By Ann Marie Pettis, RN, BSN, FAPIC, CIC; Michelle Vignari, RN, CIC

One of the more challenging tasks healthcare facilities face is the evaluation of and investment in new technologies. This is particularly true for facilities considering automated UV-C disinfection technologies for environmental disinfection. These systems are often a significant financial investment and there is a myriad of commercially available automated UV-C systems from which to choose. To further complicate matters, there are no device testing or evaluation standards available from any governmental or professional organization, leaving it to the infection preventionist, facility manager, or environmental services manager to sort through the options relatively unguided.1-2 A recently published article in the American Journal of Infection Control (AJIC) article by Spencer et al, however, offers readers a framework for approaching this evaluation process based, in part, on the example of two large, tertiary care facilities’ own experience in acquiring a UV-C system.3

There is considerable evidence in the literature today demonstrating UV-C irradiation’s role as an effective adjunct to environmental disinfection/decontamination and, more recently, evidence demonstrating its impact on reducing healthcare-associated infection (HAI) rates.4-10 By inactivating their DNA and RNA, UV-C irradiation can effectively reduce the bioburden of pathogens responsible for some of the most clinically significant HAIs, including methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile), on environmental surfaces.11 Numerous studies have shown a >3 log10 colony forming units per square centimeter reduction for HAI-causing pathogens with the use of UV-C irradiation.6,12-13 Most importantly, this germicidal capability can lead to significant reductions in HAI rates. In a recent study, Anderson et al. documented a 30 percent reduction of target organism infections or colonization when UV-C irradiation was added to the standard cleaning protocol in nine U.S. hospitals.10 In a smaller study, Napolitano et al. demonstrated a 34 percent reduction in HAIs in a California hospital when UV-C was added to their disinfection protocol.9 

While these technologies have undoubtedly enhanced infection prevention efforts, determining which system best suits your facility’s needs can be difficult. Despite the fact that the fundamental technology might be the same, no two commercially available automated UV-C systems are identical. In fact, there are multiple attributes and specifications that can vary considerably between different automated UV-C disinfection systems including, among others, capital costs, UV-C lamp costs, dose measurement capability, data capturing capability, dose-based repositioning capability, treatment time, and physical footprint. These features can have a significant impact on how well-suited a system is for a particular facility and determining which system is most compatible with your facility’s needs is critical given the significant financial outlay required for this technology. In their article Spencer et al. use the example of Vancouver General Hospital’s (VGH) experience in choosing a UV-C system to identify a number of steps critical to a comprehensive evaluation of UV-C systems.3 A pilot study performed at the hospital by Wong et al using two different UV-C disinfection systems demonstrated significant reductions in MRSA (34.4% to 3.3%), vancomycin-resistant enterococci (VRE) (29.5% to 4.9%), and C. difficile (31.8% to 0%) when UV-C disinfection was added to their manual cleaning protocols, convincing the IP team that UV-C was a worthwhile investment.3,7 As Spencer et al. describe, the VGH team, having determined that both systems were effective in environmental decontamination, embarked on a heuristic evaluation, led by their human factors engineer, to determine how the systems’ specific operational and usability differences would impact their facility. Engaging representatives from environmental services, infection prevention, infectious disease, operations, and nursing, they identified a number of key factors they were looking to find in a UV-C system: 

• Shorter average treatment time (with a near 100 percent occupancy rate, there was a high demand for rapid room turnover)

• User-friendly operation (for example, they determined that a one UV-C setting system would be less likely to result in user error than a two setting system)

• Metrics-driven data tracking (the team wanted to track data including actual dose delivered, average room treatment times, operator variability, and device utilization over time with a system’s software)

• Pause and reposition capability (instead of having to wait for a system to complete its full cycle before repositioning the device, the team wanted to be able to pause a system when the first two remote sensors had measured their delivered dose and reposition the device)

• Maneuverability (as the devices were intended for use in a variety of locations within the hospital, it was important that they could be easily maneuverable by personnel through small entrances and spaces).

The team found a system that met these needs and continued to work collaboratively to develop an implementation plan which addressed not only an operations protocol including a room prioritization system, but also off-hours (e.g. night shift) utilization strategies for high-use day rooms such as ORs, and regular software tracking system reviews to evaluate effective utilization. They further identified opportunities for mitigating operating costs through inter-departmental budget sharing. This comprehensive plan was critical since it would demonstrate how they planned to optimize utilization to the hospital administrators responsible for approving the acquisition. It also allowed them to anticipate potential utilization errors for which they could preemptively propose solutions.

