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'Environmental Cleaning & Disinfection to Eliminate

Persistent Resistant Micro Organisms

in the Healthcare Setting'

Marilyn Leadsom (Presenter)

Infection Prevention Practitioner

Maletje Griesel (Acknowledgment)

Senior Pharmacist

Netcare Ltd

A ‘Birds Eye View ‘of the

maze we must navigate!

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Hygiene in healthcare is nothing new… but the

challenges have taken on a new significance!

Florence Nightingale was a pioneer in establishing the importance of sanitation in hospitals

From 1858 she meticulously gathered data relating death tolls in hospitals to cleanliness, and,

because of her novel methods of communicating this data, she was also dubbed a pioneer in applied

statistics, through the use of the Rose Diagrams.

Nightingale noted that 10 times more soldiers died of the so-called filth diseases, such as cholera,

dysentery, typhoid etc. than those who succumbed to bullets and cannon balls.

She determined the cause to be related to the overcrowding, paltry latrines, sewer facilities &

inadequate ventilation.

So here we are 159 years later faced with a similar problem … no antibiotics then & the end of the

antibiotic era upon us.

We do however have all the expertise & support systems needed, but we should understand

healthcare hygiene ,needs to be taken to a higher level of importance.

1858-2017

From the pre to post antibiotic

era

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Environmental hygiene in healthcare facilities is important on a

number of fronts…………..

‘the patients perspective’’- we are judged on how clean our premises appear to be

- they need to be aesthetically impressive

- patients have an increased awareness of how hygiene affects infection rates

- the patient has a right to feel safe & expect results in line with healthcare costs

- patients may wonder if we cant keep our hospital clean how will we cope with the complicated work?

- will they feel confident? Will they recommend our hospital?

Its still not good

enough is it?

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Patient Feedback

‘during your hospital stay, how often was

your room & bathroom kept clean’?

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Our journey of improvement began in 2011, continues until

this present time & has evolved into the ‘Stop The Superbug

Bundle’, which still requires upscaling.

In 2011 we were unexpectedly faced with the onset of cases of Carbapenem-resistant Enterobacteriaceae

(CRE) (Klebsiella pneumoniae 0XA 181 & 48)

It was 72 days before the offending enzyme could be identified by the laboratory & by this time 21 positive

in-patients were identified by tracking & tracing throughout the hospital.

We were dealing with a situation we didn’t fully understand, was causing fear amongst the workforce from

whom there were more questions than we had answers.

The antibiotic stewardship committee was in its embryonic phase & this galvanised us into action.

There cant be too many people sitting here today who have not faced similar challenges

in the last five years & whom continue to battle with sudden increases in cases on a regular basis.

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Why is cleaning & disinfection more important now than at any other

time in recent history?

• Resistant micro-organisms have become increasingly difficult to treat in patients & eradicate from the

healthcare environment.

• The age of untreatable infections has arrived and England’s chief medical officer has recently warned

of a ‘post–antibiotic apocalypse’ & states that this will spell ‘the end of modern medicine’

• Any outbreak has a significant impact on the daily operational activities in any healthcare institution.

But without antibiotics to fight infections, common medical interventions such as caesarean sections,

transplants, hip replacements & cancer treatments would become incredibly risky, if not imponderable

as per the recent suspension of the BMT program in Italy.

• Patients do & will continue to suffer disruption to their lives at many levels. Their length of stay,

morbidity and mortality rates do increase when faced with any infection but the devastation caused by

those that are untreatable cannot be underestimated.

• We will all have concerns about our work & the health & well being of our families

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Questions & Suggestions at the ABS committee

The questions posed were:

‘how do we & can we put the cat back in the bag’?

‘how do we reduce the number of antibiotic resistant

micro-organisms, antibiotic usage & infection rates?

We began to formulate & roll out a plan to eliminate CRE

A sensible suggestion:

• In early 2012 Dr Adrian Brink arrived in Cape Town to gather epidemiological data as the cases

continued to rumble on & gave me the following advice.

• He said ‘M you will never ‘search & destroy’.

