Effectively Fighting HAIs Using an Integrated, Bundled Approach

Over the past decade, there have been significant advancements in the ongoing battle against healthcare-associated infections (HAIs). We have seen new products and practices, including automated “no-touch” technologies, such as ultraviolet (UVC) light and vaporized hydrogen peroxide, as well as continuous room decontamination methods such as continuously active disinfectants and self-disinfecting surfaces. To date, the scientific community has conducted numerous studies to test these various disinfection methods, and demonstrated effectiveness in reducing bacterial contamination of surfaces and colonization/infection in patients.^1-8

Importantly, studies are pointing to an integrated, bundled approach as an effective and efficient process for comprehensive infection prevention within a healthcare facility. But reviewing data and conclusions from various studies only go so far in protecting patients. 

Infection control specialists need to know how to successfully design and implement an effective infection prevention program. For evidence-based practices for room decontamination, as reported in the American Journal of Infection Control, healthcare facilities should establish strict cleaning/disinfection protocols, including both manual cleaning and automated, total room decontamination technology, combined with extensive training and compliance monitoring (eg, thoroughness of cleaning/disinfection) with feedback to staff.⁴

With significant data to support it, the consensus is that manual cleaning/disinfection, although a critical component in decontamination, alone does not adequately disinfect frequently touched objects in a patient’s immediate hospital environment. For example, one study revealed less than 50% of environmental hospital room surfaces were cleaned by standard terminal room cleaning and disinfection.⁵As such, automated, total room decontamination technologies after discharge of patients on contact precautions, such as UVC systems, should be incorporated as a second step to rigorous manual disinfection. UVC systems have several advantages, including reliable, rapid, and safe decontamination activity against a wide range of healthcare-associated pathogens. Broad distribution of UVC energy throughout a room, including surfaces and equipment, is achieved through an automated monitoring system that doesn’t leave any residue or cause health and safety concerns. UVC technology, however, must not replace manual cleaning/disinfection as it cannot eliminate organic dirt, dust, and debris and persons must leave the room prior to decontamination. 

A study by Duke University, sponsored by the US Centers for Disease Control and Prevention (CDC) and published in the Lancet, demonstrated that enhanced room decontamination strategies (ie, bleach and/or UVC decontamination) decreased the risk of colonization and infection caused by epidemiologically important pathogens among patients admitted to the same room by as much as 30% in hospital settings with 93% compliance of standard disinfection protocols. Individual hospital results may vary.³

The investigators concluded that comparing the best strategy with the worst strategy revealed that a reduction of 94% in epidemiologically important pathogens led to a 35% decrease in colonization and infection. 

These data demonstrated that a decrease in room contamination was associated with a decrease in patient infection. Based on this, hospitals should use a “no-touch” device for terminal room decontamination along with strict manual cleaning/disinfection procedures.^3,7

One key component of effective infection control implementation is creating an organized, standardized set of protocols and steps for cleaning and disinfecting patient rooms and equipment throughout the hospital. Procedures need to include what items must be cleaned, the type of cleaning/disinfection, the order in which to clean the items, as well as what products and dilution of products to use. Specific products should be selected for “cleaning,” including removal of surface debris, dust, and organic material and “disinfection,” referring to the use of a disinfectant or germicide designed to kill microorganisms. Cleaning/disinfection products should have a broad antimicrobial spectrum and be fast acting and non-toxic.⁴

Another critical ingredient is the proper training and education of hospital staff, including environmental services, nursing, patient equipment, and clinical teams. A facility’s policy must assign specific cleaning and disinfection responsibilities and ensure sufficient time is allowed to perform the services. A curriculum and checklists should be developed to keep steps clear and consistent. Proper training should be provided at the beginning of employment and then later on an ongoing basis. Adequate staffing, supervision and adherence to the manufacturer’s label instructions are essential to the success of evidence-based cleaning and disinfection practices.⁴

Systematic periodic monitoring of the staff’s compliance to the infection control process is also important. There are several methods of testing cleanliness, including fluorescent markers, as well as a new approach, which involves a color additive that improves visualization of surface coverage and contact time to improve thoroughness of cleaning/disinfection. Consistent feedback to staff is needed to keep the team informed and motivated.⁴

Investing in a total room, automated disinfection system may seem like a large cost for a healthcare facility; however, it’s easy to see the benefits in terms of saving money and improving patient outcomes. The following examples illustrates how UVC can be a smart investment. 

