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The Healthcare Environment: Evaluating Cleaning Practices ...
Transcript of The Healthcare Environment: Evaluating Cleaning Practices ...
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The Healthcare Environment:
Evaluating Cleaning Practices and
Improving Compliance
Philip C. Carling, M.D.
Boston University School of Medicine
Illinois Campaign to Eliminate Clostridium difficile
July 2012
Consultant – Ecolab, Steris, ASHES
Patent License - Ecolab [email protected]
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A 2012 Perspective
1990 – 2009
Next Decade
Healthcare
Environmental
Cleaning Goal
Near-Patient
Surface Bio-
burden
Reduction
Developmental Emphasis
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How is Environmental Cleaning being
evaluated in this hospital ?
Are Shiny Floors Enough ??
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A 2012 Perspective
1990 – 2009
Shinier Floors
Next Decade
Providing a safer patient environment
Healthcare
Environmental
Cleaning Goal
Near-Patient
Surface Bio-
burden
Reduction
Developmental Emphasis
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A 2012 Perspective
1990 – 2009
Shinier Floors
Disinfectant Efficacy
Next Decade
Providing a safer patient environment
Healthcare
Environmental
Cleaning Goal
Near-Patient
Surface Bio-
burden
Reduction
Developmental Emphasis
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A 2012 Perspective
1990 – 2009
Shinier Floors
Disinfectant Efficacy
Next Decade
Providing a safer patient environment
Hygienic Practice
(Technologic
Enhancements)
Healthcare
Environmental
Cleaning Goal
Near-Patient
Surface Bio-
burden
Reduction
Developmental Emphasis
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SHEA abstracts related to surface
environmental hygiene issues
28
2
37
0
25
50
SHEA 2005 DECENNIAL
2010
2011
Number of
abstracts
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Today’s Presentation • A new understanding healthcare
surfaces microbial ecology
• Defining the risk of transmission from
surfaces
• Addressing suboptimal cleaning
practice
• Does improved practice matter?
• Approaches to monitoring hygienic
practice in healthcare
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The new (clarified)
understanding of the
healthcare surface
environment
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The microbial ecology
of patient zone surfaces
All pathogens traditionally associated with health care transmission survive well on surfaces
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Survival of Pathogens on Dry
Environmental Surfaces
Pathogen Survival time on dry
environmental surface
C. difficile >5 months
Staphylococci 7 months
VRE 4 months
Acinetobacter 5 months
Norovirus 3 weeks
Adenovirus 3 months
Rotavirus 3 months
Hepatitis C 4 weeks
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Outbreak v. Non-outbreak VRE
JHI 2011
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The microbial ecology
of patient zone surfaces
All Pathogens traditionally associated with health care transmission survive well on surfaces
Organism density is generally low but infective doses are low
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The microbial ecology
of patient zone surfaces
All Pathogens traditionally associated with health care transmission survive well on surfaces
Organism density is generally low but infective doses are low
Most near-patient surfaces are sterile or contain < 2.5 ACC / cm2. Therefore, simple cleanliness (culture, ATP) can not be used as a surrogate for thoroughness of cleaning
(the most misunderstood aspect of EH)
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Defining the risk of
transmission
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Studies reporting a favorable impact of
enhanced environmental hygiene during a
CDAD outbreak
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Increased acquisition risk from prior room occupant
8 studies as of October 2010
Two additional studies showed very significant risk without quantification – Martinez (VRE) and Wilks (Acinetobacter)
0 100 200 300
Nseir
Nseir
Datta
Shaugnessy
Dress
Hardy
Huang
Increased Risk of Aquisition (%)
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Is there a better programmatic
model ?
