By Michael Burke, CEH, CLLM, Stephanie Swanson, MPH, CIC, and Paul Yee

Environmental services professionals have an ongoing mission to achieve optimal room disinfection practices. They are aware of the studies validating that pathogens can be directly transmitted simply by touching the surfaces contaminated by a previous colonized occupant, or by personnel moving in and out of the room and touching common-use surfaces and equipment. Although healthcare-associated infections have been a concern for decades, the stakes have been raised in recent years by the discovery of multi-drug-resistant pathogens that can do more harm to patients and staff than ever before. Today, reducing infection risk is not only mandatory, it’s urgent. And environmental services (EVS) teams are on the front lines.

One of the biggest challenges for every hospital EVS department is achieving consistency. Room cleaning relies on the staff members to repeatedly select the right chemistry, the right dilution, the same mopping or distribution technique, and to maintain the identical wet contact time allowance. Variation can occur with the product (cleaning chemistry) and the people. It has also been shown that even after educational campaigns, efficacy monitoring and feedback on performance, it can be challenging to maintain a cleaning protocol over time.

Collaborative continuous improvement 

At North Memorial Medical Center (Robbinsdale, MN), a collaborative team of infection prevention and EVS professionals develop their infection-prevention best practices with guidance from several agencies and professional bodies. These include: CDC Guidelines for Environmental Infection Control in Health-Care Facilities and Guidelines for Isolation Precautions: Prevention of Transmission of Infectious Agents in Healthcare Settings; and guidelines from the Minnesota Hospital Association and Department of Health. 

One state-developed protocol bundle they currently use is known as the “Safe from CDI (C. difficile Infection)” Toolkit and Roadmap, which is designed to help facilities develop a comprehensive C. diff prevention program. This bundle is part of North Memorial’s continuous quality improvement efforts to reduce the risk of healthcare-associated infection from various drug-resistant organisms, such as C. diff, MRSA, VRE and ESBL-producing organisms.

One 2011 improvement initiative involved the hiring of an EVS supervisor to oversee the integration of all surgical cleaning services under EVS jurisdiction. This new supervisor was also responsible for all room cleaning in other clinical areas of the hospital. The supervisor became part of a quality improvement team that evaluated current practices in the facility’s surgical and nursing areas. The team identified several aspects of turnaround and terminal cleaning that could be improved, including evaluating the existing chemistry and making manual processes more precise.

The EVS team began to work with North Memorial’s infection preventionist to implement a standardized manual room cleaning protocol, and to develop a performance measurement method that would help staff achieve consistent cleaning results. By doing this, the team would reduce performance variation, which in turn would reduce infection risk even further. 

In addition, since rapidly changing antibiotic-resistant organisms were a growing challenge that might require enhanced cleaning methods, the team was charged to proactively seek a no-touch surface disinfection process, to add to the standardized protocol and improve the probability of inactivating these dangerous colonizing pathogens. North Memorial’s senior leadership was already aware of the growing use of ultraviolet light (UV) disinfection in other facilities, and the research behind it. They championed an investigation of the technology for possible use at North Memorial. 

Making the case for one UV system

First, a financial comparison between purchasing and renting a UV system was completed, and the decision was made that ownership offered North Memorial the most benefits. Next, a side-by-side in-house testing process was conducted, complete with biological challenges, to validate three different UV disinfectors and identify the best real-world option for North Memorial’s needs. In addition to validation testing, each system was evaluated on price, total cost of ownership, maintenance, and service costs, and compared the levels of manufacturer support for in-house users. The final results showed that one UV-C system clearly stood out. It demonstrated validated effectiveness, was one-third the price of the others, and offered the best value for long-term ongoing service support of the system and its North Memorial operators. The hospital was already familiar with this manufacturer’s service quality from experience with other equipment, so they already trusted the relationship.

