Selecting the Ideal Disinfectant - PowerPoint Presentation

Selecting the Ideal DisinfectantOne Size does not Fit All Jim Gauthier, MLT, CIC Senior Clinical Advisor Infection Prevention

ObjectivesReview the characteristics of the ‘ideal’ disinfectantHighlight important characteristics for disinfection selectionReview procedures and validation that make up effective disinfection

3 Rutala WA, et al. ICHE 2014;35(7):855-65

Criteria of an Ideal Disinfectant Broad spectrum – kills Healthcare pathogens of concern Fast acting – short contact times (for pathogens of concern) Remains wet – must keep surfaces wet for entire contact time in single application Unaffected by environmental factors – not affected by organic soil or hard water Non-toxic and non-irritating to the user – should have lowest possible safety risk to user Compatible with surfaces – should be proven compatible with common Healthcare surfaces and equipment Persistence – should have a residual effect on surfaces

Criteria of an Ideal DisinfectantEasy to use – available in multiple forms to align with highest convenience for users Acceptable odor – should have an acceptable odor for patients and staff Economical – should not be cost prohibitive for facilitySoluble in water – so will not cause issues when it contacts waterStable - in concentrate and end use dilution Cleaner - good cleaning ability Nonflammable – should have a flash point over 150°F

The Environment Plays a Role in the Risk of Transmission Contaminated Environmental Surfaces Susceptible Patient Hands of Healthcare Providers Environmental Hygiene Hand Hygiene Direct Transmission

Healthcare Associated InfectionsHAI(p) = PA + HH + ASP + CP + FWM + EDWhere:HAI(p) = Healthcare Associated Infection PreventionPA = Patient AcuityHH = Hand HygieneASP = Antibiotic Stewardship ProgramCP = Clinical PracticesFWM = Fecal Waste Management ED = Environmental Disinfection

HAI(p) = PAvent+PApoe+PAold+PAabtic+PAco-m+ HH prod +HH place +HHaudit+HHmom+HHchamp+HHpat+HHfam/vis + ASPdrug+ASProute+ASPduration+ASPdose+ASPrestriction CPskinprep+CPdecol+CPprophy+CPbundle+FWMcontainer+FWM ppe+FWMno rinse+FWMprotocol +EDevs+ ED audit + ED nurse + ED other + ED family + ED prod + ED ppe + EDcontact+ EDdilute + EDcompat + EDresource Healthcare Associated Infections

Effective Disinfection: 3 Key Elements9 A clearly defined protocol with education Compliance monitoring with staff feedback The use of an effective disinfectant cleaner

Key Considerations for Selecting the Optimal Disinfectant for Your Facility Rutala 2014(2)

Criteria of Ideal Disinfectant: 5 Considerations 12

Kill ClaimsDoes the product kill the most prevalent healthcare pathogens, including those that: Cause most HAIs*? Cause most outbreaks? Are of concern in your facility?

+ Rutala 2014 ~27% ~53% 79% (without Yeasts)

Magill 2014

65%

Most common causes of outbreaks and ward closures by causative pathogen, which are relatively hard to killClostridium difficile spores Norovirus Aspergillus Rotavirus Adenovirus

Viral PathogensEnveloped Viruses (Easy to Kill)Influenza Respiratory Syncytial Virus (RSV) Parainfluenza virus Human Metapneumovirus Hepatitis B and C HIV18Colds

Viral PathogensNon-Enveloped Viruses (Not Easy to kill) Norovirus Rhinovirus Enterovirus Hepatitis A *Adenovirus (larger – easier to kill)19

Effect of Disinfectants on MicroorganismsOrganism Type Examples Bacterial Spores SporeBacillus anthracis, Clostridium difficile MycobacteriaBacteria M. tuberculosis Small non-enveloped virus Virus Poliovirus, Norovirus Fungal spores Fungus Aspergillus, Penicillium, Trichophyton Gram negative bacteria Bacteria E. coli , Klebsiella including CRE , Pseudomonas, Acinetobacter Fungi (Vegetative) Fungus Candida Large Virus (non-enveloped) Virus Adenovirus, Rotavirus Gram positive bacteria Bacteria Staphylococcus including MRSA Enterococcus including VRE Virus (enveloped) Virus HIV, HBV, HCV, Influenza ^ Resistant * Sensitive R^ S* Adapted from Rutala et al. ICHE 2014;35(7):862 Low Level

21 Task Oriented vs. Daily Use

Criteria of an Ideal Disinfectant: 5 Considerations 22

Kill Times and Wet-Contact TimeHow quickly does the product kill the prevalent healthcare pathogens? Does the product keep surfaces visibly wet for the kill times listed on its label?

