measuring clean may 2012 webinar handouts - … · measuring clean: audit tools and practices. ......

5/4/2012

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Welcome

Today’s program is sponsored by

Measuring Clean: Audit Tools and

Practices

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Today’s Speaker

Philip C. Carling, M.D.Boston University School of Medicine

Consultant – Ecolab, Steris Pending Patent License - Ecolab

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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A 2012 Perspective

1990 – 2009

Shinier Floors


Next Decade


Enhancements)




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



Enhancements)




A 2012 Perspective

1990 – 2009

Shinier Floors


Next Decade



Enhancements)




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A 2012 Perspective

1990 – 2009

Shinier Floors


Next Decade



Enhancements)




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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Thoroughness of Environmental Cleaning

0

20

40

60

80

100

HEHSG HOSP

IOWA HOSP

OTHER HOSP

OPERATING ROOMS

NICUEMS VEHICLES

ICU DAILYAMB CHEMO

MD CLINIC

LONG TERM

DIALYSIS

%

DAILY CLEANING

TERMINAL CLEANING

Cle

aned

Mean = 32%

>110,000 Objects

Cleaned, emptyroom

identified

Room marked Room evaluated

Terminal cleaning after 1 or 2 patient cycles

Phase I: Covert Baseline Environmental Cleaning Evaluation

Phase II: A. Programmatic AnalysisB. Educational Interventions – ES staff

Cleaned, emptyroom

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

40

50

60

70

80

Hospitals Environmental Hygiene Study Group36 Hospital Results

% o

f Obj

ects

Cle

aned

PRE INTERVENTION POST INTERVENTION

P = <.0001Resource Neutral

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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 BB CC DD

80%

64%

References 1-4

Defining the Difference Between Cleaning and Cleanliness

Cleanliness Cleaning

Definition A measure of bacteriaon 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 1,3

Impacted by Bioburden, thoroughness of recent cleaning, effectiveness of disinfectant, recent contamination or lack of

Thoroughness of evaluated cleaning practice

CDC endorsed to improve patient safety

No Yes 5

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CDC RecommendationsAcute 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

Reference 5.

We have all agreed for almost 200 years that a clean hospital is important to patient safety

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We know that these ORs are dirty…that’s easy

How have we traditionally evaluated how safe this OR is for the next patient?

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Environment of Care Rounds

Patient Safety

HCW Safety

Fire Safety

Equipment Safety

Identifying unsafe practices

Environmental Cleanliness

Conventional Monitoring of Healthcare Environmental Cleaning

“Infection Prevention

Environmental Rounds”

• Subjective visual assessment

“If something looks dirty, it means housekeeping has failed”

• Deficiency oriented

• Episodic evaluation

• Problem detection feedback

• Open definition of correctable intervention

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Approaches to Programmatic Environmental Cleaning Monitoring

Conventional Program

• Subjective visual assessment

• Deficiency oriented

• Episodic evaluation

• Problem detection feedback

• Open definition of correctable interventions

Enhanced Program

• Objective quantitative assessment

• Performance oriented

• Ongoing cyclic monitoring

• Objective performance feed back

• Goal oriented structured Process Improvement model

Reference 6.


Conventional Program Advantages

An established model

Enhanced Program Advantages

Direct evaluation of practiceUses a standardized, consistent, objective

and uniform system of monitoringProvides regular and ongoing performance

results to ES staffFacilitates the monitoring of many data

points to optimize performance analysisProvides positive practice based feedback

to ES staffAllows for objective remedial interventionsEasily adaptable to existing PI modalitiesFacilitates compliance with CMS and

JCAHO standardsExternal benchmarking, reporting and

recognition feasible

Reference 6.

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Conventional Program Limitations

Limited generalizability of findingsPoor specificity and low sensitivityIntrinsically subjective with a high

potential for observer bias

Only evaluates daily HP

Limited ability to support JCAHO standard EC.04.01.03.EP2

Limited ability to demonstrate compliance with CMS CoP 482.42

Benchmarking not feasible

Enhanced Program Limitations

Requires a new program implementation

Ongoing administrative support critical to success

Potential resistance to objective monitoring and reporting

While useful, the covert baseline evaluation may be difficult to implement effectively

Monitoring tool differences

Reference 6.


