Environmental Disinfection ~ A Review of Hydrogen Peroxide Vapor Technology Lessons from a Community...
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Transcript of Environmental Disinfection ~ A Review of Hydrogen Peroxide Vapor Technology Lessons from a Community...
Environmental Disinfection ~A Review of Hydrogen
Peroxide Vapor Technology
Lessons from a Community Hospital
Nancy Iversen, RN, CIC Director, Patient Safety & Infection Control
Billings [email protected] 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