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The Health Care Environmental
Hygiene Study Group Hospitals
Program
To develop a surrogate marking system to objectively evaluate and improve the thoroughness of environmental cleaning/disinfection of the near-patient environment
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The Targeting Solution
A mixture of several glues, soaps and a
targeting dye which:
Dries rapidly
Environmentally stable
Readily wetted by spray disinfectants
Easily removed with light abrasion
Inconspicuous
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Target After Marking
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Target Enhanced
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Evaluation of the thoroughness of
disinfection cleaning has shown
substantial opportunities for
improvement in all health care
venues studied in the U.S., Canada,
Ireland and Australia
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0
2
4
6
8
1-5% 11-15% 21-25% 31-35% 41-45% 51-55% 61-65% 71-75% 81-85% 91-95%
Baseline Environmental Evaluation of
3 Acute Care Hospitals
% of Objects Cleaned
Hospitals
Mean = 47.7 %
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0
2
4
6
8
1-5% 11-
15%
21-
25%
31-
35%
41-
45%
51-
55%
61-
65%
71-
75%
81-
85%
91-
95%
Baseline Environmental Evaluation of
35 Acute Care Hospitals
% of Objects Cleaned
Hospitals
Mean = 48.5 %
(20,056 Objects)
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0
2
4
6
8
10
12
0-5 6-10 11-
15
16-
20
21-
25
26-
30
31-
35
36-
40
41-
45
46-
50
51-
55
56-
60
61-
65
66-
70
71-
75
76-
80
81-
85
86-
90
91-
95
96-
100
Proportion of Objects Cleaned (%)
Ho
sp
itals
Baseline Environmental Evaluation of
82 Acute Care Hospitals
(44,340 Objects)
Mean = 54 %
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0
20
40
60
80
100
PROPORTION OF OBJECTS CLEANED AS PART OF
TERMINAL ROOM CLEANING IN 20 ACUTE CARE
HOSPITALS
%
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Thoroughness of Environmental Cleaning
0
20
40
60
80
100
HEHSG HOSP
IOWA HOSP
OTHER HOSP
OPERATING ROOMS
NICUEMS VEHICLES
ICU DAILY
AMB CHEMO
MD CLINIC
LONG TERM
DIALYSIS
%
DAILY CLEANING
TERMINAL CLEANING
Cle
an
ed
Mean = 32%
>110,000
Objects
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Cleaned, empty
room
identified
Room marked Room evaluated
Terminal cleaning after 1 or 2 patient cycles
Phase I: Covert Baseline Environmental Cleaning Evaluation
Phase II: A. Programmatic Analysis
B. Educational Interventions – ES staff
Cleaned, empty
room
identified
Room marked Room evaluated
Terminal cleaning after 1 or 2 patient cycles
Phase III: Re-evaluation of Cleaning and feedback to ES
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RESULTS
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40
50
60
70
80
90
PRE-INTERVENTION POST ED POST SINGLE F/U POST 2-4 F/U
% o
f O
bje
cts
Cle
an
ed
RAPID IMPROVEMENT
DELAYED IMPROVEMENT
LIMITED IMPROVEMENT
17 HOSPITALS
10 HOSPITALS
8 HOSPITALS
Terminal Room Cleaning Project
– Three Programmatic Responses
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40
50
60
70
80
Hospitals Environmental Hygiene Study Group
36 Hospital Results %
of O
bje
cts
Cle
aned
PRE INTERVENTION POST INTERVENTION
P = <.0001 Resource Neutral
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Is it a surprise that this degree of improvement
was resource neutral ??
0 10 20 30 40 50 60 700
10
20
30
40
50
60
70
80
Time (Minutes)
% S
urf
aces C
lean
ed
Terminal Cleaning Rupp ME, Adler A, Schellen M, Abstract 203 Fifth Decennial
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So much for acute hospitals
what about long term care?
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0
10
20
30
40
50
60
Pro
po
rtio
n o
f o
bje
cts
cle
an
ed
(%
) Baseline Thoroughness of Daily Disinfection Cleaning in
Nine Skilled Nursing Facilities
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J. of the American Geriatrics Society – July 2012
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J. of the American Geriatrics Society – July 2012
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29
47
28
48
62
65 66
62
48
53
80 81
0
20
40
60
80
100
HP SW EV 36 HOSPITALS
%
BASELINE POST EDUCATION POST FEEDBACK
GOAL
CLEANED
Patient Safety Environmental Cleaning
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0 20 40 60 80 100
Thoroughness of cleaning following
structured interventions
Baseline Thoroughness of Cleaning
Increased risk of prior room occupant
transmission
%
11 Studies
40%
74%
82%
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Does Improved
thoroughness of disinfection
decrease surface
contamination?
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Improving Disinfection Cleaning to Decrease
Environmental Surface Contamination
0
50
100
% Relative
Improvement
from Baseline
Improvement in
Cleaning Practice
Decrease in
Environmental Pathogens
A A B B C C D D
80%
64%
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Improved thoroughness of
hygienic cleaning is a worthy
goal given the billions of dollars
involved…but will it impact
transmission of healthcare
acquired pathogens (HAPs)?
