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//-->How Should We Clean 21stCentury Hospitals?Dr. Stephanie Dancer, NHS ScotlandTeleclass Sponsored by Diversey Inc. www.diversey.comHow Should We Clean 21stCentury Hospitals?Properties of hospital pathogensSurvival timeMRSAAcinetobacterC.difficileVRENorovirus7 days to 7 months3 days to 5 months5 months5 days to 4 months8 hours to 7 daysInfectious dose4 cfu’s250 cfu’s7 spores<103cfu’s10-100 virionsDr Stephanie Dancer, NHS ScotlandHosted by Martin Kiernanmartin@webbertraining.comTeleclass Sponsored bywww.diversey.comKramer, BMC Infect Dis, 2006; Dancer SJ, LID 2008; Chiang, Crit Care Med 2009;Wilcox M, 2010; Larson, Lancet 1978; Kjerulf et al, APMIS 1998Where are the pathogens in a hospital?Frequently touched surfaces!Carling et al, JHI 2010Do HCWs acquire pathogens from surfaces or patients?Every surface you touch…Fingertips from 500 HCWs were MRSA positive:6% after clinical contact7% after contact with the environment4% after no specific contactMRSA was recovered after using:alcohol rub (3%)chlorhexidine (6%)soap & water (3%)and on 5% occasions with NO hand hygiene!Creamer et al, JHI, 2010Hand contamination with MRSA was similar after contact with patients’skin and frequently touched environmental surfaces in patient roomsStiefel et al, ICHE 2011HCWs touch environmental sitesall the timeHosted by Martin Kiernan martin@webbertraining.comA Webber Training Teleclasswww.webbertraining.com1How Should We Clean 21stCentury Hospitals?Dr. Stephanie Dancer, NHS ScotlandTeleclass Sponsored by Diversey Inc. www.diversey.comWhat’s on YOUR hands??!A Room with a ViewEven if you always keep your hands clean, any benefits from hand hygieneare eroded if there is MRSA or C.difficile on the very next surface you touchBobulsky G et al, CID 2007; Farr et al, LID 200140x30 min covert observation periods followingentries into one isolation roomSequential hand-touch recording strategyNearTouchSitesClinicalEquipmentPatientContact[Y/N]Alcohol GelAfter Leaving[Y/N]FarTouchSitesAudit of sequential hand-touch…Who touches what?Overall compliance with hand hygiene among 154 staffbefore and after entry was25%Over half (58%) of 77 clinical staff touched the patient;Most frequently handled items inside room:IV drip&BP standOutside the room:computer, notes trolleyandtelephoneStaff MemberJunior DoctorSenior DoctorStaff NurseAuxiliary NurseCleanerCatererPharmacistRelativeAlcohol GelBefore Entry[Y/N]Since hand hygiene compliance is so low, could wetarget high risk sites for cleaning?……who cleans these?Smith et al, ECCMID 2011Dynamic transmission cycleof hospital pathogensWhich comes first? Patient or environment??@+*%$!!#?*!!White et al, AmJIC 2008Hosted by Martin Kiernan martin@webbertraining.comA Webber Training Teleclasswww.webbertraining.com2How Should We Clean 21stCentury Hospitals?Dr. Stephanie Dancer, NHS ScotlandTeleclass Sponsored by Diversey Inc. www.diversey.comCould patients’ hands constitute a missing link?Role of the air?Banfield & Kerr, J Hosp Infect 2005Cleaning patients’ hands reduces MRSA infection ratesGagne et al, J Hosp Infect 2010NHS Greater Glasgow & ClydeJust hanging around….airborne sporesSporelength0.79 mma1.04 mmb1.14mmbTerminal velocity(mm/s)0.020.0350.040.0660.13Fallout time (hours) from a height of:1m13.97.96.94.22.12m27.815.913.98.44.33m37.419.817.410.56.44m55.631.727.816.88.5How well is environmentalcleaning being done?1.42 mmb1.99 mmcabShortest overall spore lengthAverage spore lengths for 3 tested strainscLongest overall spore lengthSnelling et al, ICHE 2010Are shiny floors enough ?Carling PC, 2010How well are hand-touch sites cleaned?Fluorescent gel placed on sites in side-roomsAfter patient discharge, a site is considered cleaned if thefluorescent material is removed or disruptedEcolab®How clean are hospital surfaces?82-91%10-24%30-45%Visually cleanATP cleanMicrobiologically cleanWhat is clean?