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3 ENVIRONMENTAL SERVICES TECHNOLOGY Maureen Spencer, RN, M.Ed., CIC Infection Preventionist Consultant Universal Health Services Ann Marie Pettis, RN, BSN, CIC Direction Infection Prevention Universal of Rochester Medical Center

4 Evidence that the Environment Contributes to Transmission of Pathogens Environmental contamination and survival of pathogens on surfaces Indirection transmission by workers hands after contact with contaminated surfaces Direct transmission by contact with surfaces Reduction of pathogens with environmental decontamination technology and corresponding reduction in infection rates

5 Do healthcare associated pathogens survive for long periods on environmental surfaces?

6 High Touch Surfaces

7 Pathogens survive on surfaces Organism Survival period Clostridium difficile 35- >200 days. 2,7,8 Methicillin resistant Staphylococcus aureus (MRSA) 14- >300 days. 1,5,10 Vancomycin-resistant enterococcus (VRE) 58- >200 days. 2,3,4 Escherichia coli > days. 7,9 Acinetobacter 150- >300 days. 7,11 Klebsiella > days. 6,7 Salmonella typhimurium 10 days- 4.2 years. 7 Mycobacterium tuberculosis 120 days. 7 Candida albicans 120 days. 7 Most viruses from the respiratory tract (eg: corona, coxsackie, influenza, SARS, rhino virus) Viruses from the gastrointestinal tract (eg: astrovirus, HAV, polio- or rota virus) Few days days. 7 Blood-borne viruses (eg: HBV or HIV) >7 days Beard-Pegler et al J Med Microbiol. 26: BIOQUELL trials, unpublished data. 3. Bonilla et al Infect Cont Hosp Epidemiol. 17: Boyce J Hosp Infect. 65: Duckworth and Jordens J Med Microbiol. 32: French et al ICAAC. 7. Kramer et al BMC Infect Dis. 6: Otter and French J Clin Microbiol. 47: Smith et al J Med. 27: Wagenvoort et al J Hosp Infect. 45: Wagenvoort and Joosten J Hosp Infect. 52:226-7.

8 Hospital Privacy Curtains Contamination 42% VRE 22% MRSA 4% C.difficile Trillis F et al Infect Control Hosp Epid 2008

9 Environmental Contamination Due to MRSA 38 patients colonized or infected with MRSA 27% of surfaces contaminated 42% of personnel who touched surfaces with no direct patient contact contaminated their gloves with MRSA Boyce JM et al Infect Cont Hosp Epid 1997

10 Risk of Hand or Glove Contamination after contact with VRE Patient or Environment Setting: Medical ICU Contamination of HCWs hands or gloves after caring for VRE colonized patients HCWs were nearly as likely to contaminate their hands or gloves after touching the environment as after touching the patient Hayden MK et al Infect Cont Hosp Epid 2008

11 Prior room occupancy increases risk Study Healthcare associated pathogen Likelihood of patient acquiring HAI based on prior room occupancy (comparing a previously positive room with a previously negative room) Martinez VRE cultured within room 2.6x VRE prior room occupant 1.6x Huang MRSA prior room occupant 1.3x VRE cultured within room 1.9x VRE prior room occupant 2.2x Drees VRE prior room occupant in previous 2.0x two weeks Shaughnessy C. difficile prior room occupant 2.4x A. baumannii prior room occupant 3.8x Nseir P. aeruginosa prior room occupant 2.1x 1. Martinez et al. Arch Intern Med 2003; 163: Huang et al. Arch Intern Med 2006; 166: Drees et al. Clin Infect Dis 2008; 46: Shaughnessy. ICAAC/IDSA Abstract K Nseir et al. Clin Microbiol Infect 2010 (in press).

12 Contamination of Environmental Sites Outside Patient Rooms with C. difficile Positive broth enrichment cultures 33% physician workroom telephones 25% nursing workstation computers 33% physician portable computers 21% portable equipment Hand imprint cultures 0% for C.difficile Dumford D et al Am J Infect Control 2009;37:15-19

13 Comparison of stethoscope and hand contamination after simulated exam of chest and abdomen of patients C.Difficile infection (n = 24) MRSA colonization (n 24) Stethoscope Imprint Hand Imprint P value 3/24 (13%) 7/24 (29%) /24 (21%) 7/23 (30%) 0.08 Vajravelu BS et al ICAAC Annual Meeting, 2010

14 Acquisition of MRSA on hands after contact with skin and environment Skin contact: 40% of hand cultures positive 1 Environment contact: 45% of hand cultures positive 2 1. Stiefel U, et al. SHEA, 2010; Donskey CJ, 2. Eckstein BC. N Engl J Med 2009;360:e3.

