Environmental Disinfection ~A Review of Hydrogen

Peroxide Vapor Technology

Lessons from a Community Hospital

Nancy Iversen, RN, CIC Director, Patient Safety & Infection Control

Billings Clinicniversen@billingsclinic.org 406-657-4823

Not-for-profit, community owned and governed

Multi-specialty Physician Group Practice

3,750 employees

260 employed physicians representing 50 specialties

285-bed hospital, 90-bed LTCF

7 regional branch clinic locations

Multi-state management affiliations and support services

Member of Mayo Clinic Care Network

Health Care, Education and Research

Learner Objectives

1. Describe two unique characteristics, changing epidemiology, and environmental persistence of Clostridium difficile bacteria

2. Discuss two strategies that prevent the transmission of healthcare-associated Clostridium difficile and other pathogens

3. Describe the current environmental disinfection strategies and application of hydrogen peroxide vapor ~ BIOQUELL

4. Discuss advantages and disadvantages of hydrogen peroxide vapor disinfection technology

Health Care, Education and Research

Examples of The Unseen

What You Learn Will Creep You Out!

The Dust Mite

Photo courtesy of Janet Stout, PhD, Special Pathogens Lab

Health Care, Education and Research

About Unseen Dust Mites

• A typical mattress may have anywhere from 100,000 to 10 million mites inside.

• 10% of the weight of a

two-year old pillow can be composed of dead mites and their droppings.

Photo courtesy of Janet Stout, PhD, Special Pathogens Lab

Background

• Environmental contamination contributes to transmission of healthcare-associated pathogens1

• There is increased risk of acquisition of multidrug-resistant organisms in rooms where the previous occupant was colonized or infected with the organism2,3,

1. Weber D et el. Am J Infect Control 2010;38:25-332. Drees M et al. Clin Infect Dis 2008;46:678-853. Datta M et al. Arch Intern Med 2011;171:491-4944. Nseir S et al. Clin Microbiol Infect 2010;Nov 4

Background• Standard methods of cleaning and

disinfecting surfaces in hospitalized patient’s rooms are sub-optimal1,2

• Novel technologies used to decontaminate patient rooms include3,4

– Hydrogen Peroxide Vapor (BioQuell)– Ultraviolet Light (UV-C Radiation)

1. Boyce JM et al. Infect Control Hosp Epidemiol 2010;31:99-1012. Carling PC. J Hosp Infect 2008;68:273-2743. Nerandzic MM et al. BMC Infect Dis 2010;10:1974. Boyce JM et al. Infect Control Hosp Epidemiol 2008;29:723-7295. Havill NL. Infect Control Hosp Epidemiol 2012; 33(5):000-000

Contaminated Surfaces Can Contribute to

transmission• Contaminated environmental surfaces can

contribute to transmission of pathogens– By serving as a source from which healthcare

workers contaminate their hands or gloves

• Contaminated medical equipment that comes into direct contact with the patient can serve as a source of transmission

Boyce JM et al. Infection Control Hosp Epidemiology 1997; 28:1142Bhalla A et al. Infection Control Hosp Epidemiology 2004; 25:164Hayden MK et al. Infection Control Hosp Epidemiology 2008; 29:149Passaretti CL, Clin Infect Dis; 2013; 56(1): 27-35

Pathogens that survive well in the environment include: Clostridium difficile MRSA VREAcinetobacterNorovirus

Survival of Pathogens in the Environment

Hota B., et al. Clin Infect Dis 2004; 39:1182Kramer A., et al. BMC Infect Dis 2006; 6:130

CDI Epidemiology / Issues• Rates Increasing world wide and in US

– Outpacing MRSA Healthcare-associated Infections

• Common epidemic C. difficile strain continues to be reported from hospitals in expanding list of states

• More severe disease with – higher mortality – 6.9% (30 days), 16.7% at one year– higher readmissions– higher rates of colectomy in the elderly continues

• Point-source outbreaks well described

• Environment plays a role in transmission to other patients– Environmental survival of C. difficile spores is 5 months

Clostridium difficile Infection (CDI)2007 – December 31, 2014

Problem / Opportunity

Published incidence rate: 3.8-9.5 cases per 10,000 patient days(SHEA / IDSA Practice Guideline 2010).