“what an individual thinks it is”‘Although 40% sites were cleaned properly, they tended to be themore traditional sites (toilets and sinks) whereas sites such astelephones, doorknobs and other hand-touch surfaces werescarcely cleaned at all’Carling et al, Am J Infect Control, 2006We should not define cleanliness withoutindicating how we would assess itGriffith CJ et al , J Hosp Infect 2000Hosted by Martin Kiernan martin@webbertraining.comA Webber Training Teleclasswww.webbertraining.com3How Should We Clean 21stCentury Hospitals?Dr. Stephanie Dancer, NHS ScotlandTeleclass Sponsored by Diversey Inc. www.diversey.comSurface evaluation usingATP bioluminescenceSwab surfaceluciferase tagging of ATPHand heldluminometerATP values for sites on medical (M) & surgical (S) wardsSiteLocker (M)Locker (S)L Bed (M)L Bed (S)O/B Table (M)O/B Table (S)R Bed (M)RangeMeanRangeMeanRangeMeanRangeMeanRangeMeanRangeMeanRangeMeanRangeMeanBefore15-3161067-3251344-2431064-18110328-62511633-5502463-4091450-266118After17-148475-208914-151220632-1155613-753655-38465813-2006016-12854Site MeanATP BeforeSite MeanATP After12069105131181309Used in the commercial food preparation industry to evaluate surfacecleaning before reuse and as an educational tool for more than 30 yearsR Bed (S)13257Mulvey et al, JHI 2011Would microbiological standards help?Microbiological standards for surface hygiene in hospitalsStandard 1There should be <1cfu/cm2pathogen (MRSA;C.difficile; VRE; etc) in the clinical environmentStandard 2The Aerobic Colony Count (ACC) or total microbialgrowth level from a hand contact surfaceshould be <5 cfu/cm25 cfu/cm245 cfu/cm2Slide courtesy of Chris Griffith; Dancer, JHI 2004These standards are based upon food industry counts asapplied to food preparation surfaces but could be utilised for frequenthand touch surfaces in hospitalsDancer S, J Hosp Infect 2004Application of standards on a wardS.aureus& MRSA preferlockers, overbed tablesand beds; finding theseat a site was significantlyassociated with higheraerobic colony countsfrom that site (p=0.001)Dancer SJ et al, IJEHR 2008Application of standardson ICU25% of 200 samples failed the standards,mostly hand-touch sitesHygiene fails were associated with bedoccupancy and incidence of ICU-acquiredinfectionHygiene standards reflect patient activity andprovide a means to risk manage infectionWhite et al, AmJIC, 2008Hosted by Martin Kiernan martin@webbertraining.comA Webber Training Teleclasswww.webbertraining.com4How Should We Clean 21stCentury Hospitals?Dr. Stephanie Dancer, NHS ScotlandTeleclass Sponsored by Diversey Inc. www.diversey.comIs there a relationship between microbiologicalstandards and ATP levels from surfaces?Measuring ATP levels can tell you how good the generalcleaning is AND it encourages cleaners to improve theircleaning efficiency(Boyce et al, ICHE 2009) ……..but there is no pointroutinely measuring ATPlevels from hospital surfacesif there isn’t going to be anybenefit for patientsAerobic colony count (cfu/cm2)Relationship between aerobic colony count and its pass or fail using either ATPlevels (grey bars; fail >250 relative light units) or visual assessment (black bars)Percentage of fails using ATP and visual assessment foreach range of aerobic colony countLewis et al, JHI 2008%failsWhat is the evidence for cleaning as a viablecontrol mechanism for MRSA?We introduced one extra cleaner intotwo wards from Monday to Friday, witheach ward receiving extra detergent-based cleaning for six months in aprospective cross-over design% ATPTen hand-touch sites on both wardswere screened weekly and patientswere monitored for MRSA infectionthroughout the year-long study>40 cfu/cm2Patient and environmental MRSAisolates were characterized using DNAfinger- printing>40 cfu/cm2Mulvey et al, J Hosp Infect, 2011BBC website, 2008Dancer et al, BMC Med 2009Total aerobic colony counts (ACC) from ten hand-touchsites on two matched surgical wards; the study cleanermoved from Ward A to Ward B at week 13.What did we find?One extra cleaner was responsible for a 33% reduction incolony counts on hand-touch sites;and 27% reduction in new MRSA infections, despitebusier wards and more MRSA patient-daysAdjusting for MRSA patient-days and based upon 9 newMRSA infections found during control periods, weexpected 13 new infections during enhanced cleaningperiods rather than the four that actually occurredDNA fingerprinting confirmed indistinguishable strainsfrom both hand-touch sites and patients - some of thesewere isolated months apartNB. Middle 6 months of studyDancer et al, BMC Med, 2009Hosted by Martin Kiernan martin@webbertraining.comA Webber Training Teleclasswww.webbertraining.com5 [ Pobierz całość w formacie PDF ]