15 Environment as a Source Studies Huang SS, Datta R, Platt R. Risk of Acquiring Antibiotic-Resistant Bacteria From Prior Room Occupants. Arch Intern Med. Vol Oct. 9, 2006 Bonilla HF, Zervos MJ, Kauffman CA. Long-term survival of vancomycin-resistant Enterococcus faecium on a contaminated surface. Infect Cont Hosp Epidemiol 1996;17: Drees M, Snydman D, Schmid C, et al. Prior Environmental Contamination Increases the Risk of Acquisition of Vancomycin- Resistant Enterococci. Clin Infect Dis. 2008;46: Hayden MK, Bonten MJ, Blom DW, Lyle EA, van de Vijver DA and Weinstein RA. Reduction in Acquisition of Vancomycin-Resistant Enterococcus after Enforcement of Routine Environmental Cleaning Measures. Clin Infect Dis. June 2006:42 Dancer SJ. Importance of the environment in methicillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning. Lancet. Vol. 7. December 2007

16 Environmental Equipment and Inadequate Room Cleaning

17 Conclusion Infected Patient More Susceptible Patient Environment Plays an important role now

18 Area Micro Particle Decontamination Technologies

19 Area Micro Particle Decontamination Hydrogen peroxide vapor technologies Micro-condensation process (BIOQUELL) Dry gas process (Steris) Both technologies have been validated as effective Most experience in healthcare settings is with the microcondensation process Require room to be vacated and ventilation sealed and takes up to an hour for treatment of a room No toxic residuals following decontamination cycle McAnoyAM: Australian Government DSTO 2006 Fisher J et al. Pharmaceutical Technology 2004, pg. 68 Pottage T et al. J Hosp Infect 2010;74:55

20 Hydrogen Peroxide Dry-Mist System Hydrogen peroxide dry mist system (Sterinis) injects particles of 8 12 microns into room Disinfectant: 5% H2O2+ silver ions + phosphoric acid Reduces bacterial contamination in hospital rooms Appears to be less efficacious against C. difficile spores than hydrogen peroxide vapor Andersen BM et al. J Hosp Infect 2006;62:149 Bartels MD et al. J Hosp Infect 2008;70:35 ShapeyS et al. J Hosp Infect 2008;70:136 BarbutF et al. ICHE 2009;30:507 MikkelsenR et al. Decennial 2010, Abstr196

21 Hydrogen Peroxide Vapour (HPV) Hydrogen peroxide powerful bio-decontamination agent Hydrogen peroxide vapour technology has two key advantages: Low-Temperature: hydrogen peroxide vapour is produced in an air stream at approximately 149 F and introduced into an environment Residue-Free: Hydrogen peroxide breaks down in contact with UV light and organic material to water (humidity) and oxygen - hence there is no need for any postdecontamination clean up. Provides a rapid, low temperature, residue-free solution to bio-burden reduction

22 Hydrogen Peroxide Vapour Bioquell

23 Hydrogen Peroxide Vapour BioQuell single vapour generator is capable of bio-decontaminating a volume of approximately 5500ft Sequentially linking these generators together - any size of enclosure can potentially be bio-decontaminated. Injects a calculated high concentration hydrogen peroxide vapor stream into the room Time required to achieve micro-biological deactivation depends heavily on temperature and relative humidity

24 Hydrogen Peroxide Vapour BioQuell - at the end of the bio-deactivation phase of the process the hydrogen peroxide vapor is removed from the enclosure by the use of Clarus R2 catalytic filters which, not only decompose the hydrogen peroxide to water vapor and oxygen, but HEPA filter the air to ensure no particulate is circulated in the environment

25 Benefits of Bioquell Reduction in HAI: Bioquell has demonstrated infection rate reductions in well managed infection control programs, helping hospitals to truly Aim for Zero. Savings: Through reduction in infection rates, Bioquell can save hospitals the cost of uncompensated treatment. Supplies related savings: Bioquell is able to decontaminate unopened consumable supplies, negating the need to discard them. Rapid unit turnaround/outbreak remediation: Bioquell can return closed units to operation within 12 hours and is used frequently to stop outbreaks.

