Mitigating Risk in the Transmission of Epidemologically-Important Pathogens in the Healthcare Setting
A multi-pronged approach to environmental decontamination
There is a lot of evidence showing transmission of pathogens both from surfaces in the healthcare setting as well as on patient and healthcare workers hands as a result of a contaminated environment (1). To truly mitigate this risk institutions cannot rely on just one method or approach to environmental decontamination. Rather, a multi-pronged approach must be considered as the new “gold standard” which would include an environmental cleaning program with proven practices to reduce the transmission of organisms, a robust hand hygiene program for both staff, patients, and visitors, and the inclusion of new novel approaches such as UV technology which show proven reduction in organisms on treated surfaces (2). By utilizing a multi-pronged approach as the new standard of care, facilities are helping to decrease the risk of healthcare associated infections (HAI’s) in the hospital setting that come from a contaminated environment.
The Environment as a Source of Infection
It has never been more relevant in today’s healthcare settings to look at the environment as a critically important source of infectious disease transmission. There is a large amount of evidenced based research showing that methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), as well as other “superbugs” such as Clostridium Difficile (C-Diff) are capable of surviving for days, weeks (even months in the case of a spore forming bacteria), on environmental surfaces in healthcare facilities (3,4). Surfaces that are commonly touched by both patients and healthcare workers (“high-touch surfaces”) become an important reservoir of these organisms, which are then subsequently transferred from patient room to patient room via healthcare workers hands and contaminated equipment, enabling the dreaded HAI which healthcare facilities try to avoid at all costs.
A Bundled Approach to Environmental Cleaning
Clinicians in healthcare settings are very familiar with “bundled” approaches for the reduction of HAI’s with patient interventions such as central line and catheter insertions. The environment of the patient truly should be no different, and a bundled approach should be considered. Bundles are a set of evidence based practices that when adopted and performed correctly have shown improved patient outcomes.
A study currently underway in Australia, nicknamed the “REACH” study, hypothesizes that a bundle approach to environmental cleaning is needed. (5) The bundle would include:
- Well trained and competent EVS staff,
- Clearly defined roles and responsibilities
- Correct product use,
- Daily cleaning of high touch surfaces, and
- Follow up audits with subsequent education and communication from the results of the audit.
Donskey et.al also puts forth support for the use of a bundle in environmental cleaning including (1)
- Education and training,
- Use of a checklist
- Focus of enhanced cleaning on high-touch surfaces,
- Daily and routine disinfection of portable equipment,
- Designation of responsibility for cleaning specific items, and
- Feedback and communication to EVS staff.
If bundles are used in every other critical aspect of infection prevention processes in healthcare settings why should the environment be any different? More research is needed to standardize what would be included in this bundle, however at present each facility could develop protocols which would reflect something similar and is a best-fit for their facility based on their annual infection control risk assessment.
The Addition of UV Technology as a Supplement to Environmental Cleaning Programs in Healthcare Facilities
As healthcare moves forward into a new technological era, many novel approaches to cleaning and disinfection of the environment are being explored, including surfaces which resist microbes, antimicrobial coatings of medical devices, steam and chemical dispersal systems, and UV light technology. While many of these new and evolving technologies are promising, very few have been vetted through the rigorous process of solid evidence based research practices that include randomized clinical trials, but are rather quasi-experimental. One of the few technologies which is emerging as a proven winner is the use of UV light radiation technology. Using a machine which emits UV light, the unit is rolled into a room as the last step in a terminal room cleaning process. The UV wavelength is capable of inactivating microorganisms and is considered to be germicidal however is also chemical and residual free which is good news for the environment and leaves no harsh smells for the next patient. Multiple studies on the use of UV light technology as an approach to disinfection have shown a decrease in HAIs including C. Diff (6). In a recent multi-center cluster-randomized crossover study performed in 9 US based hospitals called the “BETR-D” study, the researchers concluded that the use of UV light technology as a strategy for disinfection reduced the incidence of the target organisms by 30% (3). Although emerging technologies such as these can be costly, evidence mounts suggesting they do indeed reduce and prevent infections.
Hand Hygiene Programs and the Role of the Patient’s Hands in Pathogen Transmission
The role of hands in the transmission of healthcare associated infections is a well-documented and researched fact. Hand hygiene programs for healthcare workers are mandated by both state and federal requirements. However, the role of pathogen transmission from the patient’s hands is often overlooked and can play a significant role in the transmission of infections (7).