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//-->How Should We Clean 21stCentury Hospitals?Dr. Stephanie Dancer, NHS ScotlandTeleclass Sponsored by Diversey Inc. www.diversey.comHow Should We Clean 21stCentury Hospitals?Properties of hospital pathogensSurvival timeMRSAAcinetobacterC.difficileVRENorovirus7 days to 7 months3 days to 5 months5 months5 days to 4 months8 hours to 7 daysInfectious dose4 cfu’s250 cfu’s7 spores<103cfu’s10-100 virionsDr Stephanie Dancer, NHS ScotlandHosted by Martin Kiernanmartin@webbertraining.comTeleclass Sponsored bywww.diversey.comKramer, BMC Infect Dis, 2006; Dancer SJ, LID 2008; Chiang, Crit Care Med 2009;Wilcox M, 2010; Larson, Lancet 1978; Kjerulf et al, APMIS 1998Where are the pathogens in a hospital?Frequently touched surfaces!Carling et al, JHI 2010Do HCWs acquire pathogens from surfaces or patients?Every surface you touch…Fingertips from 500 HCWs were MRSA positive:6% after clinical contact7% after contact with the environment4% after no specific contactMRSA was recovered after using:alcohol rub (3%)chlorhexidine (6%)soap & water (3%)and on 5% occasions with NO hand hygiene!Creamer et al, JHI, 2010Hand contamination with MRSA was similar after contact with patients’skin and frequently touched environmental surfaces in patient roomsStiefel et al, ICHE 2011HCWs touch environmental sitesall the timeHosted by Martin Kiernan martin@webbertraining.comA Webber Training Teleclasswww.webbertraining.com1How Should We Clean 21stCentury Hospitals?Dr. Stephanie Dancer, NHS ScotlandTeleclass Sponsored by Diversey Inc. www.diversey.comWhat’s on YOUR hands??!A Room with a ViewEven if you always keep your hands clean, any benefits from hand hygieneare eroded if there is MRSA or C.difficile on the very next surface you touchBobulsky G et al, CID 2007; Farr et al, LID 200140x30 min covert observation periods followingentries into one isolation roomSequential hand-touch recording strategyNearTouchSitesClinicalEquipmentPatientContact[Y/N]Alcohol GelAfter Leaving[Y/N]FarTouchSitesAudit of sequential hand-touch…Who touches what?Overall compliance with hand hygiene among 154 staffbefore and after entry was25%Over half (58%) of 77 clinical staff touched the patient;Most frequently handled items inside room:IV drip&BP standOutside the room:computer, notes trolleyandtelephoneStaff MemberJunior DoctorSenior DoctorStaff NurseAuxiliary NurseCleanerCatererPharmacistRelativeAlcohol GelBefore Entry[Y/N]Since hand hygiene compliance is so low, could wetarget high risk sites for cleaning?……who cleans these?Smith et al, ECCMID 2011Dynamic transmission cycleof hospital pathogensWhich comes first? Patient or environment??@+*%$!!#?*!!White et al, AmJIC 2008Hosted by Martin Kiernan martin@webbertraining.comA Webber Training Teleclasswww.webbertraining.com2How Should We Clean 21stCentury Hospitals?Dr. Stephanie Dancer, NHS ScotlandTeleclass Sponsored by Diversey Inc. www.diversey.comCould patients’ hands constitute a missing link?Role of the air?Banfield & Kerr, J Hosp Infect 2005Cleaning patients’ hands reduces MRSA infection ratesGagne et al, J Hosp Infect 2010NHS Greater Glasgow & ClydeJust hanging around….airborne sporesSporelength0.79 mma1.04 mmb1.14mmbTerminal velocity(mm/s)0.020.0350.040.0660.13Fallout time (hours) from a height of:1m13.97.96.94.22.12m27.815.913.98.44.33m37.419.817.410.56.44m55.631.727.816.88.5How well is environmentalcleaning being done?1.42 mmb1.99 mmcabShortest overall spore lengthAverage spore lengths for 3 tested strainscLongest overall spore lengthSnelling et al, ICHE 2010Are shiny floors enough ?Carling PC, 2010How well are hand-touch sites cleaned?Fluorescent gel placed on sites in side-roomsAfter patient discharge, a site is considered cleaned if thefluorescent material is removed or disruptedEcolab®How clean are hospital surfaces?82-91%10-24%30-45%Visually cleanATP cleanMicrobiologically cleanWhat is clean?