“No Touch” Methods for Room Disinfection

Dr. Bill Rutala

There is excellent evidence in the scientific literature that environmental contamination plays an important role in the transmission of several key healthcare-associated pathogens including methicillin-resistant Staphylococcus aureus [MRSA] , vancomycin-resistant Enterococcus [VRE], Acinetobacter, norovirus, and Clostridium difficile.^1-4  All these pathogens have been demonstrated to persist in the environment for hours to days (in some cases months)⁵, to frequently contaminate the environmental surfaces in rooms of colonized or infected patients, to transiently colonize the hands of healthcare personnel, to be transmitted by healthcare personnel, and to cause outbreaks in which environmental transmission was deemed to play a role.  Further, admission to a room in which the previous patient had been colonized or infected with MRSA, VRE, Acinetobacter or C. difficile, has been shown to be a risk factor for the newly admitted patient to develop colonization or infection.^6-8

It has long been recommended in the United States that environmental surfaces in patient rooms be cleaned/disinfected on a regular basis (e.g., daily, 3 times per week), when surfaces are visibly soiled, and following patient discharge (terminal cleaning).⁹   Studies have demonstrated that adequate environment cleaning is frequently lacking.  For example, Carling and co-workers assessed the thoroughness of terminal cleaning in the patient’s immediate environment in 23 acute care hospitals (1,119 patient rooms) by using a transparent, easily cleaned, stable solution that fluoresces when exposed to hand-held ultraviolet (UV) light.¹⁰   The overall thoroughness of cleaning, expressed as a percent of surfaces evaluated, was 49% (range for all hospitals, 35%-81%).  Further, while interventions aimed at improving cleaning thoroughness have demonstrated effectiveness, many surfaces remain inadequately cleaned and therefore potentially contaminated.  For this reason, several manufacturers have developed room disinfection units that can decontaminate environmental surfaces and objects.  These systems use one of two methods; either ultraviolent light or hydrogen peroxide.^{11, 12}  These technologies supplement, but do not replace, standard cleaning and disinfection because surfaces must be physically cleaned of dirt and debris.  Additionally, these methods can only be used for terminal or discharge room decontamination (i.e., cannot be used for daily room decontamination) because the room must be emptied of people.   This article summarizes a recent publications of this topic. ¹³

Ultraviolet Light for Room Decontamination

                UV irradiation has been used for the control of pathogenic microorganisms in a variety of applications, such as control of legionellosis, as well as disinfection of air, surfaces, and instruments.^{14, 15} At certain wavelengths, UV light will break the molecular bonds in DNA, thereby destroying the organism.  UV-C has a characteristic wavelength of 200-270 nm (e.g., 254 nm), which lies in the germicidal active portion of the electromagnetic spectrum of 200-320 nm.  The efficacy of UV irradiation is a function of many different parameters such as intensity, exposure time, lamp placement, and air movement patterns.

                An automated mobile UV-C unit (Tru-D, Lumalier Corporation) has been shown to eliminate >3-log₁₀ vegetative bacteria (MRSA, VRE, Acinetobacter baumannii) and >2.4-log₁₀ C. difficile seeded onto formica surfaces in patients’ rooms experimentally contaminated.⁴   There are three studies that have demonstrated that this UV-C system is capable of reducing vegetative bacteria inoculated on a carrier by >3-4-log₁₀ in 15-20 minutes and C. difficile by >1.7-4-log₁₀ in 35-100 minutes.^{4, 16, 17}  The studies  demonstrate reduced effectiveness when surfaces were not in direct line-of-sight.  Investigators have also demonstrated the effectives of an automated ultraviolet-C emitter against VRE, MRSA, Acinetobacter spp and C. difficile in patient rooms^{4, 18} and used a nanostructured UV-reflective wall coating that significantly reduced the time (from 25 minutes to 5 minutes for MRSA and from 44 minutes to 9 minutes for C. difficile spores) necessary to decontaminate a room using a UV-C-emitting device.¹⁹

New U.S. Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis

Preventing exposures to blood and body fluids (i.e., primary prevention) is the most important strategy for preventing occupationally acquired human immunodeficiency virus (HIV) infection.  Healthcare personnel (HCP) should adhere to the principle of Standard Precautions, including consistent use of appropriate work practices, work practice controls, and personnel protective equipment (PPE). 

