Are you seeing blue?

Painting ceilings have to be one of the worst jobs there is when it comes to painting.  I would much rather scooch around on my bum painting baseboard then craning my neck staring at a ceiling and hope I do not miss a spot.  There’s nothing worse than ending up with a sore neck, finding the spot you missed and having to go back to fix it.   In my opinion, one of the best inventions was the tinted ceiling paint that went on with a purplish or pinkish tint and dried white.  You could see where you applied and didn’t end up with irritating unpainted areas.

When it comes to cleaning and disinfection two key points of success include ensuring that the product is actually applied to the surface and achieving the contact time.  In recent years a number of studies have looked at ways to improve cleaning and disinfection as there is a direct correlation between the transmission of pathogens and the cleanliness of the environment.  Implementation of training programs that include validation or verification processes using ATP or UV reflective gel to ensure surfaces are being cleaned and disinfected have successfully shown an improvement in cleaning and disinfection.  Additional visual cues to help the environmental services team or nursing staff see where a disinfectant has or has not been applied could further improve outcomes and be a handy training tool for new staff.

In the June ICHE, a study was published looking at the effectiveness of a novel colorant additive to bleach wipes.  Similar to the concept of tinted ceiling plant, the blue dye is applied to the disinfectant wipe via a battery-driven device attached to the top of the wipes canister.  While the concept seems sound and would intuitively be thought to improve outcomes the findings of this study proved differently.  The addition of the dye did improve the cleaning of inner bathroom door knobs, however overall the non-dye impregnated wipes provided better overall results.  The researchers verified that the application of the dye was not impacting or neutralizing the efficacy of the disinfectant and looked to obtain feedback from the environmental services staff.  While they liked how the dye reduced the odor of the bleach product making it easier to work with and the fact that they liked being able to see what areas had been cleaned or not, there was a concern over the fact that residual dye was left on the surface after drying which made for additional work and effort in wiping to remove it.  The researchers then wondered if the discrepancy in the results was due to the fact that larger surfaces were not being wiped down due to concerns with staining.

While it could be easy to assume that the study was not a success, however, we need to remember that innovation takes time and needs tweaks and refinements along the way.  The overall feedback and ability to have a visual cue was positive.  Being able to see what has or has not been cleaned without a doubt can have a very real and direct impact on patient outcomes.  The best part is as this was a prototype, following the study, the company did make modifications to improve the precision in the addition of the dye.  It will be interesting to follow this innovation along and see if it can be improved to remove any concerns regarding staining with its use!

Bugging Off!

Nicole

Do You Really Want that Ultrasound Probe Used on You?

For many, we’re closing in on the 2^nd week of school.   My son has so far avoided catching his first cold of the school season but I’m sure one will hit soon enough - and of course, flu season is only a few short weeks away.  I just hope nothing too serious hits, so that we can avoid doctor’s visits or trips to the ER, especially after reading a recent article about cleaning mobile patient care equipment!

Like our personal devices, mobile patient equipment (MPE) like thermometers, blood pressure cuffs or bladder scanners can often be overlooked in terms of the frequency or thoroughness of cleaning.  While the practice can be relatively simple and effective in removing potential pathogens, it can be more difficult to effectively implement and monitor MPE cleaning and disinfection programs.  This is in part because MPEs tend to move from place to place, so unless you have a ‘tag and bag’-type process to clearly identify dirty from clean devices, it is harder to verify what ones have or have not been cleaned.  This then leads to the issue of potential transmission of pathogens when healthcare workers either fail to clean or use MPEs that have not been cleaned immediately after use on a patient.

A study published in ICHE by Reese et al discussed the implementation of cleaning and evaluation of MPE cleaning.  The study used ATP as their method for validating cleanliness.  ATP can have its challenges, and as the disinfectant or disinfectants used in the study were not disclosed, it is hard to determine if the results presented could have been skewed by quenching or enhancing of the ATP readings as a result from interactions by the disinfectant.    Regardless, the researchers started with a one-month baseline period to gain an understanding of the level of cleanliness of the MPEs.  Following the baseline period, there was a six-month implementation period with weekly ATP testing.  The results were shared with nurse educators and management, and subsequently shared with nursing staff with the provision of ongoing education.  They then entered a maintenance period for an additional six months where ATP results were collected bi-weekly.