Cost: $7179 / case (Scott, DR, Direct Medical Costs of HAI in US Hospitals, CDC, March 2009)

Vancomycin Resistant Enterococcus (VRE)1997 – March 31, 2011

2010 VRE Outbreak Investigation 6 new HA VRE cases June 2010 – October 2010

(no HAI VRE cases Jan – June ’10)• 3 HA colonizations (transmissions) • 3 HA infections PFGE Typing conducted suggested cross-transmission

VRE Cases(Community Acquired, Healthcare-associated Colonizations,

Healthcare-associated Infections, Other Facility-Acquired)

6

10

3

1

3

1

0

4

1

0 0 011111 1

44

01

222

0 000 0

2

5

2

3

6

2 2

1

0

2

4

6

8

10

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 CYTD 2011

(3mos)

# V

RE

Cas

es

Community Acquired

Healthcare-associatedColonizations

Healthcare-associatedInfections

OFA

Billings Clinic Hospital Study (August 2010)

Phase 1: Baseline Environmental Cleaning Evaluation

Study Design:

• Marked 120 high-touch surfaces in 10 Patient RoomsIPS (2 rooms, N & S)IPM (2 rooms, N & S)ICC (1 room)ATU (1 room)ICU (1 room)ICC (1 room)SSU (1 room)ED (2 rooms)

Cleaned & empty room identified

Rooms marked with fluorescent marker

DAZO, (Ecolab)

Room evaluated

Terminal cleaning after 2 patient cycles

Health Care, Education and Research

Study ResultsHigh Touch Surfaces Cleaning Study – Hospital

Baseline ~ August 2010

High Touch Surfaces cleaned 61% (73/120)

High Touch Surfaces not cleaned 39% (47/120)

High Touch Surfaces cleaned 93.2% (2116/2270)

High Touch Surfaces not cleaned 6.8% (154/2270)

Ongoing Performance ~ January - December 2013

Footboard Control Panel After Cleaning ~ Fluorescent marks remain

Computer Keyboard After Cleaning ~ Fluorescent marks remain

High Touch Environmental Surfaces Cleaning Verification

Currently, DAZO fluorescent marking system is being used for EVS training and patient room disinfection verification. Process improvement ongoing.

January – April 15, 201498.0% (1505/1536)

High Touch Environmental Surfaces Cleaning Verification

Hydrogen Peroxide Vapor Hydrogen Peroxide Vapor (BIOQUELL)(BIOQUELL)

UV-C Radiation (Tru-D)

Efficacy Complete surface sterilization ensuring total elimination of pathogens

EPA-registered room sterilant

No verification of complete surface sterilization ~ 2- 4 log kill (no higher than 4)

Not EPA registered

Inactivates Inactivates bacteria, virus’, fungi C. difficile (20 minutes), VRE,

Norovirus, MRSA, Acinetobacter (60 minutes), other Gram negs.

Log reduction of bacteria, virus’, fungi

Validation Methodology

Yes. Inactivation of 6-log Geobacillus stearothermophilus biological indicator (same method used to validate steam sterilizers)

No. Biological Indicators not used to verify efficacy.