Healthcare personnel should be aware of the recently published U.S. Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis [PEP] (http://www.jstor.org/stable/full/10.1086/672271).  This report continues to emphasize the following:

• Primary prevention of occupational exposures

• Prompt management of occupational exposures, and, if indicated, initiation of PEP

• Selection of PEP regimens that have the fewest side effects and that are best tolerated by prophylaxis recipients

• Anticipating and preemptively treating side effects commonly associated with taking antiretroviral drugs

• Attention to potential interactions involving both drugs that could be included in HIV PEP regimens and medications that PEP recipients might be taking

• Consultation with experts on PEP management strategies

• HIV testing of source patients (without delaying PEP initiation in the exposed provider) using methods that produce rapid results

• Counseling and follow-up of the exposed HCP

Recommendations included in this report may be summarized as follows:

Influenza Vaccines for the 2013-2014 Influenza Season

photo/ad credit: CDC

Influenza (the flu) is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death. Some people, such as older people, young children, and people with certain health conditions, are at high risk for serious flu complications. The best way to prevent the flu is by getting vaccinated each year.

Each year, influenza results in an average of 114,000 hospitalization and 25,000 deaths in the United States. For this reason, the Centers for Disease Control and Prevention (CDC) recommends that all persons over the age of 6 months (unless there is a medical contra-indication) should receive immunization, preferably by October. Early immunization is important because seasonal flu activity can begin as early as October and continue to occur as late as May.

Multiple influenza vaccines are now available. These include standard intramuscular vaccine, intradermal vaccine, and live attenuated vaccine. The live attenuated vaccine should be provided only to healthy non-pregnant persons (i.e., do NOT provide to pregnant women, immunocompromised persons, persons with asthma). It can be provided to healthcare personnel (HCP) but should HCP who receive this vaccine should not work in a protected environment that houses stem cell transplant patients (i.e., BMTU unit) for 5 days after immunization. They may work with all other groups of patients including neonates and immunocompromised patients. All HCP should receive influenza vaccine annually unless there is a medical contra-indication. Occupational health services may wish to stock in addition to a standard intramuscular (IM) vaccine both the intradermal (ID) and inhaled (LAIV) vaccines as some healthcare providers may prefer these vaccines. High dose vaccine is also available for persons >65 years of age; it is more immunogenic (i.e., higher antibody titers) and reactogenic (i.e., increased frequency of local reactions to the vaccine) but studies have not been published assessing whether it is more effective in preventing influenza that standard dose influenza vaccines.

2014 Proposed HAI Reporting Requirements

Per North Carolina Administrative Code (10A NCAC 41A .0106, 10A NCAC 41), Reporting of Healthcare-Associated Infections (HAIs) in North Carolina is based on the Centers for Medicare and Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) rules (Rules on Inpatient Prospective Payment Services). Because of this, when CMS adds HAI reporting rules, North Carolina requires those same HAIs be reported to the Division of Public Health (DPH) through the National Healthcare Safety Network (NHSN).

Recently, CMS published proposed rules for 2014 for public comment (http://www.gpo.gov/fdsys/pkg/FR-2013-05-10/pdf/2013-10234.pdf). If these rules are adopted they will affect you and your reporting of HAIs to CMS and to North Carolina. Two proposed rules in particular will impact data entry, beginning on or after January 1, 2014. These include:

1. Acute Care Hospitals will be required to report Central Line Associated Blood Stream Infections (CLABSIs) and Catheter Associated Urinary Tract Infections (CAUTIs) from not only all ICUS, but all medical, surgical, and medical/surgical wards.

2. The Medicare Beneficiary Number is to be reported (when applicable) for patients for all NHSN reported events.

It is currently unknown when CMS will publish the final rules so watch for information from the DPH HAI Infection Prevention Program, APIC NC and SPICE concerning the final rules.

Of additional interest regarding CMS’ validation process for 2013 data, CMS proposes to include CLABSI, CAUTI, SSI (Colon and Hysterectomy), LabID MRSA bacteremia and CDI.

For further information, you can read comments made on the proposed rules by national APIC at: http://www.apic.org/Resource_/TinyMceFileManager/Advocacy-PDFs/Comments_on_IPPS_FY_2014_FINAL_6-24-13.pdf

Special Note: In the FY 2014 IPPS proposed rule, CMS inadvertently omitted the baseline period for the CAUTI, CLABSI, and SSI measures that were proposed to be added to the Value Based Program (VBP) for FY 2016 payment. In in their comments (see website above), APIC asked for clarification on this point, and CMS added it to the OPPS/ASC proposed rule in order to get public comments in time to finalize the measures before the start of FY 2014 (October 1, 2013).

• The performance period for these measures is January 1, 2014 – December 31, 2014. The proposed baseline period is January 1 – December 31, 2012.