Conventional Program Limitations

Inability to evaluate actual practice

Based only on negative outcome analysis

Limited generalizability of findings

Poor specificity and low sensitivity

Subjectivity with a high potential for observer bias

Poor programmatic specificity

Potential for observer bias

Only evaluates daily HP

Unable to support JCAHO standard EC.04.01.03.EP2

Limited ability to demonstrate compliance with CMS CoP 482.42

Benchmarking not feasible

Enhanced Program Limitations

Requires a new program implementation

Ongoing administrative support critical to success

Potential resistance to objective monitoring and reporting

While useful, the covert baseline evaluation may be difficult to implement effectively

Potential monitoring tool issues

Carling PC, Bartley JM. AJIC 2010

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Objective Approaches to Monitoring Environmental Hygiene

Understanding the Tools

Evaluating Patient Zone Environmental Cleaning

Method

Covert Practice

Observation

Swab cultures

Agar slide cultures

Fluorescent gel

ATP system

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Method Ease of Use

Identifies Pathogens

Useful for Individual Teaching

Directly Evaluates Cleaning

Published Use in

Programmatic Improvement

Covert Practice

Observation

Swab cultures

Agar slide cultures

Fluorescent gel

ATP system


Method Ease of Use




Published Use in


Covert Practice Low No Yes Yes 1 Hospital

Observation

Swab cultures

Agar slide cultures

Fluorescent gel

ATP system

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Method Ease of Use




Published Use in



Observation

Swab cultures High Yes Not Studied No 1 Hospital

Agar slide cultures

Fluorescent gel

ATP system


Method Ease of Use




Published Use in



Observation


Agar slide cultures

Fluorescent gel

ATP system

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Method Ease of Use




Published Use in



Observation


Agar slide cultures Good Limited Not Studied No 1 Hospital

Fluorescent gel

ATP system


Method Ease of Use




Published Use in



Observation



Fluorescent gel

ATP system

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Method Ease of Use




Published Use in



Observation



Fluorescent gel High No Yes Yes 49 Hospitals

ATP system

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

Limitations of ATP evaluation of cleanliness in healthcare settings

Three studies of ATP sensitivity and specificity clarify the limits of the ATP “Cleanliness Standard” as it was proposed several years ago

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Reference 7.

2007

Study # 1.

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%

Study # 2. Correlation between RLU & Microbial Contamination. Mulvey D, et al. J Hosp Infect 2011

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Study # 2. 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

Dr. John Boyce’s Conclusion

ICHE December 2011

Study # 3.

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The major reason using ATP to spot check cleanliness has

not worked…..

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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Use of Cultures to Evaluate Cleaning Performance

AdvantagesCan be pathogen specificTouch slide procedure can easily confirm heavy

contamination or sterility

DisadvantagesPathogen Specific:

Very costlySeveral research methodologies used

Touch Slides:“Hygienic Standards” suggested but not validatedLogistical issues – Timing of monitoring

– Labor intensive– Does light growth mean low contamination or

relatively good cleaning?

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

But then you will need to deal with the other implication

of…..

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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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New TJC ES Leadership Requirement

February 2009

New TJC ES Leadership Requirement

February 2009

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The Environmental Hygiene Imperative

EVS Leadership and IPs,

Optimize current practice

The Environmental Hygiene Imperative

EVS Leadership and IPs,

Optimize current practice

Innovation – Demand evidence based support

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ES Management Bottom Line

Optimized Measurement

=

Optimized Management

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.

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References

1. Hayden MK, etal. Clin Infect Disease2006;42:11,1552-60.

2. Hota B, etal. J Hosp Infect. 2009 Feb;71(2):123-31.

3. Datta R, etal Arch Intern Med. 2011 Mar 28;171(6):491-4.

4. Munoz-Price etal. Inf Control Hosp Epid. 2012 (in-press)

5. Options for Evaluating Environmental Cleaning October 2010. Found at :

6. Carling P, Bartlet J. Am J Infect Control. 2010 Jun;38(5 Suppl 1):S41-50

7. National Health Service. Link 195.92.246.148/knowledge_network/documents/Bioluminescence_20070620104921.pdf

8. Mulvey D, et al. J Hosp Infect 2011

9. Boyce J, etal. Infect Control Hosp Epidemiol. 2011. 32: 1187-93

10. Options for Evaluating Environmental Cleaning,October 2010http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html

Thanks for inviting me !!

Questions – Comments? [email protected]

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