Dry Time vs. Label Contact Time 24 Omidbakhsh 2010 IHP (0.5% Hydrogen peroxide)

Criteria of an Ideal Disinfectant: 5 Considerations 25

SafetyDoes the product have an acceptable toxicity rating? Does the product have an acceptable flammability rating? Is a minimum level of Personal Protective Equipment (PPE) required? Is the product compatible with the common surfaces in your facility?

Sporicidal Everywhere?“Effectiveness of an environmental cleaning management plan implemented by the quality department”Change Management Plan – Interventions: Stakeholder meetings Education Cleaning carts and checklistsDaily duties distributed to staffSwitched to sporicidal for daily cleaningMahmutoglu D, Haque J, Graham Munoz-Price LS. Division of Infectious Diseases, Medical College of WI – SHEA 2016 Poster

High Touch Surfaces

Different Units

ConclusionsA quality-driven change management plan was unsuccessful to improve environmental cleaningBoth daily and terminal cleaning were found suboptimal before and after the implementation of interventionsCleaning of bedrails was found significantly less after the implementation of interventionsNew sporicidal daily cleaning solutions which have a strong and irritating odor might be playing a major role in this decrease

Criteria of an Ideal Disinfectant: 5 Considerations 33

Ease of UseIs the product odor considered acceptable? Does the product have an acceptable shelf-life? Does the product come in convenient forms to meet your facility’s needs (e.g. liquids, sprays, refills, and multiple wipe sizes, etc.)?

Ease of UseDoes the product work in the presence of organic matter? Is the product water soluble? Does the product clean and disinfect in a single step? Are the directions for use simple and clear?

Disposable Disinfectant Wipes 36 Study Demonstrated Disinfectant wipes increased compliance and improved speed. Disinfectant wipes yielded a cost savings over traditional towel and bucket method Wiemken et al. AJIC 2014;42:329-30 Point out here that The right products/procedure Can improve compliance and reduce labor costs

Microfiber vs. Disposable Wipes

Quat Binding Some cleaning tool fabrics, such as cotton and microfiber, are known to bind with quaternary ammonium compounds (“ quats ”). This is known as “ quat binding ” Active ingredients ( quat ) have a tendency to become attracted to, and absorbed into, microfiber and cotton fabrics Cotton fabrics and most microfibers are negatively charged or anionic

Quat Binding Quats are positively charged, or cationic, and are attracted to the negatively charged fabric surfaces Some non-woven disposable wipes have no charge, and do not demonstrate binding with quats or other disinfectantsCONSEQUENCE: A portion of the quat actives become unavailable to disinfect hard surfaces making the disinfection process ineffective! 39

Quat Binding Boyce 2016 Microfiber wipers , cotton towels, and 1 of 2 types of disposable wipes soaked in a Quat disinfectant revealed significant binding of the disinfectant.

Dispensers – 33 StationsNumber of DispensersIssue 7 <200 ppm 17 200-400 ppm 6400-600 ppm2No Concentrate1Inoperative

Other FactorsDoes the supplier offer comprehensive t­raining and ongoing education, both in-person and virtual? Does the supplier offer 24-7 customer support? Is the overall cost of the product acceptable (considering product capabilities, costs of infections that may be prevented and costs per compliant use)? Can the product help standardize disinfectants used in your facility?

Total Score? Consideration Score (1-10) Kill Claims Kill Times and Wet Contact TimeSafetyEase of UseOther Factors

Integrating safe, and effective products and tools, into cleaning processes to deliver better outcomes Understand current cleaning methodsIntegrating the products, tools, and equipment to drive improved results and operational efficiencyFinding the comprehensive bundle for the specified needs Procedures

Roles and Responsibilities 46 Define… Who? When?What?Where?How?

Cleaning and DisinfectionWhat surfaces/equipment need to be cleaned, how often, what product should be used, what cleaning tool, what dilution, amount needed, contact time?Is there product available where/when needed?Is the product being used properly, PPE donned correctly (if needed), right technique used, contact time achieved, feedback provided?

