Unprecedented Collaboration to Eliminate Infection and Illness Caused by Contaminated Surfaces in Healthcare Environments

By Matthew Hardwick, PhD; Debra Harris, PhD; Linda Lybert; and Amber Mitchell, DrPH, MPH, CPH

In a world full of conflict and complexity, we seek solidarity and simplicity. In an age of globalization of travel and medical tourism, we need the delivery of healthcare to make common sense for all who access it. A healthcare facility must be a safe place designed for health and healing. If its surfaces cannot be effectively cleaned, disinfected and/or sterilized, it is not a healing environment.  

A design cannot just be created, initiated and executed by architects, designers, engineers, builders, without input from clinicians, specialists, scientists, manufacturers, advocates, and educators. The problem we continue to see is that manufacturers often develop new products to solve a specific problem without input from healthcare professionals that will be responsible for the care and maintenance of them. In particular, those who are in daily contact with patients and personnel have a different level of understanding and knowledge of infection prevention as it relates to surfaces. Ensuring all key stakeholders are at the table for all discussions provides invaluable insight and knowledge of protocols and process for cleaning and disinfection. 

The Healthcare Surfaces Summit (HSS) is just that -- a collaboration of stakeholders adamant about making healthcare environments and the delivery of healthcare free from harm. 

HSS is a collaboration between infection preventionists, epidemiologists, infectious disease experts, scientists, laboratorians, engineers, occupational health and safety experts, and architects working in healthcare, manufacturing, academic, entrepreneurial, government, standards setting, and non-profit organizations. All are focused on creating measures, metrics, standards, research, outreach and education to reduce preventable infections by interrupting the transmission of surface-related pathogens in healthcare in support of community health.

Readers of Infection Control Today well know that 1 out of 25 patients will acquire an infection while being treated for something else.1 This statistic is unacceptable. We also know that this is not just an issue for patients, but that healthcare personnel also experience increased incidences of illness and infection and are continually at risk.2 Exposure to pathogenic microorganisms that can cause morbidity and mortality in patients and personnel, also carry risk to the public and impact overall global public health.3 This is not just the case in crowded, heavily occupied healthcare facilities.  In fact, it may potentially be more pertinent -- especially with hearty environmental microorganisms like Clostridium difficile -- in regular, everyday settings like moderately occupied acute care hospitals and outpatient clinics.4

Together, HSS is pulling together all science, research, and resources necessary to create meaningful tools and resources for the healthcare industry.  HSS is working to ensure that healthcare surfaces – including items such as countertops, toilets, sinks, patient care items, machines and appliances, textiles, upholstery and medical devices – become less of a culprit for harboring pathogens and contaminants that cause infection and illness in patient and personnel.

To best identify where we need to go, it is important to identify where we have been and what the science tells us.  As a result, the HSS has commissioned an extremely robust literature review and meta-analysis. The purpose of the literature review is to develop collaborative strategies to design, specify, maintain and use surface materials that contribute to a solution to reduce the risk of healthcare associated infections (HAI). Often, research focuses on the cleaning process, but not the material being cleaned. Similarly, studies focus on transmission via healthcare practitioner and hand washing strategies without controlling for contact with surfaces prior to patient interaction. 

Understanding the contributing factors to the selection, maintenance, and use of environmental surfaces in healthcare facilities is the foundation to identifying successful processes and innovating new solutions to mitigate infection and illness. This study utilizes a peer-reviewed assessment method and ranking system for published journal articles and will conduct meta-analysis to evaluate the evidence and identify gaps where additional research is needed. By systematically reviewing the literature and investigating practice processes, collaborators across interested disciplines can work together to define best practices, develop guidelines and standards, and provide educational opportunities to increase compliance and reduce infections and illness.

We know that to tackle an issue so complex and wide-reaching, that there needs to be focused efforts in several different and distinct arenas.  As part of HSS, there has been ongoing, focused work among and between four initiative workgroups with the following missions:

- Research: Evidence-based efforts to demonstrate the connections between HAI transmission and healthcare surfaces and provide best practices guidance to accelerate the adoption of new innovations and interventions for surface decontamination.
Standards and Utilization: Evaluate and implement objective measurement tools for disrupting pathogen transmission. Review products and technology for decontaminating surfaces 

- Surface Disinfection and Compatibility: Develop testing guidelines for surface disinfection incompatibility by evaluating disinfection process, products and protocol to understand the relationship between surface damage and microbial acquisition and transmission.

- Education: Create and disseminate tools, resources, educational material, and other critical information for providers, patients, and the public to reduce transmission of surface related pathogens.  A range of materials including infographics, presentations, checklists, training parameters, and educational curricula will be developed to target individuals at all levels of awareness to improve their knowledge, skills, and ability to act as agents of change.  

