Cleaning and Disinfection in the Long-term Care Setting...
27
3/27/2017 1 Cleaning and Disinfection in the Long-term Care Setting: Where Do We Start? Deb Patterson Burdsall PhD, RN-BC, CIC, FAPIC
Transcript of Cleaning and Disinfection in the Long-term Care Setting...
3/27/2017
1
Cleaning and Disinfection in the Long-term Care Setting:
Where Do We Start?
Deb Patterson Burdsall PhD, RN-BC, CIC, FAPIC
3/27/2017
2
The Role of The Infection Preventionist in Environmental
Services
Disclosures The following speakers disclose no actual or potential conflicts of interest in relation to this program/presentation:
• Deb Patterson Burdsall PhD, RN-BC, CIC, FAPIC
The following planning staff report no actual or potential conflicts of interest in relation to this program/presentation:
• Carol McLay, DrPH, MPH, RN, CIC
• Kristen Henry
• Kathryn Hitchcock
3/27/2017
3
Objectives
• Describe how the healthcare environment can become a reservoir for organisms that cause infections
• Differentiate between cleaning and disinfecting
• Understand chemical contact time
• Apply strategies for an interdisciplinary team approach to cleaning and disinfecting in the long-term care (LTC) environment
Polling Question • How many attendees are:
– Nursing (Director or Assistant Director of Nursing with responsibilities as Infection Preventionist (IP)
– Infection Preventionist (IP)
– Environmental Services (EVS) supervisor or director
– Facility Administrator
– Corporate
– Public Health
3/27/2017
4
Why Does Infection Prevention and Control Need to be Involved?
• The goal is to prevent infections related to the environment
• A safe and sanitary environment for residents,
patients, families, staff and volunteers
• The Revised Centers for Medicare and Medicaid Services (CMS) Reform of Requirements for Long-Term Care Facilities Final Rule: 10/4/16
Source: CMS Reform of Requirements for Long-Term Care Facilities Final Rule: https://www.gpo.gov/fdsys/pkg/FR-2016-10-04/pdf/2016-23503.pdf
Personal Cost of HAIs
• Between 1.6 and 3.8 million HAIs in nursing homes every year
• Infections result in an estimated 150,000 hospitalizations, 388,000 deaths
Source: Castle, et al., Nursing Home Deficiency Citations for Infection Control, AJIC, May 2011;39,4
3/27/2017
5
Causative Agent (Pathogen)
Mode of Transmission
Chain of Infection
9
Causative Agents: Pathogens
• Microorganisms
• Invades host and causes disease
Source: Lee, Microbial Pathogenicity and Host Response, APIC Text Online, 2017, http://text.apic.org/toc/microbiology-and-risk-factors-for-transmission/microbial-pathogenicity-and-host-response#book_section_511
3/27/2017
6
Reservoir
• Habitat where infectious agent lives and multiplies
• Human: clinical cases and carriers
• Environment: water, fluids, medical equipment and devices, physical environment (cooling towers, shower head, ice machines)
Portal of Exit
3/27/2017
7
Mode of Transmission
Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE+ Patient Environment. Hayden, M. ICAAC, 2001, Chicago IL
Rooms
• Private, double, triple, and quadruple occupancy
• Increase in patient acuity and complexity of care
• Lots of equipment and high touch areas
• Few opportunities for hand hygiene
3/27/2017
8
Fomite • An inanimate object or material becomes
contaminated with an infectious agent
Source: CDC, https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section10.html
Pathogen Survival on Environmental Surfaces
Organism Length of Survival
Clostridium difficile >5 months
Staphylococci 7 months
VRE 4 months
Acinetobacter baumanii 5 months
Norovirus 3 weeks
Escherichia coli 1.5 hours up to 16 months
Klebsiella spp. 2 hours up to >30 months
SARS, HIV etc. Days to weeks
Pseudomonas aeruginosa 6 hours to 16 months
Kramer et al. How Long do Nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious Diseases 2006, 6:130.
www.biomedcentral.com/1471-2334/6/130
3/27/2017
9
People may be Reservoirs and Mode of Transmission
• Social interaction and Care
–Residents/Patients
– Families, volunteers, visitors
– Staff
Mommarazzi Images © 1991
Portal of Entry
• Urinary Catheters
• Ventilators
• Surgery
• Injections and IV therapy
• Dialysis
• Non-intact skin
3/27/2017
10
Susceptible Host
• Individuals with underlying diseases
• Elderly, waning immunity
• Poor nutrition
• Immunocompromised
• Non-intact skin (surgery, burns, pressure ulcers)
• Antibiotics and effect on microbiome
Break the Chain of Infection
20
3/27/2017
11
How does Environmental Services Break the Chain?