Cleaning and DisinfectionAssess the adequacy of room cleaning If room cleaning and disinfection practices are deemed to be inadequate, focus on reviewing and improving cleaning and disinfection techniques Create a unit-specific checklist based on cleaning protocols and perform observations to monitor cleaning practice Consider environmental decontamination with sodium hypochlorite or EPA-approved sporicidal agent if room cleaning and disinfection is deemed to be adequate but there is ongoing CDI transmission ( Dubberke 2014

Elbow grease does the jobEfficacy of Different Cleaning and Disinfection Methods against Clostridium difficile Spores: Importance of Physical Removal versus Sporicidal Inactivation Tested the removal of C. difficile spores from environmental surfaces using various cleaners, disinfectants and wipes. Wipes with a non-sporicidal agent showed 2.9 log 10 reductions of C. difficile spores. Wiping with a sporicidal agent increased the removal efficacy by 1 log10 (3.9 log10).Results: Just wiping the surface (physical removal) resulted in a ~3 log10 reduction in C. difficile sporesRutala 2012

C. difficile Eradication from ToiletsFew alternatives to bleach for non-outbreak conditions have been evaluated in controlled healthcare studies.METHODS:This study was a prospective clinical comparison during non-outbreak conditions of the efficacy of an improved hydrogen peroxide cleaner (0.5%) with respect to spore removal from toilets in a tertiary care facility. CONCLUSION : I HP formulation evaluated that has some sporicidal activity and provides a one-step process that significantly lowers the C. difficile spore level in toilets during non-outbreak conditions without the workplace safety concerns associated with 5000 ppm bleach. 2-3 Log10 kill after 1 minuteAlfa 2010

First Clinical study to show that improved compliance with environmental surface disinfection using IHP reduced HAI rates for VRE, MRSA and C. difficile 3 key components to ensure reduction of HAI : Alfa 2015 Cost avoidance of $668,000/year due to HAI rate reduction Proven Solution to Reduce HAI All rates reduced by > 20% A clearly defined protocol with education Compliance monitoring with staff feedback The use of an effective disinfectant cleaner

Quat BindingDr. Alfa’s study would be very applicable in this case!

A New Study with Improved Hydrogen peroxide (IHP) Presented at APIC 2016 John M. Boyce, MD AJIC 2016;44(6)Suppl:S16

Study Design12-month prospective trial with cross-over design conducted on two campuses of a university-affiliated hospital On each campus, 2 wards were randomized to have EVS perform routine daily cleaning/disinfection of surfaces: IHP disinfectant wipes containing 0.5% IHP Quat disinfectant currently used in the hospital , applied using a disposable wipe made of meltblown polypropylene (same material as disposable wipe above)

Study DesignThe 4 study wards included: An MICU and its step-down unit on one campus Two general medical wards on the other campus After the initial 6 months, ward assignments were changed

Two Facilities – Two TechnologiesOne: Quat-based disinfectant cleaner/meltblown polypropylene disposable wipes for daily cleaning; addition of bleach wipes for C. diff rooms (EVS and Clinical) Two : Improved h ydrogen peroxide (0.5%IHP ) for all cleaning; all quat and bleach wipes removed from the wardsHand hygiene compliance rates comparable on study wards

MethodsAnalysis included data for months when wipe rates on study wards were > 80% IHP wards – 16 months (10,741 patient-days) Quat wards – 17 months (11,490 patient-days)

ResultsMean ACC/surface after cleaning: On IHP wards (14.0 CFUs/surface) On Quat wards (22.2 CFUs/surface) ( p = 0.003)

ResultsLogistic regression analysis revealed that the proportion of surfaces yielding no growth after cleaning On IHP wards (240/501 [47.9%]) On Quat wards (182/517 [35.2%]) ( p < 0.0001) Both microbiological outcomes favored IHP over Quat

Results 23% fewer cases/1000 Pt -days on IHP wards Antibiotic usage: Non-C. difficile agent use was 10.8% higher on IHP wards which would be expected to lead to more VRE, MRSA and CDI outcomes, not fewer as observed

Training & Tools Drives Competence Example Example Facilitate best practice adoption Support tools that demonstrate the proper workflow and procedures Training content delivery in multiple languages and formats to support needs Bringing optimized procedures to life – adapting to individual facilities needs

Are we missing anything?

The Patient’s Environment EVS cleans 1x per day What happens the other 23.5 hrs ?