“what an individual thinks it is”‘Although 40% sites were cleaned properly, they tended to be themore traditional sites (toilets and sinks) whereas sites such astelephones, doorknobs and other hand-touch surfaces werescarcely cleaned at all’Carling et al, Am J Infect Control, 2006We should not define cleanliness withoutindicating how we would assess itGriffith CJ et al , J Hosp Infect 2000Hosted by Martin Kiernan martin@webbertraining.comA Webber Training Teleclasswww.webbertraining.com3How Should We Clean 21stCentury Hospitals?Dr. Stephanie Dancer, NHS ScotlandTeleclass Sponsored by Diversey Inc. www.diversey.comSurface evaluation usingATP bioluminescenceSwab surfaceluciferase tagging of ATPHand heldluminometerATP values for sites on medical (M) & surgical (S) wardsSiteLocker (M)Locker (S)L Bed (M)L Bed (S)O/B Table (M)O/B Table (S)R Bed (M)RangeMeanRangeMeanRangeMeanRangeMeanRangeMeanRangeMeanRangeMeanRangeMeanBefore15-3161067-3251344-2431064-18110328-62511633-5502463-4091450-266118After17-148475-208914-151220632-1155613-753655-38465813-2006016-12854Site MeanATP BeforeSite MeanATP After12069105131181309Used in the commercial food preparation industry to evaluate surfacecleaning before reuse and as an educational tool for more than 30 yearsR Bed (S)13257Mulvey et al, JHI 2011Would microbiological standards help?Microbiological standards for surface hygiene in hospitalsStandard 1There should be <1cfu/cm2pathogen (MRSA;C.difficile; VRE; etc) in the clinical environmentStandard 2The Aerobic Colony Count (ACC) or total microbialgrowth level from a hand contact surfaceshould be <5 cfu/cm25 cfu/cm245 cfu/cm2Slide courtesy of Chris Griffith; Dancer, JHI 2004These standards are based upon food industry counts asapplied to food preparation surfaces but could be utilised for frequenthand touch surfaces in hospitalsDancer S, J Hosp Infect 2004Application of standards on a wardS.aureus& MRSA preferlockers, overbed tablesand beds; finding theseat a site was significantlyassociated with higheraerobic colony countsfrom that site (p=0.001)Dancer SJ et al, IJEHR 2008Application of standardson ICU25% of 200 samples failed the standards,mostly hand-touch sitesHygiene fails were associated with bedoccupancy and incidence of ICU-acquiredinfectionHygiene standards reflect patient activity andprovide a means to risk manage infectionWhite et al, AmJIC, 2008Hosted by Martin Kiernan martin@webbertraining.comA Webber Training Teleclasswww.webbertraining.com4How Should We Clean 21stCentury Hospitals?Dr. Stephanie Dancer, NHS ScotlandTeleclass Sponsored by Diversey Inc. www.diversey.comIs there a relationship between microbiologicalstandards and ATP levels from surfaces?Measuring ATP levels can tell you how good the generalcleaning is AND it encourages cleaners to improve theircleaning efficiency(Boyce et al, ICHE 2009) ……..but there is no pointroutinely measuring ATPlevels from hospital surfacesif there isn’t going to be anybenefit for patientsAerobic colony count (cfu/cm2)Relationship between aerobic colony count and its pass or fail using either ATPlevels (grey bars; fail >250 relative light units) or visual assessment (black bars)Percentage of fails using ATP and visual assessment foreach range of aerobic colony countLewis et al, JHI 2008%failsWhat is the evidence for cleaning as a viablecontrol mechanism for MRSA?We introduced one extra cleaner intotwo wards from Monday to Friday, witheach ward receiving extra detergent-based cleaning for six months in aprospective cross-over design% ATPTen hand-touch sites on both wardswere screened weekly and patientswere monitored for MRSA infectionthroughout the year-long study>40 cfu/cm2Patient and environmental MRSAisolates were characterized using DNAfinger- printing>40 cfu/cm2Mulvey et al, J Hosp Infect, 2011BBC website, 2008Dancer et al, BMC Med 2009Total aerobic colony counts (ACC) from ten hand-touchsites on two matched surgical wards; the study cleanermoved from Ward A to Ward B at week 13.What did we find?One extra cleaner was responsible for a 33% reduction incolony counts on hand-touch sites;and 27% reduction in new MRSA infections, despitebusier wards and more MRSA patient-daysAdjusting for MRSA patient-days and based upon 9 newMRSA infections found during control periods, weexpected 13 new infections during enhanced cleaningperiods rather than the four that actually occurredDNA fingerprinting confirmed indistinguishable strainsfrom both hand-touch sites and patients - some of thesewere isolated months apartNB. Middle 6 months of studyDancer et al, BMC Med, 2009Hosted by Martin Kiernan martin@webbertraining.comA Webber Training Teleclasswww.webbertraining.com5 [ Pobierz całość w formacie PDF ]