26 Indications and Use of BioQuell Single room to an entire unit, or even an entire hospital. Hospital staff can be trained to perform decontaminations safely and effectively.: After the patient has vacated housekeeping remove the bed linens and trash. Set up the room and equipment Enter user password in control panel - Select "parametric cycle" on control panel - Select the room being sterilized from the menu Start the process - When the control panel indicates the process is complete confirm the concentration is less than 1 ppm. Remove the equipment and return the room to service

27 Bioquell and C.difficile Bioquell s hydrogen peroxide vapour (HPV) technology is an effective, automated and repeatable surface biodecontamination system. It is designed to achieve total eradication of C. difficile from the environment, verified by inactivation of 6-log Geobacillus stearothermophilus biological indicators, the same method used to validate steam sterilizers/ autoclaves.

28 Percentage of MRSA swabs positive Conventional cleaning vs HPV 100 Overall MRSA results Effect of cleaning Effect of BIOQUELL s RBDS Cleaning ineffective: poor level of reduction % (264 out of 359) swabs positive for MRSA 90% (111 out of 124) swabs positive for MRSA 66% (82 out of 124) swabs positive for MRSA 72% (61 out of 85) swabs positive for MRSA BIOQUELL s technology: dramatic reduction in MRSA contamination 10 0 Overall assessment 1%* Before cleaning After cleaning Before bio-decon After bio-decon French et al J Hosp Infect. 57:31-7. * 1 swab out of 85 on enrichment only

29 CDI cases /1,000 Pt days Published C. difficile data Environmental* Standard swabs: Pre and post BIOQUELL Post: Bleach BIOQUELL C.diff: 5% 0% MRSA: 6% 0% VRE: 14% 0% HAI rates** 53% reduction (p=0.047) CDC sponges Pre and post BIOQUELL Post: Bleach BIOQUELL C.diff: 24% 0% first author: John Boyce, Professor of Medicine Yale co-author: CDC: Centers for Disease Prevention & Control * Boyce JM, SHEA annual conference, March 2006 ** Boyce JM, Infect Cont Hosp Epidemiol, 2008;29:

30 Bioquell on the Burn Unit, Washington Medical Center Burn unit in Washington DC 80 percent increase in MDR Acinetobacter rate Rooms bleach cleaned Room surfaces and portable equipment swabbed 23 % produced GNR, 4 % produced Acinetobacter Rooms treated with Bioquell individually No GNR and no Acinetobacter detected using swabs Rate of Acinetobacter infection reduced from 6.0 per 1,000 patient days prior to Bioquell to 1.7 per 1,000 patient days after. After one year rates started to increase and Bioquelling repeated Donegan 2010 Vaporized Hydrogen Peroxide as Part of a Control Intervention during an Outbreak of Acinetobacter in an ICU, SHEA 30

31 Acinetobacter and GNR Otter, et al. Hydrogen peroxide vapor decontamination of an intensive care unit to remove environmental reservoirs of multidrug-resistant gram negative rods during an outbreak, Journal of Infection Control December 2010

32 Acinetobacter and GNR Gelderse Vallei Hospital ICU with multiple cases of GNR infections including Acinetobacter (8) and Enterobacter cloacae (15) in one year period prior. Following high level cleans with bleach multiple surfaces test positive for GNR (47.6 percent). Following whole unit Bioquell (including portable equipment) none of 63 sites test positive for GNR. No transmission of GNR or Acinetobacter infection for three months Otter 2010 Hydrogen peroxide vapor decontamination of an intensive care unit to remove environmental reservoirs of multidrug-resistant gram negative rods during an outbreak, Journal of Infection Control December 32