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0 20 40 60 80 100
Programmatic decrease in environmental
contamination
Thoroughness of cleaning following structured
interventions
Baseline thoroughness of Cleaning
Increased risk of prior room occupant
transmission
%
11 Studies
8 Reports MRSA, VRE, CD, AB
40%
74%
82%
73%
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Brigham & Woman’s ICU Study
44
71
0
20
40
60
80
PRE-INTERVENTION POST INTERVENTION
%
THOROUGHNESS OF
CLEANINGMRSA/VRE
CONTAMINATION
Goodman R,
ICHE 2009
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Brigham & Woman’s ICU Study
44
71
45
27
0
20
40
60
80
PRE-
INTERVENTION
POST
INTERVENTION
%
THOROUGHNESS OF CLEANING
MRSA/VRE CONTAMINATION
Goodman R,
ICHE 2009
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Brigham & Woman’s ICU Study
Datta B, Arch Int Med
March 2011
45
27
0
20
40
60
80
PRE-
INTERVENTION
POST
INTERVENTION
%
ENVIRONMENTAL
CONTAMINATION
Result of the intervention
MRSA Acquisition Decreased 50% p<0,001)
VRE Acquisition Decreased 28% (p<0.02)
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0 20 40 60 80 100
Programmatic decrease in aquisition
Programmatic decrease in
environmental contamination
Thoroughness of cleaning following
structured interventions
Baseline thoroughness of Cleaning
Increased risk of prior room occupant
transmission
%
11 Studies
8 Reports
4 Studies MRSA, VRE
40%
74%
82%
68% MRSA, VRE, CD, AB
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CDC Recommendations Acute Care Hospitals should implement a:
Level I Program:
Basic interventions to optimize disinfection cleaning
policies, procedures and ES staff education and practice.
When completed move to Level II Program
Level II Program:
All elements of Level I + Objective monitoring
Options for Evaluating Environmental Cleaning
October 2010
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CDC Recommendations
Web Link:
http://www.cdc.gov/HAI/toolkits/Evaluating-
Environmental-Cleaning.html
Options for Evaluating Environmental Cleaning
October 2010
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So much for the why
Let’s get to the how
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First establish a structure for the program
• Early joint planning to
define expectations,
clarify policies and foster
mutual respect
• One sided programs fail
on many levels Infection Prevention
AND
Environmental
Services
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Systems of Objectively Monitoring
Hygienic Practice
What are the merits and limitations of
the tools that can be used to objectively
monitor the thoroughness of patient
zone cleaning?
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Defining the Difference Between Cleaning and Cleanliness
Cleanliness Cleaning
Definition A measure of bacteria
on a surface
Measured by evaluating
process
Defined Criteria No
“Cleanliness Standard”
Compliance with existing
cleaning policy
Improvement shown to
decrease bacterial
transmission (Published)
None Two
Impacted by Bioburden,
thoroughness of recent
cleaning, effectivness of
disinfectant, recent
contamination or lack of
Thoroughness of
evaluated cleaning
practice
CDC endorsed to
improve patient safety
No Yes
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Evaluating Patient Zone Environmental Cleaning
MethodEase of
Use
Identifies
PathogensAccuracy
Useful for
Teaching
Use in
Programmatic
Monitoring
Direct observation
Culture swab
Agar culture system
Fluorescent system
ATP Bioluminescence
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Evaluating Patient Zone Environmental Cleaning
MethodEase of
Use
Identifies
PathogensAccuracy
Useful for
Teaching
Use in
Programmatic
Monitoring
Direct observation Low No Variable Yes Difficult
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Evaluating Patient Zone Environmental Cleaning
MethodEase of
Use
Identifies
PathogensAccuracy
Useful for
Teaching
Use in
Programmatic
Monitoring
Direct observation Low No Variable Yes Difficult
Culture swab High Yes High No No
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Evaluating Patient Zone Environmental Cleaning
MethodEase of
Use
Identifies
PathogensAccuracy
Useful for
Teaching
Use in
Programmatic
Monitoring
Direct observation Low No Variable Yes Difficult
Culture swab High Yes High No No
Agar culture system Moderate Possible Moderate No Possible*
* Measures cleanliness at that moment but NOT the process of cleaning
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Evaluating Patient Zone Environmental Cleaning
MethodEase of
Use
Identifies
PathogensAccuracy
Useful for
Teaching
Use in
Programmatic
Monitoring
Direct observation Low No Variable Yes Difficult
Culture swab High Yes High No No
Agar culture system Moderate Possible Moderate No Possible*
Fluorescent system High No High Yes Yes
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Evaluating Patient Zone Environmental Cleaning
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Surface evaluation using
ATP bioluminescence
Swab surface luciferace tagging of ATP Hand held luminometer
Used in the commercial food preparation industry to evaluate surface
cleaning before reuse and as an educational tool for more than 30 years.