A community hospital found after the implementation of a hand hygiene program focused on patients and visitors that there was a reduction in nosocomial MRSA infections. (8) Sunkelusa et.al proposed a “four moments for patient hand hygiene” which is loosely based on the WHO 5 moments for hand hygiene and states that patient should wash their hands at specific times (9). These times include before meals, after using the restroom, when entering or leaving the patient room, and after touching wounds or medical devices such as catheters. A poster was placed in the room reinforcing four moments, and 97% of patients in the study stated it helped them know when to wash their hands and also was a good reminder to wash.
Another study was performed at a 495-bed university-affiliated medical center where a hand hygiene program was provided to patients that included education and reminders, as well as assistance with hand hygiene throughout the day by healthcare staff especially for bedbound patients. Soap and water as well as a PDI Sani-Hands® “bedside pack” of alcohol impregnated antiseptic wipes were provided to the patients in the study for hand hygiene. Results showed a statistically significant decrease in C. Diff transmission rates and the authors concluded that “Improving HH in general influences CDI (C. difficile Infection) incidence. Similarly, although the alcohol wipes may not kill CD spores, improved compliance of patient hand hygiene may potentially assist in controlling CD events in the hospitalized patient” (7).
The environment of care in healthcare facilities is ever evolving and can seem at times an insurmountable challenge for those who are focused on preventing infections. Infection Preventionists and administrators who are responsible for the oversight of this arena are looking ever more closely at multi-pronged approaches to help mitigate the risk of HAI’s. Bundles in cleaning processes should be considered and would need to include proven processes in both daily and terminal cleaning routines. Hand hygiene programs cannot exclude patients and visitors and should be re-evaluated to provide ways for the patient to perform hand-washing. And finally, included in the bundle should be the newest proven approach to environmental decontamination of UV-C light emitting technology for terminal disinfection of patient care rooms and areas.
- Donskey, Curtis J. Does improving surface cleaning and disinfection reduce healthcare associated infections? May 2013, AJIC, Vol. 41; 5: S12-S19.
- Fleming M., Patrick, A. Gryskevicz, N. M., Hassmer, L., Shimp, K., Cooper, K. ,Doll, M., Stevens, M. , Bearman, G. Deployment of a touchless ultraviolet light robot for terminal room disinfection: The importance of audit and feedback. February 2018; AJIC Vol. 46, 2: 241-243.
- Deverick J Anderson, Luke F Chen, David J Weber, Rebekah W Moehring, Sarah S Lewis, Patricia F Triplett, Michael Blocker, Paul Becherer, J Conrad Schwab, Lauren P Knelson, Yuliya Lokhnygina, William A Rutala, Hajime Kanamori, Maria F Gergen, Daniel J Sexton. 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, multicentre, crossover study. January 16, 2017. The Lancet, Vol 389, No. 10071, 905-814.
- Environmental Cleaning for the Prevention of Healthcare-Associated Infections. Agency for Healthcare Research and Quality U.S. Department of Health and Human Services. August 2015, Technical brief no. 22.
- Dancer, Stephanie J. Controlling Hospital-Acquired Infection: Focus on the Role of the Environment and New Technologies for Decontamination. 2014 October; 27 (4): 665-690.
- Anderson, D., Gergen M., Smathers E., Sexton DJ., Chen LF., Weber DJ., et al. Decontamination of targeted pathogens from patient rooms using an automated ultraviolet C-Emitting device. Infection Control Hospital Epidemiology 2013; 34: 466-71.
- Marian Pokrywka MS, CIC,, Michele Buraczewski BSN, Debra Frank MSN, BSN, Heather Dixon MSN, BSN, Juliet Ferrelli MS, MT(ASCP), CIC, Kathleen Shutt MS, Mohamed Yassin MD, PhD. Can improving patient hand hygiene impact Clostridium difficile infection events at an academic medical center? Sept 1st, 2017. AJIC. Volume 45, issue 9, pg 959-963.
- Gagné D, Bédard G, Maziade PJ. Systematic patients’ hand disinfection: impact on methicillin-resistant Staphylococcus aureus infection rates in a community hospital. J Hosp Infect 2010; 75:269–272.
- Sunkesula VC., Knighton S., Zabarsky TF., Kundrapu S., Higgins PA., Donskey CJ. Four Moments for Patient Hand Hygiene: A Patient-Centered, Provider-Facilitated Model to Improve Patient Hand Hygiene. Infection Control Hospital Epidemiology. August, 2015; 36(8):986-9.