Reference published studies to verify efficacy

Sporicical Yes ~ Kills C. difficile in 20 minutes No. 4 log reduction C. difficile in 50 minutes

Compatibility Safe for porous (fabrics, curtains) and non-porous materials & electronics

Safe for porous (fabrics, curtains) and non-porous materials & electronics

Literature Support

Substantial peer-reviewed, published scientific papers, abstracts

Little scientific evidence. Limited application in HC

Comparison of Disinfection Technology

Hydrogen Peroxide Vapor (BIOQUELL)

UV-C Radiation (Tru-D)

Purchase Price / Lease Option

$56k (lease to own option available)

Includes Training

$125k

Ongoing Operational

Expense

$20kHydrogen peroxide

Tape

$5kBulbs

Data Tracking System Included

Yes No

Education & Training

ProvidedOn-site Support

ProvidedOn-site Support

Additional Uses

Odor

Safe in REI / IVF LaboratoriesDoes not produce off-gassing ~

will not harm embryos

Light hydrogen peroxide odor

Safe in REI / IVF LaboratoriesDoes not produce off-gassing ~

will not harm embryos

Lingering odor ~ electrical fire

Comparison of Disinfection Technology

Bacterial Growth Before & after Decontamination ~

HPV vs. UV-C

Num

ber

of p

ositi

ve s

ampl

es

70 68

5

33

N = 75

HPV vs. UVC (p <0.0001)Havill NL, Moore BA, Boyce JM, Infect Control Hosp Epidemiol 2012;33(5):000-000

Bacterial Growth After Decontamination

5 Surfaces using HPV vs. UV-C N

umbe

r of

pos

itive

sam

ples

Cultures with no growth before decontamination excluded

2

4

0

21

5

1

12

1

10

HPV: Shadowed vs. non-shadowed (p =1)UVC: Shadowed vs. non-shadowed (p <0.0001)

Non-shadowed

Shadowed

Havill NL, Moore BA, Boyce JM, Hosp Infect Control Epidemiol 2012;33(5):000-000

C. difficile Log Reductions Achieved

Log

re

duct

ions

2.53.0

2.2 1.7 1.8

Havill NL, Moore BA, Boyce JM, Infect Control Hosp Epidemiol. 2012;33(5):000-000

Hydrogen Peroxide Vapor (Bioquell)

ProcessEvaluation Period Feb. 2011• Room cleaned of visible soil• Ventilation & doorways sealed• Generator creates HPV from

35% Hydrogen Peroxide• Aeration unit catalytically

converts HPV to oxygen and water vapor

• Computer allows for process control and auto shut off

BioQuell Q-10 Room Sterilization SystemHydrogen Peroxide Vapor (HPV)

Biological Indicator ~ Test OrganismGeobacillus stearothermophilus

• Purchase HPV 106 BI’s from outside lab

• Run quarterly testing to verify efficacy

• Expose 4-5 HPV BI discs to 10 grams Hydrogen Peroxide

• Incubate at 55-600 C for 7 days

• Chemical indicator pilot Ongoing verification of 106 log reduction

BIOQUELL Unit ~ Vent Sealing DeviceOne to three units per room

BioQuell Unit in Use ~ ICU Room 211710 min. set-up; 90 min. cycle time; 5 min. tear down

BioQuell Trial ~ ICU Room 211710 min. set-up; 90 min. cycle time; 5 min. tear down(ICC Room ~ 4466 = 2 hrs, 40 min. / ICU 2114 = 75 min.)

Consumables (tape) from one room

UV-C Process

• Room cleaned of visible soil• UVC device placed in the

center of the room• Door closed• UVC (254 nm range) delivers

22,000 uW sec/cm2

• Hand held device controls settings monitors the process

Tru-D Unit Setup ~ ICC Room 44655 min. set-up; 90 min. cycle time; 10 min. tear down

Tru-D Unit In-Use ~ ICU Room 212112 min. set-up; 54 min. cycle time; 10 min. tear down

Conclusions

• HPV and UV-C significantly reduce bacterial contamination in patient rooms

• HPV is significantly more effective than UV-C for the eradication of bacteria, including spores

• UV-C is significantly less effective in shadowed areas from the device

Recommendation• Acquire BioQuell Q-10 Unit (HPV) technology for

terminal room disinfection

• Adopt objective measurement for cleaning & disinfection processes (e.g. fluorescent marker, ATP)– CDC recommendation, CMS requirement