·      If UVC usage reduced HAIs for approximately 20% of patients (eg, patients on contact precautions) by 10-30% as demonstrated in a randomized trial,³the number of infections prevented in a 900-bed hospital with an infection rate of ~4 per 1000 patient days would be approximately 18-55 per year. 

·      If each HAI cost $24,000 on average⁹the hospital would need to prevent only 23 HAIs in the first 2 years to cover the acquisition and operational costs of the UVC program for a 24-month period. 

·      If the hospital prevented 30% of infections per year (55 per year) for 2 years, the cost savings would be $2,085,000. 

A bundled approach to infection control requires all elements to be evidence-based and implemented consistently and completely. Once all the procedures are in place, a hospital needs to communicate its infection prevention measures throughout the organization and share its progress. Infection prevention is a collaborative effort that should be embraced from top to bottom in order to make a difference in improving patient outcomes and providing the cleanest environments possible. 

William A. Rutala, PhD, MPH, CIC, is a consultant for PDI. He is also director of the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) and a professor at the University of North Carolina School of Medicine. 

References:

1. Weber DJ, Kanamori H, Rutala WA. “No touch” technologies for environmental decontamination: Focus on UV de-vices and hydrogen peroxide systems. Current Opinions Infect Dis. 2016 Aug;29(4):424-31. doi: 10.1097/QCO.0000000000000284.

2. Weber DJ, Rutala WA, Anderson DJ, Chen LF, Sickbert-Bennett EE, Boyce JM. Effectiveness of UV devices and hy-drogen peroxide systems for terminal room decontamination: Focus on clinical trials. Am J Infect Control. 2016 May 2;44(5 Suppl):e77-84. doi: 10.1016/j.ajic.2015.11.015.

3. Anderson DJ, Moehring RW, Weber DJ , et al. Effectiveness of targeted enhanced terminal room disinfection on hospital-wide acquisition and infection with multidrug-resistant organisms and Clostridium difficile: a secondary analysis of a multicentre cluster randomised controlled trial with crossover design (BETR Disinfection). Lancet Infect Dis. 2018 Aug;18(8):845-853. doi: 10.1016/S1473-3099(18)30278-0. Epub 2018 Jun 4.

4. Rutala WA, Weber DJ.  Best practices for disinfection of noncritical environmental surfaces and equipment in health care facilities: A bundle approach. Am J Infect Control. 2019 Jun;47S:A96-A105. doi: 10.1016/j.ajic.2019.01.014.

5. Rutala WA, Gergen MF, Weber DJ. Room decontamination with UV radiation. Infect Control Hosp Epidemiol. 2010 Oct;31(10):1025-9. doi: 10.1086/656244.

6.   Rutala WA, Weber DJ.  Best practices for disinfection of noncritical environmental surfaces and equipment in health care facilities: A bundle approach. Am J Infect Control. 2019 Jun;47S:A96-A105. doi: 10.1016/j.ajic.2019.01.014.
7. Rutala WA, Kanamori H, Gergen MF, et al. Enhanced disinfection leads to a reduction in microbial contamination and a reduction in patient infection and colonization. Infect Control Hosp Epidemiol. 2018 Sep;39(9):1118-1121. doi: 10.1017/ice.2018.165. Epub 2018 Jul 31.
8.  Weber DJ, Rutala WA, Sickbert-Bennett EE, Kanamori H, Anderson D, CDC Prevention Epicenters Program. Continu-ous room decontamination technologies. Am J Infect Control. 2019 Jun;47S:A72-A78. doi: 10.1016/j.ajic.2019.03.016.
9.  Zimlichman E, Henderson D, Tamir O, et al. Health care-associated Infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46. doi: 10.1001/jamainternmed.2013.9763.