• ‘search & contain’ is your only hope!

• And so began our journey into the unknown!

We were trying to put the ‘cat back in the bag’ and were informed ‘the horse had already bolted’!

This conundrum set the scene of everything we have sought to implement since!

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The IPP & Clinical Pharmacist proposed the following theory

• Increased infection rates lead to an increase in antibiotic usage

• The latter increases the likelihood of antibiotic resistance developing

• Infections become more difficult & expensive to treat

• Infections and resistance to antibiotics increase the risk of morbidity and mortality

Conversely…………aims

• If infections are reduced

• Less antibiotics will be needed

• Resistance is less likely to develop

• Infections become more easily treatable

• Morbidity and mortality rates are reduced

• Patient outcomes are improved

Context

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M & M’s Model – we can choose the A Virtuous upward Circle or

suffer the consequences of A Vicious downward Spiral

• Increased Resistance

• Increased Patient M&M

• Increased Use of Antibiotics

• Increased Infection Rates

Decreased

Infection Rates

Decreased Use of

Antibiotics

Decreased Resistance

Decrease In Patient

M&M

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In order to co-ordinate preventative processes to achieve the aims we

DEVELOPED A BUNDLE OF BUILDING BLOCKS (concentrating on 6

basic areas) which when applied rigorously & consistently can & do

improve patient outcomes

Improved Patient

Outcome

Early Detection

Isolation Precautions

Hand Hygiene

Enhanced Environment

al Hygiene

Best Care Always

Antibiotic Stewardship

ABS & HH get

maximum

coverage in the

press but EEH not

so much.

As the antibiotic

armamentarium

dwindles we will

become more

intent in

eliminating micro-

organisms from

the healthcare

environment to

limit exposure &

spread.

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Role of environmental surfaces in the

transmission of healthcare related pathogens

Environmental surfaces were once thought to play a negligible

role in the endemic transmission of healthcare related pathogens.

(Weber DJ, et al. The role of the surface environment in healthcare-associated infections. 2013)

However, recent data indicates that contaminated surfaces & equipment act as reservoirs, are transmitted

by hands & play an important role in both endemic and epidemic transmission of certain

pathogens that cause HAI. Biofilms not fully understood until recently, urgently need disrupting!

CDI, MRSA, VRE, CRE, Norovirus, but to name a few pathogens share the ability to be shed from

infected or colonised patients, have the ability to survive on dry surfaces for extended periods, and are

difficult to eradicate by routine cleaning and disinfection.

It is well documented that pathogens are left behind by prior occupants in patient care areas despite

cleaning having occurred.

(Huang, et al 2006)

The continued emergence of antimicrobial resistance demands collaboration between the

environmental services team & that they be included in the healthcare delivery team

.

.

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• The Infectious Disease Society of America has highlighted a clique of micro-organisms –

acronymically termed the ESKAPE pathogens – capable of ‘escaping’ the biocidal action of

antibiotics & sometimes disinfectants. They collectively represent new paradigms in

pathogenesis, transmission and resistance.

• Urgent focus on preventing these dangerous pathogens plus detecting, containing and

eliminating them should now be regarded as routine.

• The ‘stop the superbug bundle’ is central to the infection prevention strategy, which will serve

to eliminate the ESKAPED pathogens below

• E Enterococcus faecium (VRE) 5 days to 46 mnths

• S Staphylococcus aureus (MRSA) 7 days to 12 mnths

• K Klebsiella pneumoniae (ESBL) 2 hrs to 30 mnths

• A Acinetobacter baumannii (MDR/CRAB) 3 days to 11 mnths

• P Pseudomonas aeruginosa (MDR/CRPA) 6 hrs to 16 mnths

• E Enterobacter spp

• D Clostridium Difficile (CDI) > 5 mnths

Ref: BMC Infectious Diseases 20016 & adapted from

Kramer et al

One of many references each varies slightly

Norovirus

8 hrs to 2

months

CAURIS

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The IPC should consider

• the service level agreement. Are there sufficient staff & how are absences dealt with?