33 Decontamination of unused, packaged consumables contaminated with vancomycin-resistant enterococci using hydrogen peroxide vapour Jonathan A. Otter, Mike Duclos, Elaine Nowakowski, Catherine L. Passaretti and Trish Perl, MD, MSc Abstract SHEA 2010 Results: Seven (7%) of 100 items sampled before HPV grew VRE and none of 100 paired items cultured after HPV grew VRE (p =0.014, Fisher's Exact Test). Contaminated consumables were identified in four (20%) of the 20 rooms sampled. We did not note any damage on the consumables due to HPV exposure. The average value of disposed consumables was $92 per discharge. Conclusions: Consumables in rooms of patients with VRE were likely contaminated by healthcare workers' hands as they selected other supplies. In our study, HPV was effective for the decontamination of unused, packaged consumables. Our findings support either disposing of or decontaminating adequately unused, packaged consumables when a patient on precautions for VRE is discharged. Routine use of HPV for the decontamination of unused, packaged consumables that would otherwise have been disposed of would save $92 per discharge, thus offsetting the cost of HPV.

34 Additional References French GL, Otter JA, Shannon KP, Adams NM, Watling D, Parks MJ. Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination. J Hosp Infect. 2004;57:31-37 Boyce JM, Havill NL, Otter JA, et al. Impact of hydrogen peroxide vapor room decontamination on Clostridium difficile environmental contamination and transmission in a healthcare setting. Infect Control Hosp Epidemiol. 2008;29: Passaretti K, et al, Adherence to Hydrogen Peroxide Vapor (HPV) Decontamination Reduces VRE Acquisition in High Risk Units, ICAAC Schouten MA, Otter JA, van Zanten AR, Houmes-Zielman G, Nohlmans- Paulssen MK. Environmental decontamination of an intensive care unit to control outbreaks of multidrug-resistant Gram-negative rods using hydrogen peroxide vapor (HPV). Int J Antimicrob Agents. 2007;29 Suppl. 2:S479

35 Dri Mist Hydrogen Peroxide Sterini

36 Hydrogen Peroxide Dry- Mist System Hydrogen peroxide dry mist system (Sterinis) injects particles of 8 12 microns into room Dry aerosol technology guarantees destruction of microorganisms by bringing the diffused disinfectant into contact with all surfaces even those unreachable or hidden. It thoroughly disinfects the surfaces and airspace that other treatments can t reach. Appears to be less efficacious against C. difficile spores than hydrogen peroxide vapor Andersen BM et al. J Hosp Infect 2006;62:149 Bartels MD et al. J Hosp Infect 2008;70:35 ShapeyS et al. J Hosp Infect 2008;70:136 BarbutF et al. ICHE 2009;30:507 MikkelsenR et al. Decennial 2010, Abstr196

37 Sterusil disinfectant Compounds: information Hydrogen peroxide H2O2: 5% Silver cations Ag+: <50 ppm Excipient: Sterile water: 95% Stabilizer: Ortho-phosphoric acid: <50 ppm

38 Sterini Study Invitro Challenge 2 bed room had been cleaned, sheets removed, drawers and cupboards emptied, ventilation closed and taped Inoculum of 0.5 MacFarland broth Staph aureus in 15 different locations 1.5 hr treatment time and first set of samples collected, then process repeated again with Staph aureus

39 Sample after 1.5 hrs Rodac plate after 1.5 hrs 2 nd Sample 20 hrs later 2 nd Rodac 20 hrs later Cabinet 1 0 growth 0 growth 0 growth 0 growth Cabinet 2 0 growth 0 growth Light S. aureus 0 growth Windowsill 0 growth 0 growth 0 growth 0 growth Radiator 0 growth 0 growth Bed 2 0 growth 0 growth 0 growth 0 growth Mattress 0 growth 0 growth Telephone 0 growth 0 growth TV 0 growth 0 growth 0 growth 0 growth Cabinet 1 0 growth 0 growth Cabinet 2 0 growth 0 growth Bathroom 0 growth 0 growth 0 growth 0 growth Toilet 0 growth 0 growth 0 growth 0 growth Shower 0 growth 0 growth Bed 1 0 growth 0 growth

40 Binary Ionization Technology (BIT )

41 Binary Ionization Technology (BIT ) Binary Ionization Technology is a process that applies cold plasma to a spray of disinfecting solution usually, a weak hydrogen peroxide solution Creates a mist with a high concentration of reactive oxidative species (ROS) BIT spray can break down the cell walls of microorganisms and can denature toxic chemicals Because of its fast-acting, broad spectrum, environmentally friendly characteristics, products designed using BIT are ideal for clean rooms, hospitals, food processing, mold remediation, doctor's offices, pharmaceutical manufacturing, aseptic packaging