Between 5 AM and 8 PM, (ICU and Med/Surg Unit)Number of room entries = 5.5/hour (28 max)Number of different staff entering room = 3.5/hour (18 max) Number of people in room during waking hours = 15 hrs * 5.5 / hr = 82.5 peoplePatient Room Entries (Cohen)

45% = Nursing staff23% = Personal visitors17% = Medical staff 8% = Nonclinical staff 4 % = Other clinical staff Who came in room ?

What do they touch while in the room? 33.5% = contact with the environment only Most common level of touch 27.1% = patient’s intact skin 17.8% = blood or body fluids 16.0% = the person touched nothing in the roomCohen, et. al., “Frequency of patient contact with health care personnel and visitors: implications for infection prevention”, Jt Comm J Qual Patient Safety, 2012; 38 (12): 560-565

What do they touch while in the room? Staff frequently enter a room and either touch nothing or only touch the environment. This may help explain low hand hygiene rates. Cohen, et. al., “Frequency of patient contact with health care personnel and visitors: implications for infection prevention”, Jt Comm J Qual Patient Safety, 2012; 38 (12): 560-565

Huslage and Rutala (2010) studied HTS in an ICU and a general med-surg unit.In the ICU (contacts per interaction): Bedrails = 7.8 Bed surface = 6 Supply cart = 4 Surface Contact

In the Med-Surg unit (contact per interaction)Bedrails = 3.1Over-bed table = 1.6 IV pump = 1.4 Bed surface = 1.3 Average surfaces per interaction: ICU = 44, Med- Surg = 15Surface Contact

Room entries per hour = 5.5Bedrail contacts per hour = 17.1 (5.5 x 3.1)Bedrail contacts per 15 hour patient ‘awake’ day = 256Number of times per day bedrail is disinfected by EVS = 1Probability of EVS disinfecting the bedrail = 50% More Math!

?255?

Number of times per day bedrail is disinfected by the clinical staff = ? (probably zero)Probability of Clinical staff performing hand hygiene = 40%We should not be surprised that surfaces in the patient zone contribute to infection risk given the frequency of contact and the limited disinfection Math!

Recognize that high touch surfaces are done every 24 hoursSubsets may be done 2x per dayPoint of Care PreventionCertain procedures need disinfection of surfacesEnvironmental Disinfection (ED)

Point of Care DisinfectionIt is everyone’s job to disinfect, but it is not everyone’s job to disinfect everythingTraining cards for:Clinician – workstation on wheels, bed rails Food servers – over bed table, sanitize patient hands CNAs – bedrails, other bed controls Blood lab tech – bedrail, bed controls Respiratory therapists – bedrail, bed controls

6 Moments of Surface DisinfectionBefore placing a food tray on an over-bed table After any procedure involving feces (or body fluids) within the patient bed space After any wound dressing change After patient bathing (within bed space) After assistance with productive cough or vomiting Any time surfaces are visibly soiled

Point of Care DisinfectionDisinfectant at point of care!0/0/0 HMIS – can’t be flammable, can’t be causticFast contact time

Suggestion Family and VisitorsFeel free to use our disinfectant wipe on hard surfaces around the patient (not a “baby wipe”) Dispose in the regular garbage Please do not flush!

Are you Confident? The Job has been completed? All areas are in compliance? All surfaces are cleaned? Procedures are followed? Validation

CDC GuidanceBased on strong evidence that transmission of HAPs is related to contamination of near patient surfaces and equipment CDC issued a guidance document “Options for Evaluating Environmental Cleaning,” December 2010 Recommends that all hospitals develop programs to optimize the thoroughness of high-touch surface cleaning as part of terminal room cleaning http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html

Cleaning and DisinfectionRoutinely assess adherence to protocols and adequacy of cleaning and disinfectionAssess the adequacy of cleaning and disinfection practices before changing to a new cleaning product ( e.g. bleach)Dubberke 2014

Cleaning and DisinfectionConsider sporicidal if:Cleaning and disinfection are deemed adequate, but still ongoing CDI transmission For disinfection of the environment in outbreak or hyperendemic settings in conjunction with other IPC measures

Environmental Cleaning Evaluation Program – Level I ProgramCleaning responsibilities and frequencies clearly definedStructured education of staff Implementation of a monitoring system that measures staff competency and incorporates patient satisfaction survey resultsContinuous monitoring of the programInterventions to improve the quality of cleaning and disinfection Consideration and documentation of feasibility of moving to a Level II program www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf

Environmental Cleaning Evaluation Program – Level IIEverything in Level I ANDImplementation of a monitoring system that covertly assesses terminal room thoroughness of surface disinfection cleaning using one or more generally accepted methods The learning from the monitoring of surfaces should be used to improve processes and overall cleaning outcomesAccepted MethodsDirect ObservationFluorescence- ATP- Culturing Not recommended - Post Cleaning Inspections

Establishing a Baseline for Cleaning Evaluation ProgramThe program requires a baseline to be established10-15% of rooms should be included in the baseline calculation - or 15 rooms if the facility has less than 150 roomsThis is referred to as the pre-intervention thoroughness of disinfectant cleaning (TDC score) TDC Score = # of objects cleaned/total number of objects evaluated X 100 The baseline learning should be used to optimize programmatic interventions

Cleaning Evaluation ProgramOngoing measurement of high touch surfaces is recommended at least 3 times/yearThe ongoing measurement should be compared to the baseline to determine if cleaning practices are improving or deteriorating

Florescent Marker, Light & Audit Tool S imple web-based data entry and analysis On-line, Real-time Reporting Deploy for Compliance Monitoring and Improvement Measure AnalyzeActivate Improve Validation Monitoring and ongoing feedback are key

Summary89

Sporicide vs. Effective Cleaning and DisinfectionMost of our pathogens are easy to killIf you have transmission of MRSA, VRE, ESBL or CRE – moving to a sporicide will not help!Find your ideal disinfectantReview the moments for environmental disinfection! 90

91 Products that staff can use confidently and efficiently. Fast-acting disinfectant cleaners kill tough pathogens in as little as one minute, but are gentle on staff and surfaces.Procedures that standardize processes and help ensure consistent performance. Training programs and best-practice protocols enhance cleaning and disinfection efficiency and effectiveness.Validation system that provides actionable intelligence that can be used to provide feedback to employees, improve the cleaning and disinfection of high touch surfaces and empower employees to drive continuous improvement. Example

92 Products Procedures Validation

Questions?

ReferencesAlfa MJ et al. Improved eradication of Clostridium difficile spores from toilets of hospitalized patients using an accelerated hydrogen peroxide as the cleaning agent. BMC Infect Dis 2010:10:268-76. http://www.biomedcentral.com/1471-2334/10/268 Alfa MJ, et al. Use of a daily disinfectant cleaner instead of a daily cleaner reduced hospital-acquired infection rates. AJIC 2015;43:141-6Boyce JM, et al. Quaternary Ammonium Disinfectant Issues Encountered in an Environmental Services Department. ICHE 2016;37(3):340-2

ReferencesCohen, et. al., “Frequency of patient contact with health care personnel and visitors: implications for infection prevention”, Jt Comm J Qual Patient Safety, 2012; 38 (12): 560-565 Dubberke ER, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 Update. ICHE 2014;35(6):628-45Hawley B, et al. Respiratory symptoms and skin irritation amoung hospital workers using a new disinfection product – Pennsylvania, 2015. MMWR 2005;65(10):400-1Huslage K et al. A Quantitative approach to defining “high‐touch” surfaces in hospitals. ICHE 2010;31(8):850-3

ReferencesKundrapu S, et al. Daily disinfection of high-touch surfaces in isolation rooms to reduce contamination of healthcare workers’ hands. ICHE 2012;33(10):1039-42Magill SS, et al. Multistate point-prevalence survey of health care–associated infections. N Engl J Med 2014;370:1198-208.Omidbakhsh N. Theoretical and experimental aspects of microbicidal activities of hard surface disinfectants: are their label claims based on testing under field conditions? J AOAC Inter 2010;93(6): 1-8Rutala WA, et al. Efficacy of different cleaning and disinfection methods against spores: Clostridium difficile: importance of physical removal versus sporicidal inactivation ICHE 2012;33(12):1255-8

ReferencesRutala WA, et al. Selection of the ideal disinfectant. ICHE 2014;35(7):855-65Rutala 2014(2). Selection of the ideal disinfectant. Accessed 20160111 from: Disinfectionandsterilization.orgWiemken TL, et al. The value of ready-to-use disinfectant wipes: compliance, employee time, and costs. AJIC 2014;42:329-30

james.gauthier@sealedair.comkimberly.dwyer@sealedair.com