Over all, the ATP results and therefore, the cleanliness of the MPEs did improve and was maintained with a 75% improvement in the levels of cleanliness.  The study also highlighted the areas where no significant improvement was seen.  The ultrasound probes tested in the ED consistently had higher than acceptable ATP readings, and this is consistent with similar studies looking at cleaning in the ED due to the large number of patients and high turnover of patients.

So what can we learn from this study?  It highlights that with focus on MPEs in most areas of a healthcare facility, sustained improvements in the level of cleanliness can be achieved which in turn should minimize the risk of transmission of infectious pathogens and improve overall patient outcomes.  It also highlights that the ED is an area of consistent issues in cleaning MPEs. Perhaps due to the nature of the ED with rapid patient turnover, high patient throughput and the fact that many patients can be critical and take more time, additional staff should be responsible for cleaning of MPEs (and perhaps even implementing a bag and tag program) to ensure that ED staff can immediately identify which MPEs are clean and safe to use and which MPEs are dirty and should not be touched.

If you happen to find yourself in an ED, feel free to do your own audit of cleaning.  Unless you’re in critical condition you’re likely going to have time to waste!  The only issue is that conducting your own audit may then make you wish you had just stayed home!

Bugging Off!

Nicole

Practicing Protection or Causing Contamination?

I think it would be safe to say that we have been told that Personal Protective Equipment (PPE) is intended to protect you from infections pathogens.   Gloves are the most commonly used PPE item.  We see healthcare providers (doctors, nurses, phlebotomists, dentists etc.) wearing gloves.  From a healthcare perspective the gloves work in two ways: they are intended to protect us as patients and of course protect the healthcare worker from picking up the bugs we carry.  If you travel, you likely see the TSA officers wearing gloves, and if you’re astute enough you may also see the fact that their hands are sweating in the gloves, meaning they’ve had them on for most of their shift.  In their case, they put them on with the belief they are protecting themselves from the germs we bring into the airport. In reality they really are just becoming a source for moving and most likely transmitting pathogens like colds and flus from all the surfaces they touch during the course of the time they are wearing gloves.  Then there are the food service workers who put on the disposable gloves on before they make our sub.  They change between customers, but do they wash their hands before putting on the next set?  Did they take them off to ring in your order and take your money?  Think on that.

A study published in the March 2019 Special Edition of The Journal of Hospital Infection looked at what role removing and disposing gloves has on contaminating the environment.  In the study, the researchers observed three disposal methods: an underhanded throw or overhand throw into or towards the garbage bin and my personal favorite: pulling on the gloves to stretch and launch into or towards the garbage bin. When surveyed, none of the participating healthcare workers indicated they disposed their gloves by “flinging” and most indicated they “placed” them into the garbage bin.  In practice, no one placed the gloves into the garbage bin.  Most “tossed” them and missed getting their second glove into the garbage bin 50% of the time.  The next favorite disposal method is the “fling” and that method led to a 40% success rate in getting the second glove into the bin.

When researchers sampled the area around the garbage bin, the vast majority of the sampled areas were contaminated by the gloves seeded with bacteriophage. In addition, the fluorescent dye used was found to extend outside of the sampled area and was widely found within a 0.61m circumference of the participant, as well as on their wrists, fingers and forearms.   As expected, the “flight path” of the glove did show contamination, with the highest contamination directly around the garbage bin.

It has been well established that mixed policies from facilities or government, policy ambiguity and lack of in-depth training leads to workplace non-compliance with PPE protocols. In this study it was assumed that all healthcare workers that participated were aware of the CDC doffing protocol and were not using a personally devised protocol.

The long and the short is during the doffing of gloves, the environment and the healthcare worker can be contaminated.  The question then becomes, if a healthcare worker (who undoubtedly at some point has had training on donning and doffing procedures for PPE and would certainly understand the potential impact on their health) can contaminate themselves and the environment so widely, what do you think is happening in industries outside of healthcare, where the training for donning and doffing likely does not take place?

It certainly makes me think of gloves in a different light and you can be sure I will be watching the doffing procedures for gloves.  If “flinging” is involved I just may choose the exit as quickly as I can, and will certainly try to avoid touching surfaces and wash my hands at the first chance I get!

Bugging Off!