42 Binary Ionization SteraMist, Binary Ionization utilizing patented Technology (BIT ), assures that micro organisms (including spores) are destroyed in even the most hard-to-reach areas Process applies cold plasma activation to a hydrogen peroxide-based aerosol to create Reactive Oxygen Species (ROS)

43 Binary Ionization SteraMist provides fast acting, broad spectrum biological disinfection, and leaves no residue or noxious fumes. Environmentally safe for staff and hospital equipment, while providing maximum biological log reduction for hospitals and other mobile medical units.

44 MAX Dispersal Gun MAX is specifically designed for use in healthcare facilities and EMS applications. MAX includes all of the cutting-edge Micro-Mist technology that are standard in the reaction oxygen species, with the addition of Steri-Mist Applicator A micro-droplet dispersal gun which permits the operator to rapidly manually apply EPA-registered disinfectants and sanitizers to individual objects (e.g., needle drawers, ambulance seats, steering wheels, bed/gurney rails, call boxes, wheelchairs) that are invariably contaminated by high concentrations of dangerous and infectious bioburdens

45 Zimek Microparticle Generator with Microban

46 Zimek Systems Zimek Systems automatically apply EPA-registered disinfectants and sanitizers to any environment without human intervention using the Micro-Mist ultra-low volume delivery technique and Z-vac air filtration process Zimek's Micro-Mist consists of micro-droplets of disinfectants or sanitizers which defeat surface tension to access and kill infectious microbes wherever they may hide, wherever free air flows, causing a highly effective application Once the water evaporates, residues are lower than if less efficient means of distribution such as wipes or coarse sprays (applied while personnel are present) had been used

47 Zimek Systems Zimek's Micro-Mist Generator introduces a stream of air which is added to a mist of disinfectant or sanitizer generated by ultrasonic vibration Unlike thermal foggers or hydrogen peroxide vapor treatments Zimek's Micro-Mist does not involve heating the disinfectant or sanitizer Zimek's ultrasonic generated Micro-Mist is created in a manner virtually identical to the mist created by ultrasonic humidifiers

48 Other Gas, Mist or Fogging Technologies for Area Decontamination Quaternary ammonium fogging system CadnamJL et al. Decennial 2010, Abstr205 Super-oxidized water fogging Clark J et al. J Hosp Infect 2006;64:386 Gaseous ozone Sharma M et al. AJIC 2008;36:559 Alcohol/Quaternary ammonium mist system Jury LA et al SHEA meeting, abstr278 Low-level (0.02 ppm) hydrogen peroxide gas Muto CA et al. Decennial 2010, Abstr208 and 209

49 Clinical Use of Zimek and BioQuell at New England Baptist Hospital, Boston, MA

50 2008 New Surveillance Definitions

51 NEBH Cases Per New Definitions Month Hosp Community Indeterminate Communityacquired Total Onset Onset HAI October November December January February 2 2 March April 0 May 0 June July 2 2 Aug Sep Total Analyzing nursing units found 81% of the 2008 cases were on one nursing unit formed a task force to evaluate the situation and conduct case review

52 Leased Zimek Decontamination Unit for J4East Three Day Cleaning Process for 19 rooms ~ $

53 Control Measures in August 08 Nursing unit with 81% of the cases was J4East Decontaminated 19 rooms on J4East with the Zimek machine Instituted Use of Chlorox Bleach Wipes for all precaution rooms Keep CDI patients on precautions until day of discharge Restrict transfer of patients in hospital beds Enhanced Education for Staff and Physicians Monitoring for New Cases with new definitions Formation of C.Difficile Team: Chief of Surgery, Chief of Gastroenterology, Nurse Manager, J4East, Microbiology Supervisor, Infection Control Retrospective Case Review of all CDI cases

54 Case Review FY08 34 CDI cases Proton pump inhibitors 13 (67%) Cancer 12 (35%) Fluorquinolones use 9 (26%) Obesity 9 (26%) CT Scan before onset 6 (18%) MRSA Colonization 5 (15%) VRE Colonization 3 (9%) Diabetes 3 (9%)