• Priority Applications ~ Terminal Disinfection– C. difficile rooms

– VRE rooms

– IVF Laboratory

– Equipment Disinfection ~ create BioQuell Room– Norovirus – Unused supplies in isolation rooms

Current Applications• Priority Applications ~ Terminal Disinfection

– Clostridium difficile rooms (20 minute kill time)– VRE rooms– Norovirus – Emerging Multi-drug Resistant Organisms (MDRO)

• ESBL, CRE• Acinetobacter (BIOQUELL kill time 60 minutes)• Other Resistant Gram-negative bacteria

– IVF Laboratory in Surgery Center– Disinfection of Equipment / Unused Supplies

• Unused medical supplies in isolation rooms Otter JA, Infect Control Hosp Epidemiol May 2013, Vol. 34, No.5.7-9% contamination VRE/MDRO, None of the items were contaminated after HPV (p<.02)Annual cost of supplies discarded at hospital discharge was $387,055.

– Currently run cycles in equipment storage rooms, gait belts.

Health Care, Education and Research

BIOQUELL Cost Per Patient Room

• $56.00 per 500ml bottle of peroxide• 2 – 500ml bottles per room• 1 tech at $17.00/hour plus benefits • Average time per room start to finish 3.5 hours (set

up 30 minutes)

• Total cost per room = $185.00 • Updated 2014 : $220.00 new larger rooms

– Room size ranges 40-172 m3

Health Care, Education and Research

BIOQUELL ~ 1 Year Cost

• 281 patient rooms • 281 rooms at $185

per room• $51,985.00• $5,000 Annual P.M.

and training• Total Annual Cost:

$56,985.00

• $13,500/month or• Total Annual Cost:

$162,000

Internally Managed Program BIOQUELL Managed Program

Projected 2014 cost (larger rooms)

25 rooms / month ~ 300 / year$220.00 per room + $5,000 annual P.M.

Total Annual Cost: $71,000

BIOQUELL Use Summary • Began November 1, 2011

• 793 applications– 75% C. difficile rooms

– 20% cycle cleans

– 4% other MDRO’s ~ VRE, Norovirus, ESBL

– 1% other (IVF, equipment rooms)

• Average cycle time 3.5 - 4 hours, 30 min. set-up

• Perform initial terminal clean with bleach disinfectant

• Run BI’s quarterly, evaluating CI’s (12 rooms)

Lessons Learned

AdvantagesEfficacy

Efficacy validated

Retain EVS personnel Decontamination Specialists Substantial salary increase

Staff acceptance high Gait belts Equipment storage areas

DisadvantagesCustomer service decline

Recent breakdowns

Longer room turnover

Missed decontaminations High census, velocity Breakdowns

Health Care, Education and Research

Learner Objectives

1. Describe two unique characteristics, changing epidemiology, and environmental persistance of Clostridium difficile bacteria

2. Discuss two strategies that prevent the transmission of healthcare-associated Clostridium difficile and other pathogens

3. Describe the current environmental disinfection strategies and application of hydrogen peroxide vapor ~ BIOQUELL

4. Discuss advantages and disadvantages of hydrogen peroxide vapor disinfection technology

Questions?

Inter-rater Reliability StudyNovember 2013 – February 28, 2014

Unit Results

ATU 56% (51/91)

ED 71% (85/119)

FBC/LDRP 73% (19/26)

ICC 66% (59/89)

ICU 71% (49/69)

IPM 74% (185/250)

IPS 63% (95/150)

NICU 76% (25/33)

SSU 75% (53/71)

Aspen 81% (44/54)

TCU 33% (22/67)

Dialysis 69% (20/29)

Radiology 45% (5/11)

Surgery Center 58% (11/19)

Overall Performance 67% (712/1058)

Hand Hygiene Study