Getting Shown the Light: A First-Person Perspective of Deploying a UV-C Disinfection Program
At the beginning of 2016, I was facing a problem. My 653-bed adult and pediatric academic medical campus had received a hefty healthcare associated conditions (HAC) penalty in large part because of a higher than expected rate of hospital onset Clostridioides difficile infections (CDI). This, despite the fact that the organization had a well-established antimicrobial stewardship program1, used a sporicidal disinfectant for all environmental cleaning with good compliance in cleaning high touch objects as measured through an established monitoring program, leveraged a nursing delegated protocol for testing, consistently held high compliance rates with hand hygiene and isolation precautions and enjoyed an engaged senior administration commitment to excellence in infection prevention2. Ultimately, CDI fits very nicely into the oversimplified “disease triangle” – host, pathogen and environment3 and in early 2016, it seemed like we were addressing nearly all the modifiable aspects of each in this triad and yet rates remained unacceptably high.
In my two-decade career as an infection preventionist, I saw my fair share of “snake oil” solutions to all manner of Healthcare Associated Infections (HAIs). Premium escalator handrails coated in silver to solve your hand hygiene woes was a personal favorite. So, when the director of environmental services (EVS) approached me wanting to discuss a germ-killing robot I was, to put it politely, skeptical and I set out to help my colleague understand why the idea was little more than hocus pocus. What I discovered was a historical treasure trove of rational explanations and early examples of UV-C light’s bactericidal success. From Robert Koch (of Koch’s postulates fame) discovering that sunlight killed isolates of Mycobacterium tuberculosis 8 years after discovering the organism itself4 to Duke University’s long history of using UV-C light in the ventilation, which services the operating room resulting in “no serious staphylococci problem in the operating room” for over 20 years5 and the BETR-D study whose early findings had just been presented at ID Week the previous fall6. A sound theoretical basis (UV-C binds up the thiamine bases in the organisms’ DNA), demonstrable published evidence since 18774 and now a novel delivery system-I was still skeptical, but now I was also intrigued. In order to realize a statistically significant 20% further reduction in CDI (rates were trending down in the first 6 months of 2016), we would need to use this technology for approximately 2 years. If the organization opted to pilot the program on only a few select units, it would take longer and leave the results open to a wide range of extraneous variables. As an organization, it was decided to enter into a rent-to-own agreement with Tru-D® SmartUVC and that August fourteen machines arrived on our dock.
Infection prevention is ultimately 5% knowing what to do and 95% figuring out how to do it. This axiom is especially true when the “doing” involves a substantial disruption to long-standing norms and practices. To be successful, an IP’s best bet is to develop implementation strategies utilizing the Systems Engineering Initiative for Patient Safety (SEIPS) model first described by Carayon and colleagues and contextualized specifically to infection prevention by Carla Alvarado (See Figure 1)7,8. This model describes the feedback loops between a work system, processes and outcomes and elegantly recognizes the complex interplay within work system elements including people (P), technology/tools (TT), organization (O), tasks (T) and the environment (E). Failure to adequately address one element of that work system and everything is in jeopardy of collapse.
Fourteen machines (TT) for 30+ inpatient units cannot be deployed without a high degree of coordination. We used a year’s worth of unit-specific CDI data to determine optimum placement/storage of the machines (E) so that the users (trained EVS workers) wouldn’t have to go far to get what they needed (T). We optimized the bed board to communicate isolation status (TT) and included such information in the page sent to the assigned EVS worker (P) when the patient was discharged or transferred (T) and worked with nursing (P) to ensure that documentation in the electronic health record was accurate to avoid miscommunication. The organization opted to use a Tru-Dâ device on all confirmed or suspected CDI patient rooms (required), all other isolation rooms (including other multi-drug resistant organisms or MDROs) and select high-risk patient areas as able (encouraged). We measured compliance with using Tru-Dâ where it was needed and broadcast the data (>90% 2016-2018) throughout the organization on a monthly basis (O) and addressed shortcomings in a timely manner (P). The organization averaged using a Tru-Dâ device in over 49 rooms per day.
In hindsight, the decision to simplify the process and only use the sporicidal disinfection cycle regardless of isolation status and disengage the faster bacterial cycle (TT) may have made it easier for the EVS worker (P, T) but also resulted in delayed bed availability (O). This practice was suspended in 2019 and the bacterial cycle was engaged allowing and necessitating a full re-education of EVS staff. Despite ongoing communication with unit-based staff (P), concerns regarding personnel safety of UV-C light penetrating patient door glass (it doesn’t) persisted.
After 12 months of using the Tru-Dâ device, the organization had realized a 54% reduction in hospital onset CDI and went from renting the machines to purchasing them outright without waiting the additional 12 months. The CDI reduction has been sustained ever since with 2019 on track to be the best yet. All other MDROs dropped 27% over the two years.
On November 7, 2019 PDI acquired majority share in Tru-Dâ SmartUVC. Between the demonstrable effectiveness of PDI’s environment of care line of disinfectants and disinfectant wipes and the Sensor360â technology of Tru-Dâ SmartUVC, patients can be cared for in cleaner environments than ever before.
1. Schulz, L., Osterby, K., & Fox, B. The Use of Best Practice Alerts with the Development of an Antimicrobial Stewardship Navigator to Promote Antibiotic De-escalation in the Electronic Medical Record. Infection Control & Hospital Epidemiology, 34(12), 1259-1265. doi:10.1086/673977
2. Knobloch, MJ et al. Leadership rounds to reduce health care–associated infections American Journal of Infection Control, Volume 46, Issue 3, 303 – 310.
3. Principles of Epidemiology in Public Health Practice. 3rd Available at: https://www.cdc.gov/csels/dsepd/ss1978/ss1978.pdf
4. Reed, N.G. The History of Ultraviolet Germicidal Irradiation for Air Disinfection Public Health Rep. 2010 Jan Feb; 125(1): 15–27.
5. Hart D. Bactericidal ultraviolet radiation in the operating room: twenty-nine-year study for control of infections. JAMA. 1960;172:1019–28.
6. Anderson1 BETR available at https://idsa.confex.com/idsa/2015/webprogram/Paper53062.html
7. Carayon P, Schoofs Hundt A, Karsh BT, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006;15 Suppl 1(Suppl 1):i50–i58.
8. Alvarado C. Chapter 47 in Carayon, P. (2012). Handbook of Human Factors in Health Care and Patient Safety. (2nd ed.) CRC Press: Boca Raton, FL.
9. Available at: https://wearepdi.com/pdi-acquires-majority-share-of-tru-d-smartuvc