55 Results after use of Zimek (rate per 10,000 days) FY 2008 FY 2009 Total HAI 21 Patient Days Rate/PtDays 7.3 Hospital Onset 13 Rate/PtDays 4.5 Medical nursing unit 17 Comm Onset HA 8 Rate/PtDays 2.8 Total HAI 13 Patient Days Rate/PtDays 4.6 Hospital Onset 10 Rate/PtDays 3.5 Medical nursing unit 3 Comm Onset HA 3 Rate/PtDays % reduction

56 Environmental Disinfection FY 2008 FY 2009 FY 2010 Total HAI Patient Days 28,914 28,382 24,768 Rate/10,000 Pt Days Hospital Onset Rate/10,000 Pt Days Comm Onset HA Rate/10,000 Pt Days Medical Unit J4East 13 (81%) 3 (23%) 3 (43%) Admitted through ACU NA NA 6 (86%) 56

57 Review of Cases in cases of CDI reduced rate to 2.83/10,000 patient days However, 3 of the cases had only received three doses of surgical prophylaxis and developed CDI after 48hrs of hospitalization None were admitted to the ICU 6 (86%) of CDI cases were admitted through the Ambulatory Care Unit Inspected the ACU and process of placing CDI patients on precautions and disposing of commodes Found environmental contamination likely in the shared bathroom where commodes were being emptied Inadequate environmental cleaning by EVS

58 July 17, 2009 Decontamination of Ambulatory Care Unit with Vaporized Hydrogen Peroxide Leased BioQuell Vaporized Hydrogen Peroxide room decontamination unit July hr process to clean 1-3 cubicle bays and 2 precaution rooms (bays 4-5) and bathroom in the ACU Cost: ~$

59 Shared Bathroom and Area where commodes were being emptied

60 FY 2008 FY 2009 FY 2010 FY2011 (Oct-Apr) Total HAI Patient Days 28,914 28,382 24, Rate/10,000 Pt Days Hospital Onset Rate/10,000 Pt Days Comm Onset HA Rate/10,000 Pt Days

61 C.Difficile HA rate by 10,000 patient days Aug 2008 Zimek and Enhanced Environmental Controls

62 ? Problems with Fogging Disinfectants

63 Zimek EMS workers in a fog over disinfectant s feared danger Published: Saturday, December 25, 2010 by Matt Fair/The Times (Florida)

64 Zimek and Ambulance Workers It took a few months before officials with the Professional Emergency Medical Services Association of New Jersey (PEMSA) say they put two and two together. In the months after the Monmouth-Ocean Hospital Service Corporation (MONOC) began using newly acquired machines to disinfect its ambulances in May 2009 by pumping the vehicles full of pesticide fog, paramedics began experiencing troubling ailments, PEMSA officials say. PEMSA represents emergency medical personnel across New Jersey. In June, we started getting complaints from people about odors in the ambulances and people were developing different symptoms: migraines, nausea, asthma, eye irritation, skin irritation. It was a long list of symptoms, said Deborah Ehling, the union s president. More than a year later, according to Ehling, more than 100 MONOC employees report they re showing signs of illness, allegedly after exposure to the disinfectant chemical Zimek QD.

65 Zimek MSDS NOTE: Hazard information is based on the characteristics of the components of this mixture Ingestion - May cause abdominal discomfort, nausea, vomiting and diarrhea. Drowsiness or unconsciousness may occur. Inhalation - Low concentration of the vapor may cause irritation of the respiratory tract with possible chest pain and coughing. High concentrations may cause headache and drowsiness. Eye Contact - Causes eye irritation and possible permanent eye injury. Skin Contact - Prolonged contact may cause discomfort, redness, drying and defatting of the skin.

66 In Conclusion An advantage of micro-mist decontamination technology is that medical equipment that is difficult to disinfect or frequently escapes disinfection can be effectively decontaminated Shortcomings of decontamination technology include the inability to perform the procedure in rooms currently occupied by patients the need for well-trained personnel and special equipment the higher costs, compared with those associated with routine terminal room cleaning and longer turnaround times before vacated rooms are ready for occupancy by newly admitted patients Question of safety of some of the particles sprayed in the environment

67 Thank you