Nicole

First Day, First Cold

For many, next Tuesday (September 3^rd) is the first day back to school.   For my son, the emails of who his teacher will be next year arrived and with it, a flurry of texts to all my mom friends to find out who else was going to be in his class.  He got lucky; several of his buddies are with him.  A few of his friends, however, did not get so lucky.  I expect there will be a lot of grumbling around the dinner table on Tuesday as we try to pry out how the first day of school went.

The first day of school signifies a number of things; the end of summer, back to school shopping, nerves over meeting your new teacher and entering a new grade where you know the work is going to get harder.  For parents it also signifies cold and flu days. 

According to the CDC, 40% of children aged 5 – 17 missed 3 or more school days last year because of illness or injury.  If you count up all the students, that means nearly 22 million school days are lost due to colds and 38 million school days are lost due to the flu each year.  Although 3 days may not seem like a lot to our children, I’m sure that for many of you, 3 days of staying home with a sick kid seems like an eternity and invariably we, as the caretakers, end up getting sick.  Thankfully, it’s not that hard to keep germs at bay.

Teach Cough and Snot etiquette because 10,000 is the number of bacteria in a sneeze:

• To avoid spreading germs, teach your child to cough into their elbow and not their hand.  This helps minimizing a germ-laden hand from touching all of the high touch surfaces.  
• Pack tissue in your child’s bag or send a box of tissue they can keep at their desk so that they can blow their nose and dispose of the contents, rather than wipe their nose with the back of their hand and increase the chance for their secretions to be left on another surface for someone to touch.

Teach hand hygiene, because cold and flu germs can survive on surfaces for 72 hours:

• Teach your children early the importance of washing their hands, especially before they eat and always after they have blown their nose or coughed into their hand.
• Help your child’s teacher keep the classroom healthy by donating alcohol-based hand sanitizer.

Help keep the classroom clean, because on average, your kid touches 300 surfaces in 30 minutes:

• This is not just the job of the teacher or custodian.  Send wet wipes with your child’s lunch and have them get into the practice of wiping down their desk top before they eat.  The more frequently the desk top is wiped the less chance germs have to stay on the surface and make your child sick.
•  Provide sanitizing wipes to your child’s teacher for their use in the classroom.  The more readily available they are, the easier it is to wipe down high touch surfaces that everyone in the class touches, which will help stop the spread of germs.

Vaccinate:

• Vaccination is one of the most effective ways to stop the spread of disease.  Before heading off to school, make sure your child’s vaccinations are up-to-date and that they get the annual flu shot.

You can be sure that on Tuesday, aside from taking the obligatory first day of school picture, I’ll be “reminding” my son to wash his hands and help keep the classroom clean! 

Bugging Off!

Nicole

Does Time Matter?

Has anyone ever told you “slow and steady wins the race”?  Even as a child I was an avid reader.  I had a large volume of Aesop’s Fables.  I quite literally read that book to death.  One of my favorites was The Hare and the Tortoise.

The Hare was once boasting of his speed before the other animals. "I have never yet been beaten," said he, "when I put forth my full speed. I challenge any one here to race with me."
The Tortoise said quietly, "I accept your challenge."
"That is a good joke," said the Hare; "I could dance round you all the way."
"Keep your boasting till you've beaten," answered the Tortoise. "Shall we race?"
So a course was fixed and a start was made.

The Hare darted almost out of sight at once, but soon stopped and, to show his contempt for the Tortoise, lay down to have a nap.

The Tortoise plodded on and plodded on, and when the Hare awoke from his nap, he saw the Tortoise just near the winning-post and could not run up in time to save the race.

Then said the Tortoise: "Plodding wins the race."

What does this do with cleaning and disinfection?  Well, as with many things, it takes time to do things right. There is enough published evidence to support the fact that when cleaning and disinfection is not completed correctly, or rushed, corners are cut which leads to adverse outcomes.  The question becomes: how much time does it take to clean and disinfect a patient room? 

The Association for the Healthcare Environment (AHE) recommends 20 – 45 minutes should be dedicated for terminal cleaning of a room.  A recent study by Chopin et al. investigated whether increased time spent on terminal cleaning would in fact lead to improved disinfection.  Surprisingly, it did not.  The study included 3 arms in which housekeepers were given 25mins, <45mins or >45mins to clean a room. They found that time spent beyond 25mins did not affect disinfection of the high-touch surfaces tested in the study.  In fact, the longer the time spent cleaning, the higher the post-cleaning bioburden was found to be.  The results could be due to random chance or may be a result of different cleaning activities, such as cleaning more surfaces without focusing on properly applying the disinfectant used.