New best practices

The new mobile UV disinfection system was delivered in June 2015. Since then, the EVS-IP team has prioritized the nursing units for initial application of no-touch disinfection after manual cleaning, and has been rolling the new program out thoughtfully. They have communicated with hospital staff in all affected departments, to notify and prepare them for the new protocol. They have also delivered training to staff members who now operate the system. 

The EVS-IP team has made every effort to integrate UV disinfection into the hospital’s workflow, and to cause as little disruption as possible. Dedicated UV system operators are scheduled between the hours of 6:30 a.m. and 10:00 p.m., seven days a week, and are currently completing 16 –18 rooms per day. Room disinfection is prioritized based on patient infection status, such as those with C. diff infection and those with a history of multiple-drug resistant organisms. If time allows, prophylactic disinfection of additional patient rooms is performed on a case-by-case basis.

To help reduce potential operator variability, the EVS supervisor has also worked with the manufacturer to create drawings of each North Memorial room type and indicate the proper preparation and placements of the unit for optimal disinfection. These guides are attached to the UV system for ongoing reference as it is moved from room to room.

Benchmarking for results

The EVS-IP team has begun monitoring the staff’s cleaning performance and reviewing hospital infection data, to evaluate the effectiveness of the standardized manual cleaning program and the UV disinfection protocol. Although the data is not yet statistically significant, the results to date have been positive. The HCAHPS scores related to EVS cleanliness have begun to show improvement since the protocol’s implementation. As EVS fully implements tent cards notifying patients and families that their rooms have been disinfected with UV technology, patient satisfaction scores are expected to continue improving. Healthcare-associated infection data, particularly for C. diff infections, is trending in the right direction.

The UV process has already been well-received by clinical staff; in fact, both clinical and non-clinical departments have begun calling to request treatment with the UV system. Although many are not part of the current protocol, the team is investigating potential uses for UV disinfection in other areas of the facility, such as in operating rooms, supply rooms, soiled utility rooms, and other areas where cross-contamination could occur. In addition, a process improvement charter has been approved to enable the facility’s Quality Improvement Team to use UV disinfection for the supply chain after patient rooms are disinfected.

Infection prevention is a never-ending effort that requires proactive thinking. By standardizing manual processes as much as possible, and then proactively adding a no-touch automated room disinfection method for another “dose” of disinfection, the North Memorial EVS-IP team expects to stay a step ahead of the pathogens.

Michael Burke, CEH, CLLM, is the environmental service manager at North Memorial Medical Center. Stephanie Swanson, MPH, CIC, is North Memorial Medical Center’s infection prevention manager. Paul Yee is the environmental services supervisor for North Memorial Medical Center. 

References

1. https://en.wikipedia.org/wiki/Ultraviolet_germicidal_irradiation 

2. http://www.journalofhospitalinfection.com/article/S0195-6701(12)00336-2/pdf

3. http://www.modernhealthcare.com/article/20150110/MAGAZINE/301109980 

4. http://www.health.state.mn.us/divs/idepc/diseases/cdiff/toolkit/ 

5. http://www.infectioncontroltoday.com/news/2012/10/study-shows-effectiveness-of-ultraviolet-light-in-hospital-infection-control.aspx 

6. http://www.hpnonline.com/inside/2012-09/1209-OR-Cleaning.html 

7. http://www.beckershospitalreview.com/quality/5-latest-findings-on-uv-light-disinfection-in-hospitals.html 

8. http://www.hfmmagazine.com/display/HFM-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HFM/Magazine/2013/Aug/0813HFM_FEA_Marketplace 

9. http://www.medpagetoday.com/MeetingCoverage/IDWeek/54043 

10. http://www.healio.com/infectious-disease/nosocomial-infections/news/print/infectious-disease-news/%7B5a57d8d9-1353-4528-a273-7d03a09324b1%7D/infection-control-in-hospitals-the-role-of-environmental-disinfection 

11. http://www.steris.com/products/ultraviolet-disinfection