• Keep the environment, equipment and supplies clean, disinfected
• Keep everything properly stored
• Separate clean and dirty
• Staff needs to be trained and competencied
• Chemicals and supplies available for appropriate cleaning and disinfecting
Polling Question
• I have direct supervisory responsibility for the Environmental Services Staff
– Yes
– No
3/27/2017
12
EVS Staff • EVS staff are critical members of the healthcare team • EVS staff need to receive explicit training
– Role and responsibilities – Preparation and handling of cleaners and disinfectants – Proper use and maintenance of cleaning equipment and
supplies – Appropriate precautions and use of personal protective
equipment
• Empower staff with knowledge • Involve staff in selection of cleaning agents and
supplies • Minimize staff turnover
Environmental Service Barriers
• Language barriers
• Lack of support
• Lack of supplies
• Lack of training
–Dilution of product (automated vs. manual)
– Sequence of room cleaning
– Lack of supervision
3/27/2017
13
Polling Question
• I have had formal training to properly use the cleaning/disinfecting chemicals and supplies that I use in my job
– Yes
– No
Cleaning and Disinfecting
• Two step process requires cleaning THEN disinfecting
• One step products clean AND disinfect
• Simplify chemicals
3/27/2017
14
Cleaning
• Removal of visible soil, blood, protein material, microorganisms and other debris from the surfaces, crevices, joints and lumens of instruments and equipment
• Done by mechanical or manual process • Done before disinfection or sterilization process • Cleaning reduces the bioburden and removes foreign
material that can interfere with processing
Disinfection
• Thermal or chemical destruction of pathogenic and other types of microorganisms
• Considered less lethal than sterilization
• Does not necessarily destroy ALL microbial forms, e.g. spores
• Special disinfection procedures are needed to destroy spores (e.g. bleach for Clostridium difficile spores )
3/27/2017
15
Dilution • “The action of making a liquid more dilute”
• How much do I need to add?
• The amount of cleaner/disinfectant must be carefully measured
– Ready to use
– Dispensing systems
Source: Oxford Dictionary https://en.oxforddictionaries.com/definition/dilution
Contact Time
• Disinfectants must remain in contact with surfaces for a period of time to destroy pathogens (Contact time or wet time)
• Shorter is better
Source: Rutala& Weber, ICHE, 35, 7, 2014. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/B234721A16E7FD0A3960FD5DA3E95790/S0899823X00192293a.pdf/div-class-title-selection-of-the-ideal-disinfectant-div.pdf
3/27/2017
16
General Principles
• Mops, brushes, cloths must be compatible with the cleaning/disinfecting solutions
• Change reusable mop heads with each solution change and as needed
• Move from clean areas to dirty areas
• Check label for any special storage or disposal instructions
Source: CDC, www.cdc.gov/ncidod/dhqp/gl_environinfection.html, 2003
Properties of Ideal Disinfectant
• Kill a wide variety of microbes, including
pathogens that commonly cause HAI and outbreaks
• Rapid kill/contact time
• Mix easily in water and remain potent
• Should keep surfaces wet long enough to kill microbes
Source: Rutala& Weber, Selection of the Ideal Disinfectant, ICHE, July 2014 35, 7. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/B234721A16E7FD0A3960FD5DA3E95790/S0899823X00192293a.pdf/div-class-title-selection-of-the-ideal-disinfectant-div.pdf
3/27/2017
17
Properties of Ideal Disinfectant
• Should kill microbes even if there is organic matter
present (e.g., blood, feces)
• Be compatible with soaps and other chemicals
• Nontoxic and non-irritating: Choose products with lowest toxicity
• Should not damage surfaces
• Easy to use
• No strong odors
• Economical
Source: Rutala& Weber, ICHE, 35, 7, 2014. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/B234721A16E7FD0A3960FD5DA3E95790/S0899823X00192293a.pdf/div-class-title-selection-of-the-ideal-disinfectant-div.pdf
Disinfectants must be Environmental Protection Agency
(EPA) Registered • Hospital disinfectants are EPA approved for use in
hospitals and other medical facilities and must kill microorganisms often found in healthcare i.e., Staphylococcus, Salmonella and Pseudomonas
• Label must have EPA registration number
• Label must display kill claim of organisms