Because the acquisition of new technologies like UV-C systems requires a significant investment, it is imperative that facility managers and infection preventionists have a robust, numbers-based business plan to present to their administration. In their article, Spencer et al. describe how Rochester General Hospital’s (RGH) infection prevention team, along with three other local hospitals involved in a C. difficile reduction collaborative, identified a UV-C system compatible with their needs and developed a compelling business case for it. The hospital had seen a significant rise in their C. difficile infection (CDI) rates and decided to incorporate UV-C disinfection into their environmental decontamination efforts. Much like the team at VGH, the RGH team determined several key considerations they were looking for in a UV-C system: metrics-driven data tracking (the team wanted to track data including actual dose delivered, average room treatment times, operator variability, and device utilization over time with a system’s software), rapid treatment time (to meet their need for rapid room turnover), pause and reposition capability (to more effectively disinfect rooms with shadowed areas and recessed spaces), and comprehensive data capturing and analysis (to enhance their campaign to reduce CDI rates). Having identified a system with these attributes, the team began building their business case for the C-suite. This involved creating a multidisciplinary team to develop an implementation plan, engaging an executive sponsor to be an inside champion with the administration, proposing savings achieved through an incremental reduction in infection rates, and demonstrating how the chosen UV-C system’s attributes would facilitate achieving reduced HAI rates. As Spencer et al. describe, the team outlined a measurable return on investment by using their current infection rates for high risk pathogens, cost of care for each, and UV-C system cost to demonstrate how incremental reductions in HAIs would result in savings for the hospital. The authors go on to report that after implementing UV-C systems as part of their overall environmental disinfection strategy, RGH saw a 56 percent reduction in CDI rates between 2011 and 2015.3

Automated UV-C disinfection technology has added a vital new dimension to the world of infection prevention, but in this era of value-based purchasing, it is imperative that facilities take an educated, evidence-based approach when investing in it. Spencer et al.’s recent AJIC publication offers facilities a constructive template for this endeavor.

References

Cowan TE. Need for Uniform Standards Covering UV-C Based Antimicrobial Disinfection Devices. Infect Control  Hosp Epidemiol. 2016;37(08):1000-1.

Nerandzic MM, Donskey CJ. Response to Cowan on Need for UV-C Antimicrobial Device Standards. Infect Control  Hosp Epidemiol. 2016;37(08):1001-2.

Spencer M, Vignari M, Bryce E, Boehm Johnson H, Fauerbach L, Graham D. A model for    choosing an automated ultraviolet-C disinfection system and building a case for the C-suite: Two case reports. Am J Infect Control. 2016, In press. Available from: http://dx.doi.org/10.1016/j.ajic.2016.11.016

Rutala WA, Gergen MF, Weber DJ. Room decontamination with UV radiation. Infect Control Hosp Epidemiol. 2010; 31(10): 1025-1029.

Anderson DJ, Gergen MF, Smathers E, et al. Decontamination of targeted pathogens from patient rooms using an automated ultraviolet-C-emitting device. Infect Control Hosp Epidemiol. 2013; 34(5): 466-471.

Nerandzic MM, Fisher CW, Donskey CJ. Sorting through the wealth of options: comparative evaluation of two ultraviolet disinfection systems. PloS one. 2014;9(9):e107444

Wong T, Woznow T, Petrie M, Murzello E, Muniak A, Kadora A, Bryce E. Postdischarge decontamination of MRSA, VRE, and Clostridium difficile isolation rooms using 2 commercially available automated ultraviolet-C–emitting devices. Am J Infect Control. 2016;44(4):416-20.

Boyce JM, Havill NL, Moore BA. Terminal decontamination of patient rooms using an automated mobile UV light unit. Infect Control Hosp Epidemiol. 2011; 32(8): 737-742.

Napolitano NA, Mahapatra T, Tang W. The effectiveness of UV-C radiation for facility-wide environmental disinfection to reduce health care–acquired infections. Am J Infect Control. 2015 ;43(12):1342-6.

 Anderson DJ, Chen LF, Weber DJ, Moehring RW, Lewis SS, Triplett PF, et al. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (The Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicenter, crossover study. Lancet. 2017, In press. Available from: http://dx.doi.org/10.1016/50140-6736(16)31588-4.

 Kowalski, Wladyslaw. Ultraviolet Germicidal Irradiation Handbook: UVGI for Air and Surface Disinfection; New York, NY: Springer Science and Business Media; 2010: p.21.

 Otter JA, Yezli S, Salkeld JA, French GL. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J  Infect Control. 2013; 41(5):S6-11.

Manian FA, Griesnauer S, Bryant A. Implementation of hospital-wide enhanced terminal cleaning of targeted patient rooms and its impact on endemic Clostridium difficile infection rates. Am J Infect Control. 2013; 41(6):537-41.