Historically, infection prevention research focuses largely on handwashing and antibiotic stewardship. There is also a vast body of research that indicates the primary role of healthcare surfaces in the transmission of pathogens. Much of the current surface research examines the bacterial-reducing efficacy of specific interventions, but it fails to provide any evaluation of the surface materials used to construct healthcare facilities and how they can or cannot support microbial growth and movement. Additionally, surface materials used for healthcare products such as furniture, medical equipment and medical devices are typically made of multiple surface materials that cannot all be cleaned, disinfected or sterilized in the same way or with the same disinfectant products. When these surfaces are damaged during the cleaning process, the question remains: How is microbial growth and ultimately the acquisition and transmission of microbes affected? 

While this oversight may seem inconsequential, several disinfectants are known to compromise both hard and soft healthcare surfaces. The HSS Research Initiative is performing research to identify incompatibilities between current disinfectants, both physical and chemical, and existing healthcare surfaces. To this end, we are currently studying the impact of disinfectants and various wiping techniques on bacterial reduction on a variety of healthcare surfaces. This data will inform development of modernized cleaning techniques, incompatibility issues between disinfectants and surfaces, and highlight the need for more collaboration between the research community and disinfectant manufacturers, as well as healthcare environment designers. While the work of the HSS Research Initiative is largely independent, much of our work will be a collaborative effort with industry groups. After all, reduction of HAIs is a global need and requires the input of all stakeholders.

There is a great deal of fragmentation within oversight and standards setting groups for healthcare surfaces that can impact the transmission of infections and illness in healthcare facilities. This is especially true as it pertains to protocols for surface testing, materials compatibility, cleanability, contamination rates, durability, testing methods, and outcome and intervention measures. For years, consensus, specification, performance, and testing standards organizations like AAMI, ASTM, ISO and others have built and published parameters to designers, manufacturers, and oversight organizations for commercialization of products – medical devices, personal protective equipment, textiles, chemicals, and their subsequent components.  These groups set standards for all sorts of processes, procedures, and products including diagnostic testing, materials compatibility, safety, shelf life, packaging, sterility, quality measures, biocompatibility, and electrical, physical, and flammability parameters. However, there are no standards set for the selection on surface materials used to manufacturer these products. 

In addition, regulatory, licensing, and accreditation institutions like the Joint Commission and State Departments of Health and Public Health, OSHA, EPA, FDA, and many more incorporate consensus standards into their regulations, standards, and guidance.  It is then that professional and trade associations and member organizations -- the alphabet soup of AHA (American Hospital Association), ANA (American Nurses Association), AMA (American Medical Association), APIC (Association for Professionals in Infection Control and Epidemiology), ACHA (American College of Healthcare Architects), ASM (American Society of Microbiology), ASCLS (American Society for Clinical Laboratory Science), ABSA (The Association of Biosafety and Biosecurity), IAFF (International Association of Fire Fighters), SHEA (Society for Healthcare Epidemiology of America), AdvaMed, PhRMA, and so many more - craft “evidence-based” standards and best practices for adoption among their members and clients.  These standards are often only available to paying members in good standing or to the public for a fee. Open, free access to timely, accurate, and succinct information is simply not happening. A widely adopted standard does not currently exist. 

The HSS and its stakeholder members are dedicated to joining forces to make this a common practice. They are creating an evidence-based consensus standard to serve as a foundation to manufacturers, architects, engineers, and construction trades in healthcare to balance the specifications needed for healthcare surfaces that are safe and safely able to be cleaned, disinfected, and/or sterilized. The HSS workgroups will collectively provide information to achieve this goal.  It will be determined at a future time, what standards-setting organization would provide the best platform for publication and dissemination of such a standard.

Many areas of work that need to be completed and the need for collaboration have been identified. The challenge is bringing people together for discussion and testing and developing a clear understanding of what systems can be put together that provide sustainable solutions. Ultimately, the end goal we all share is reducing risk and mitigating the spread of pathogens that cause infections and illness. A new project for HSS is the development of an incubator. Much like a business incubator that helps new and startup companies develop services, HSS will utilize this concept to develop a testing site.

Working through the Initiative Groups, we will look at all aspects of the problem and test solutions as a system. Manufacturers will have the opportunity to interact with many healthcare professionals to understand what they do and how they operate. They may also gain input from them on innovative new ideas and solutions. 

References:
1. CDC. HAI Data and Statistics. https://www.cdc.gov/hai/surveillance/index.html
2. van Vugt, JLA, Coelen RJS, van Dam DW, et al. Surgical Infections. April 2015.
3. Mitchell A, Spencer M, Edmiston C Jr. Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. J Hosp Infect. 2015 Aug;90(4):285-92.
4. Mahshid Abir, MD, MSc, Jason Goldstick, PhD, Rosalie Malsberger, MS, et al. The Association of Inpatient Occupancy with Hospital-Acquired Clostridium difficile Infection. Journal of Hospital Medicine. Web June 27, 2018.