3/27/2017
18
Disinfectants must be Environmental Protection Agency
(EPA) Registered
• Label must display hazards related to humans and animals (with recommendations for personal protective equipment [PPE] use)
• Contact times must be listed on label
• Label will have treatment information if splashed into eyes or ingested
Environmental Protection Agency Registration
3/27/2017
19
EPA Pesticide Product Label System
Source: EPA, https://iaspub.epa.gov/apex/pesticides/f?p=PPLS:1
OSHA's Hazard Communication Standard (HCS)
Safety Data Sheets (SDS)
• Ensure chemical safety in the workplace
• Information about the identities and hazards of the chemicals
• Information available so workers know and understand how to safely work with chemicals Source: Occupational Safety and Health
Administration (OSHA), Hazard Communication https://www.osha.gov/dsg/hazcom/index.html
3/27/2017
20
Safe handling of Linen • Don’t shake out linens
• Bag or contain contaminated linen at point of use
• Need hand washing and PPE anywhere linen is handled
• Modern-day detergents are more effective in removing soil and reducing the presence of microbes
Source: CMS State Operations Manual, 2017 https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-07.pdf
Safe handling of Linen Continued
• Laundry equipment should be used and maintained according to the manufacturer’s instructions
• Don’t leave damp linen in machines overnight. The CDC recommends leaving washing machines open when not in use
Source: CMS State Operations Manual, 2017 https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-07.pdf
3/27/2017
21
Safe handling of Linen Continued
• Facilities may use any detergent designated for laundry in laundry processing. Further, laundry detergents used within facilities are not required to have stated anti-microbial claims
• Closely follow manufacturer’s instructions for laundry detergents used (temperature and concentration)
Source: CMS State Operations Manual, 2017 https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-07.pdf
Safe handling of Linen Continued • Consider a resident’s individual needs (e.g.,
allergies) when selecting methods for processing laundry
• If laundry chutes are used, it is recommended that they are properly maintained
Source: CMS State Operations Manual, 2017 https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-07.pdf
3/27/2017
22
Training and Competency
• EVS staff need to be trained prior to working in a healthcare setting
• Need to ensure competency upon hire and at least annually
• Whenever a problem is suspected or detected
Training and Competency Checklist
• CDC checklist for monitoring
• Move from clean to dirty
– Main room then bathroom and toilet last
• Bedrails, tray tables
• Selecting the appropriate agent
• Using right tools for the job
• Monitor how EVS staff move around rooms
3/27/2017
23
Monitoring and Cleaning Practices
• Multiple studies have shown that EVS personnel wipe only 50% of surfaces targeted for cleaning1
• Environmental rounds
• Visual inspection
Monitoring and Cleaning Practices Continued
• Environmental monitoring systems for quality improvement
–Use checklists as audit tool
– Include staff in auditing practices and give them feedback
– Environmental marking (fluorescent marking of hard surfaces)
3/27/2017
24
“Johnny Mops” Used in both Sinks and Toilets
3/27/2017
25
Food and Unlabeled Chemicals
“Pink” Soap
3/27/2017
26
Making Cleaning Disinfecting Available at Point of Care
Wipes available at point of care Automatic Mixing
CDC EVS Recommendations • Joint infection prevention / EVS team effort
• Base on Facility Assessment
• Responsibilities for cleaning high touch surfaces (e.g., nursing, activities, culinary surfaces) must be clearly defined
• Training and competency must be maintained
• Quality assessment and assurance (QAA)/ quality assurance and performance improvement (QAPI) processes should be ongoing
Guh & Carling, 2010 https://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html
3/27/2017
27
Conclusion • Environmental Services requires explicit
knowledge and training and dedicated staff
• The facility Infection Preventionist (IP) has responsibility for the EVS program as it relates to infection prevention and control
• There are manufacturers, distributors and service companies with healthcare EVS expertise
Thank you! Questions?
