oriented • Episodic evaluation • Problem detection feedback • Open definition of correctable interventions • 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: S 41 -50 (June) AJIC Title Picture Am J Infect Control 2010; 38: S 41 -50 (June)

Conclusion – Where we are now Conclusion – Where we are now

Conclusion – Where we can and need to go Conclusion – Where we can and need to go

So what about the disinfectant? So what about the disinfectant?

Don’t forget the Rutala Equation Product + Practice Don’t forget the Rutala Equation Product + Practice

Issues with disinfectants, detergents, cloths, etc. • What is the true role of bleach 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 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 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 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

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 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? pcarling@cchcs. org Thanks for inviting me !! Questions – Comments? pcarling@cchcs. org