• how much time is allocated to routine work & how will non routine work be accommodated

without other areas falling behind?

• the role of surface selection (hard & soft surfaces) – new technologies

• training of housekeeping, nursing & paraprofessional staff

• behavioural change through education, understanding & involvement

• designated housekeeping technicians (internal & external pre VHF)

• methods of cleaning: who does what, with what, to what, how & when

• which disinfectants to use & when. Who mixes them & how

• knowledge of all areas to be cleaned (MRI, portable x-ray, dialysis machines)

• methods of evaluating cleaning, using which comprehensive tools both during &

afterwards?

• on the spot visual checks, detailed inspections/hygiene audits (internal & external)

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The Ten & Twelve Do’s Of

Destruction

2011-2013

“The Twelve D’s of Destruction” (Search & Destroy/Control)

•Detect (screen on arrival and every 3rd day)•Dedicated (staff/restrict staff movement)•Divert (close the unit)•De-clutter (all unnecessary items to be removed from patient areas as a preventative measure)

•Deep & detailed cleaning ( meticulous & vigorous physical cleaning with detergent)•Decontaminate (terminal disinfection)•Destroy (anything that cannot be disinfected)•Decorate (painting if required preferably with anti-microbial paint)•Discharge (as soon as possible directly from the source unit)•Discourage dissemination (isolate, do not move patients unless essential)•Drains (replace old ‘u’ bends and taps. Treat drains regularly & after affected patients)•Disinfect (with dry mist vaporised hydrogen peroxide)

Preventative &

Curative Measures

shown in Italics

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Declutter - miss one spot? You miss the lot!

Scrutinise the environment & move out

any non essential items

Keep organised

Reduce contamination & therefore

cleaning & dissemination

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Declutter & utilise Dust Cover

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High Touch Points – Bio Fluorescence Technology

Measuring the effectiveness of cleaning

10 or more high touch

points are checked by

housekeeping

& a further 10 by

nursing staff

(utilising a checklist

which calculates the

score)

We use this

-randomly for routine

cleaning

-specifically in isolation

areas

-deep cleaning blitzes

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Environmental Cleaning Technicians

‘The Glitterbug Kit’

With kind permission

of Thelma Dyantyi

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Decontaminate….. is the equipment clean & well

maintained? Who cleans it, when with what etc.

How often do we inspect it?

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Think of the waterless world with no antibiotics.

Wipes are available & more hygienic!

Patient Wash Wipes?

Environmental Cleaning Wipes?

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Preventative or Curative Cleaning & Disinfection?

• We should not base our

methodology on actually identifying

an isolate

• Many micro organisms go

undetected

• Because if no action is taken, it has

been estimated that drug resistant

infections will kill 10 million people a

year by 2050

With kind permission of Ndileka

Ngxambuza

An Environmental Cleaning Technician

(with permission)

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Destroy anything that cannot be

cleaned & disinfected

Sticky Stuff.Sellotape is like Sushi for Serratia

• Line ends of tape in a drawer

• Half empty tubes

• Tape dangling from equipment

• Prestik

• Cardboard Boxes

False

Economy

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Destruction – when in doubt throw it out!

Toilet rolls

Paper Towels

Contaminated

Disinfectants

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Preparation & attention to detail is the key to success

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All surfaces must be

exposed to the fog

Mattress & pillows are

checked & discarded if

torn or perished

Pre packed items on

bed frame can be

fogged as can

paperwork

A drying rack for wet

laundry is useful for the

paperwork!

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Those ‘hard to reach nooks & crannies’

(nightmare on wire street)

A solid reason for using fogging or other similar

technologies

A bed being cleaned & disinfected ready

for VHP between patients in UK

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Drains can be death traps?

Splashback of Biofilm.

Ref: Applied and Environmental Microbiology, 2017

Basins

Baths

Toilets

Sluices

Macerators

Design of

reticulation

system & hand

washing basin

Drain cleaning after

ESKAPED organisms

& regularly routinely

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Is your facility ‘super clean’?