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The ATP tool in context
Industrial Use • Developed in the 1970s for commercial food preparation
• Used when very clean surfaces are important
• High-grade disinfectants + Rinsing
• Testing immediately after cleaning and just before use is the standard
Healthcare Use • Griffiths – JHI studies – Effectively used cultures and
ATP to debunk the “visibly clean ” standard
• He and later Dancer showed that most surfaces had both high bacterial and ATP counts (89% of surfaces “Failed”) (many appeared dirty!)
• The Hygienic standard is proposed
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Limitations of ATP evaluation of cleanliness
in healthcare settings
Two independent studies of ATP
sensitivity and specificity have clarified
the limits of the ATP “Cleanliness
Standard” as it was proposed several
years ago
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National Health Service. Link
195.92.246.148/knowledge_network/documents/Bioluminescence_200706201
04921.pdf
2007
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Correlation between ATP bioluminescence
(RLU/Swab) and aerobic colony count (cfu/swab)
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Correlation between ATP bioluminescence
(RLU/Swab) and aerobic colony count (cfu/swab)
Satisfactory by RLUs
but Unsatisfactory by #
CFU
Bioluminescence
PPV = 63% NPV= 71%
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Correlation between RLU & Microbial
Contamination. Mulvey D, et al. J Hosp Infect 2011
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Lack of Correlation between RLU & Microbial
Contamination.
“Routine cleaning with
detergent can reduce
concentration of microbes
& organic matter by RLU.
The effect is not large,
with many sites exhibiting
similar values after
cleaning as they did
before. …Further work is
required to refine practical
sampling strategy and
choice of benchmarks.”
GOOD
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Mulvey D, et al. J Hosp Infect 2011
Conclusion
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The other problem with using an
evaluation of cleanliness by
agar dip slide or ATP
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Proposed “Hygienic Standard”
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Basic cleanliness* of healthcare surfaces
0
20
40
60
80
100
%
* No aerobic growth or < 2.5 CFU/cm2
Nine Published studies 2006 - 2011
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Despite their limitations, can dip slide
cultures or ATP be theoretically used to
evaluate cleaning practice?
The CDC Guidance says yes……But
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Using tools that measure cleanliness to systematically
evaluate cleaning process
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But then you will need to deal
with the other implication of
the…..
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Most surfaces have too low a bioburden to evaluate… you
need to mark two to three times the number of surfaces
you planned to get an appropriately sized sample to detect
a 20% change in process
0
20
40
60
80
100
%
* No aerobic growth or < 2.5 CFU/cm2
Nine Published studies 2006 - 2011
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So what about the
disinfectant?
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Don’t forget the Rutala Equation
Product + Practice
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Issues with disinfectants, detergents, cloths, etc.
• What is the true role of bleach in
disinfection cleaning?
• How effective will new green
disinfectants be?
• When is it okay to use detergents?
• Where are we going with dwell
time?
• Where does microfibre fit in?
• If effective killing with bleach takes
many minutes, what is the clinical
efficacy of bleach wipes?
• What is the correct amount of
quat?
• Are disinfectants being mixed
accurately?
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So what about
Hand Hygiene??
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Hand Hygiene Issues
What did Mark Anthony have to
say about HH?
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Hand Hygiene Issues
Friends, Romans and Minnesota IPs,
I come not to bury Hand Hygiene but to
praise it (in context)
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Hand Hygiene Issues
Success stories were based on mixed
interventions….Not enhanced HH alone
Logistical limitations are becoming clarified
There may be a “compliance ceiling”
Microbial efficacy – Product Differences
Microbial resurgence is rapid following HH
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HH in Complex Intense Environments is
Very Difficult
30 to 40 HH “Moments” per Hour during direct patient care
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HH in Complex Intense Environments is
Very Difficult
30 to 40 HH “Moments” per Hour during direct patient care
WHO = 20 to 30
sec.
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How Rapidly does HH compliance deteriorate
during a single patient encounter?
0
10
20
30
40
50
60
70
AVG 2 3 4 5 6 7 8
%
Number of Successive Contacts
Evillard etal J Hosp Infect – July 2009
HH Opportunities
PT to Environment
Environment to PT
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Conclusions
• It is very likely that surfaces in the Patient Zone are of
relevance in the transmission of Healthcare Associated
Pathogens.
• While optimizing hand hygiene and isolation practice is
clearly important there is no reason why the
effectiveness and thoroughness of environmental
hygienic cleaning should not also be optimized,
particularly since such an intervention can be essentially
resource neutral.