Investigation of Adverse Events after Methylprednisolone Acetate Injections, 2013

On May 22, 2013, the North Carolina Division of Public Health (NCDPH) was notified by the US Food and Drug Administration (FDA) of two adverse events reported to MedWatch, FDA’s Safety Information and Adverse Event Reporting Program. Two patients had developed soft tissue abscesses after receiving methylprednisolone acetate (MPA) injections at the same clinic. The injections contained preservative-free (PF) MPA 80mg/mL from 10mL vials compounded and distributed by Main Street Family Pharmacy (MSFP) located in Newbern, Tennessee. Five similar adverse events associated with the same MPA formulation from MSFP had been identified in April among Illinois residents. Concerns about widespread use of a potentially contaminated product led to a multi-state investigation.

As of July 25, 2013, 81 facilities in 15 states administered any MPA product from MSFP to their patients; national estimates of exposed patients were unavailable. A total of 26 cases were reported from four states: Arkansas, Florida, Illinois and North Carolina. All 26 illnesses were skin or soft-tissue abscesses at the site of injection; no life-threatening infections were reported. Four case patients had positive bacterial culture or histopathologic findings including Enterobacter cloacae, Klebsiella pneumonia, and Aspergillus species.

In North Carolina, public health and healthcare professionals partnered to mitigate further exposure and identify any additional cases. The North Carolina Board of Pharmacy (NCBOP) identified five clinics that received MPA products from MSFP and instructed clinics to discontinue use and sequester any remaining MPA products. The NCBOP also obtained the voluntary surrender of MSFP’s license in North Carolina. NCDPH and affected county health departments worked with the five clinics to notify 1,045 patients who received MPA injections of their potential exposure and to assess for any adverse events. No further cases were identified.

There was strong evidence to support that the source of the outbreak was contaminated PF MPA compounded at MSFP. FDA product testing of recalled, unopened MPA products detected bacterial and fungal pathogens from two separate lots. Pathogens included Acinetobacter ursingii, Alternaria species, Bacillus cereus/thuringiensis/mycoides, Bacillus licheniformis, Bacillus pumilus, Cladosporium species, Roseomonas gilardii and Penicillium species. Detailed information can be found on the FDA website at http://www.fda.gov/Drugs/DrugSafety/ucm355575.htm.  

As a final note, this investigation raised the following important issues. PF MPA products in 10mL vials were used for multiple doses; however, as a preservative-free product it should have been treated patient as a single-dose vial and used for one patient. Healthcare professionals should be familiar with safe injection practices including appropriate use of single-dose and multi-dose vials. For more information, visit the One and Only Campaign website at http://www.oneandonlycampaign.org/.  FDA’s MedWatch was a valuable tool for identifying this multistate outbreak where few cases were dispersed throughout the country. Healthcare providers and consumers may complete a MedWatch report (http://www.fda.gov/Safety/MedWatch/default.htm) when an adverse event to a drug, product, or medical device is suspected.

SPICE Announces Gowns and Gloves Challenge Winner

Ever wonder what YOU can do help stop the spread of serious illness due to bad bugs like Antibiotic Resistant Bacteria? SPICE is creating four educational modules on infection prevention designed for all nursing home staff. The first two modules have been completed and distributed.To assist in motivating and engaging  employees to complete the modules, SPICE established the Gowns and Gloves Infection Prevention Challenge. 

Gowns and Gloves is the name of the nursing home soap opera that is embedded in the first two learning modules. The embedded video is an entertaining way to convey important information, and  the soap opera episodes with professional actors engage viewers and create some buzz about the modules.  

The objective of the Gowns and Gloves Challenge was to maximize the number of nursing home employees that complete  Modules 1 and 2 of the Enhanced Education of Infection Prevention in Nursing Homes program. Participating nursing homes had from March through July to get as many employees to view the modules as possible, with the winning nursing home to receive a party with cake and balloons!

Congratulations to our Gowns and Gloves Challenge Winner:

(drum roll, please!)

Wilkes Senior Village, North Wilkesboro, NC

121 completed modules; 90% of employees!!

Wilkes Senior Village

HONORABLE MENTIONS:

Warren Hills Nursing Center, Warrenton, NC: 90 completed modules; 69% of employees

Mountain Vista Health Park, Denton, NC: 66 completed modules; 49% of employees

Carol Woods, Chapel Hill, NC: 163 completed modules; 49% of employees

THE STATS:

Nursing Homes registered for the Gowns and Gloves Challenge: 72

Nursing Homes with 25 or more people completing a module: 13

Total modules completed to date: 985 !!

STAY TUNED FOR MODULES 3 AND 4 COMING SOON!!

For more information on Enhanced Education of Infection Prevention in Nursing Homes: www.spiceducation.unc.edu