An external objective auditor with the

authority not to continue if not clean

(fogging technician) is appointed

Clear instructions with name of chemical

and dose & time of opening on the sealed

door.

Maximise on the occasion as it is not

cheap! Add in other items that need super

cleaning.

Nurses are very inventive

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Cleaning Run Chart – Housekeeping – A Story Board

If you cant measure it you cant manage it!

92,5

98

93

95

98

99,5

93,2

91,3

94,6

86,9

90,5

97,5

96,4

97,5

80,0

82,0

84,0

86,0

88,0

90,0

92,0

94,0

96,0

98,0

100,0

Compliance %

Median 1

Not enough

staff for size &

high tech

surfaces

Low morale as

news of

changes

Started training

Morale

restored.

Extra Staff

Shiny New

Hospital

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What quality assurance can we give our patients?

What evidence do we have to support the provision of safe clean

environment?

How much are we prepared to pay to ensure the above?

Cost the 2011 outbreak was estimated as R750,000

Cost of 2017 outbreaks in London & Manchester cost the NHS 10 million

GBP

Medico-legal risk & compensation?

The full extent of the ESCAPED organisms is not known, reporting is not

mandatory & healthcare institutions do not publish cases even locally so we

can put alert systems in place

‘Lets face it nobody should get sick whilst trying to

get well’!

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Processes Demonstrated & Now Outcomes

The infection rate has been reduced from

• 5/1000 patient days in 2012

• 1/1000 patient days in 2017

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CRE cases between 2012 & 2017

0

50

100

150

200

250

300

03-Dec-11 03-Dec-12 03-Dec-13 03-Dec-14 03-Dec-15 03-Dec-16

Da

ys

Be

twee

n

DaysBetween()

SICU & CCU

Closures

21 cases Dec 2011 to Dec 2012

4 cases in 2013

4 cases in 2014

5 cases in 2015

2 cases in 2016

SICU & CCU

Closures

21 cases Dec 2011 to Dec 2012

4 cases in 2013

4 cases in 2014

5 cases in 2015

4 cases in 2016

4 cases in 2017

10 D's 12 D's SSBBBuidling Blocks

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Hand Hygiene

Compliance

October 2016 –

September 2017

5023 HH Interventions Measured

Compliance 87.22

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Oct/14

No

v/1

4

De

c/1

4

Jan/1

5

Fe

b/1

5

Ma

r/15

Apr/

15

Ma

y/1

5

Jun/1

5

Jul/15

Aug/1

5

Sep/1

5

Oct/15

No

v/1

5

De

c/1

5

Jan/1

6

Feb

/16

Ma

r/16

Apr/

16

Ma

y/1

6

Jun/1

6

Jul/16

Aug/1

6

Sep/1

6

Oct/16

No

v/1

6

De

c/1

6

Jan/1

7

Feb

/17

Ma

r/17

Apr/

17

Ma

y/1

7

Jun/1

7

Jul/17

Aug/1

7

Sep/1

7

Hospital Antibiotics Utilization - DDD per 100 Bed Days

Netcare CBMH

Median

DDD/100 bed day run chart (Oct 2014-Sept 2017)

* DDD – Define Daily Dose (WHO)

March 2012: ABS

prescription

implemented

March 2013:

Collaboration between

IPP & Senior

PharmacistOct 2015: Building Blocks

implemented

Feb 2015: Electronic ABS and

IPP modules launched

Oct 2013:12 D’s of destructionDec 2016: Hospital move

2017: Enhanced

Environment Cleaning

2017: ABS improve clinician

collaboration

Improvement

shown –

reduction of

DDD’s in last 6

months

10%

reduction in

DDD’s in

last 3 years

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Conclusion…………interconnectedness ….a

world view

An interconnected system in the workplace is the process of linking

manpower, technological resources & other items of capital together.

Typically it will improve efficiency, effectiveness & accountability

throughout the organisation

If these three key disciplines are aligned then

‘#superbugswillfall’

Reduction of

Persistent Resistant

Micro-organisms

ABS

EEHHH