An Environmental Disinfection Odyssey
An Environmental Disinfection Odyssey
Objective. Effective disinfection of hospital rooms after discharge of patients with Clostridium difficile infection (CDI) is necessary to prevent transmission. We evaluated the impact of sequential cleaning and disinfection interventions by culturing high-touch surfaces in CDI rooms after cleaning.
Design. Prospective intervention.
Setting. A Veterans Affairs hospital.
Interventions. During a 21-month period, 3 sequential tiered interventions were implemented: (1) fluorescent markers to provide monitoring and feedback on thoroughness of cleaning facility-wide, (2) addition of an automated ultraviolet radiation device for adjunctive disinfection of CDI rooms, and (3) enhanced standard disinfection of CDI rooms, including a dedicated daily disinfection team and implementation of a process requiring supervisory assessment and clearance of terminally cleaned CDI rooms. To determine the impact of the interventions, cultures were obtained from CDI rooms after cleaning and disinfection.
Results. The fluorescent marker intervention improved the thoroughness of cleaning of high-touch surfaces (from 47% to 81% marker removal; P < .0001). Relative to the baseline period, the prevalence of positive cultures from CDI rooms was reduced by 14% (P = .024), 48% (P < .001), and 89% (P = .006) with interventions 1, 2, and 3, respectively. During the baseline period, 67% of CDI rooms had positive cultures after disinfection, whereas during interventions periods 1, 2, and 3 the percentages of CDI rooms with positive cultures after disinfection were reduced to 57%, 35%, and 7%, respectively.
Conclusions. An intervention that included formation of a dedicated daily disinfection team and implementation of a standardized process for clearing CDI rooms achieved consistent CDI room disinfection. Culturing of CDI rooms provides a valuable tool to drive improvements in environmental disinfection.
Contaminated environmental surfaces are an important source for transmission of healthcare-associated pathogens, including Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Unfortunately, environmental cleaning in healthcare facilities is often suboptimal. In recent years, 2 promising strategies have been used to improve cleaning and disinfection. First, routine monitoring of cleaning with feedback to environmental services personnel has been effective in achieving sustained improvements in standard cleaning practices. Methods of monitoring have included direct observation of cleaning, use of fluorescent markers to monitor the thoroughness of cleaning, and adenosine triphosphate (ATP) bioluminescence to evaluate for the presence of residual organic material after cleaning. Second, automated room disinfection devices have been developed as a means to reduce dependence on appropriate application of disinfectants by environmental services personnel. For example, automated ultraviolet (UV) radiation devices have been shown to reduce levels of pathogens, including C. difficile spores, in hospital rooms. Although these strategies are promising, limited data on their effectiveness in improving disinfection in real-world settings are available.
The Louis Stokes Cleveland Veterans Affairs (VA) Medical Center experienced a large outbreak of C. difficile infection (CDI) from 2002 through 2004 and subsequently has maintained a high endemic CDI incidence (~15 cases per 10,000 patient-days). In 2009, we demonstrated that environmental cultures collected from CDI rooms were often positive after completion of terminal room cleaning by environmental services personnel. In response, we initiated an intervention to improve cleaning and disinfection of CDI rooms. Here, we report the impact of sequential interventions on the frequency of C. difficile environmental contamination in CDI rooms after completion of cleaning and disinfection. The goal of the intervention was to achieve consistently negative cultures from high-touch surfaces after cleaning of CDI rooms (ie, zero or close to zero positive cultures).
Abstract and Introduction
Abstract
Objective. Effective disinfection of hospital rooms after discharge of patients with Clostridium difficile infection (CDI) is necessary to prevent transmission. We evaluated the impact of sequential cleaning and disinfection interventions by culturing high-touch surfaces in CDI rooms after cleaning.
Design. Prospective intervention.
Setting. A Veterans Affairs hospital.
Interventions. During a 21-month period, 3 sequential tiered interventions were implemented: (1) fluorescent markers to provide monitoring and feedback on thoroughness of cleaning facility-wide, (2) addition of an automated ultraviolet radiation device for adjunctive disinfection of CDI rooms, and (3) enhanced standard disinfection of CDI rooms, including a dedicated daily disinfection team and implementation of a process requiring supervisory assessment and clearance of terminally cleaned CDI rooms. To determine the impact of the interventions, cultures were obtained from CDI rooms after cleaning and disinfection.
Results. The fluorescent marker intervention improved the thoroughness of cleaning of high-touch surfaces (from 47% to 81% marker removal; P < .0001). Relative to the baseline period, the prevalence of positive cultures from CDI rooms was reduced by 14% (P = .024), 48% (P < .001), and 89% (P = .006) with interventions 1, 2, and 3, respectively. During the baseline period, 67% of CDI rooms had positive cultures after disinfection, whereas during interventions periods 1, 2, and 3 the percentages of CDI rooms with positive cultures after disinfection were reduced to 57%, 35%, and 7%, respectively.
Conclusions. An intervention that included formation of a dedicated daily disinfection team and implementation of a standardized process for clearing CDI rooms achieved consistent CDI room disinfection. Culturing of CDI rooms provides a valuable tool to drive improvements in environmental disinfection.
Introduction
Contaminated environmental surfaces are an important source for transmission of healthcare-associated pathogens, including Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Unfortunately, environmental cleaning in healthcare facilities is often suboptimal. In recent years, 2 promising strategies have been used to improve cleaning and disinfection. First, routine monitoring of cleaning with feedback to environmental services personnel has been effective in achieving sustained improvements in standard cleaning practices. Methods of monitoring have included direct observation of cleaning, use of fluorescent markers to monitor the thoroughness of cleaning, and adenosine triphosphate (ATP) bioluminescence to evaluate for the presence of residual organic material after cleaning. Second, automated room disinfection devices have been developed as a means to reduce dependence on appropriate application of disinfectants by environmental services personnel. For example, automated ultraviolet (UV) radiation devices have been shown to reduce levels of pathogens, including C. difficile spores, in hospital rooms. Although these strategies are promising, limited data on their effectiveness in improving disinfection in real-world settings are available.
The Louis Stokes Cleveland Veterans Affairs (VA) Medical Center experienced a large outbreak of C. difficile infection (CDI) from 2002 through 2004 and subsequently has maintained a high endemic CDI incidence (~15 cases per 10,000 patient-days). In 2009, we demonstrated that environmental cultures collected from CDI rooms were often positive after completion of terminal room cleaning by environmental services personnel. In response, we initiated an intervention to improve cleaning and disinfection of CDI rooms. Here, we report the impact of sequential interventions on the frequency of C. difficile environmental contamination in CDI rooms after completion of cleaning and disinfection. The goal of the intervention was to achieve consistently negative cultures from high-touch surfaces after cleaning of CDI rooms (ie, zero or close to zero positive cultures).
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