As the researchers indicated, their study did not include observing environmental services (EVS) staff cleaning, so achieving contact time and product application was not recorded.  Again, in recent years a fair number of studies have been published investigating the role that contact time has in ensuring disinfection is achieved.  In general, the longer the contact time the harder it is to achieve the level of kill desired in healthcare facilities.  Similarly, there are different disinfectant chemistries that while contact times may be short their active ingredients dry so quickly that they cannot achieve the contact time as approved by the Health Canada or the EPA.

Does this mean we can skimp on the time we give our staff to clean?  No.  What it continues to highlight is that we need to find that balance between time (both contact time and the time given to clean rooms) and the process used by EVS to clean and disinfect.

Bugging Off!

Nicole

Pigs’ Ears – a Tasty Treat and Health Hazard

If you’re a pet lover you may be among those who like to spoil their pets.  My cats get the occasional treat, but being cats they’re finicky and the organic, meat-only healthy treats that cost an arm and a leg don’t pass muster.  They prefer the easy-to-find on sale Temptations Cat Treats.  I have also spent a fair chunk of change on fluffy, plush cat beds.  It was a waste of money.

Dog lovers have a never-ending supply of treats they can pick up for their beloved canine friends, from rawhide and animal bones to pigs’ ears and raw food.  If you think you dog may like it, you can probably find it.  Unfortunately, pet treats and raw food does have some pitfalls and can adversely impact not just your pet’s health, but yours as well.   Case in point, pig ears sold as dog treats in 33 states are being recalled due to an outbreak of Salmonella. At least 127 people have now been stricken with the bacteria, with 26 of them hospitalized.   Thankfully no one has died.

Salmonella can affect animals eating contaminated products as well as the humans who handle the sickened animals or the infected product. Affected pets may become lethargic and have diarrhea, fever and vomiting.  Dog owners who have come in contact with the pig ear treats should see if a doctor if they experience high fever (temperature over 102˚F), blood in stool, diarrhea, or frequent vomiting that prevents keeping liquid down, and are concerned about the symptoms. People infected with Salmonella are usually ill for 4-7 days and recover without treatment.

Some key recommendations from the CDC include:

1.  Do not feed any pig ear treats to your dog. Throw them away in a secure container so that your pets and other animals can’t eat them.

·     Even if some of the pig ears were fed to your dog and no one got sick, do not continue to feed them to your dog.

·     Wash containers, shelves, and areas that held any pig ear dog treats with hot, soapy water. Be sure to wash your hands after handling any of these items.

2.  Shop safely

·      Always wash your hands thoroughly with soap and water after touching unpackaged dog food or treats, including products in bulk bins or on store shelves.

3. Take extra care around young children

·     Children younger than 5 should not touch or eat dog food or treats.

·     Young children are at risk for illness because their immune systems are still developing and because they are more likely than others to put their fingers or other items into their mouths.

Thankfully, as a vegetative bacteria, Salmonella spp. are among the easier-to-kill pathogens.  Until recently, Salmonella was one of the 3 main bacteria that had to be tested in order to receive a Hospital-Level disinfectant designation by the EPA.  While it is no longer required to be tested, virtually every consumer and professional product carries the claim due to its importance and association with foodborne illnesses.

If you have any pig ears at home, please take care and make sure your home is Salmonella-free!

Bugging Off!

Nicole

Cleaning, a Good Investment that Saves Lives

Do you ever feel like you’re bashing your head against a wall or like a salmon swimming upstream? Having been in the infection control arena, focusing on cleaning and disinfection, I often wonder why we have to repeat the same things over and over. Why do we keep having to prove the things we know to be true and know that work over and over and over again?

A recent article published in ICHE titled “Sustained improvement in hospital cleaning associated with a novel education and culture change program for environmental service workers” concluded that the program the researchers introduced was able to address environmental service worker’s knowledge gaps, challenges and barriers resulting in behaviour change and sustained improvements in cleaning. I don’t mean to sound callous or disrespectful of the researchers, but this is not rocket science.

In June 2011, in my “To Clean or Not to Clean”, I referenced a collection of articles published by APIC, where the take home message was cleaning is important. Cleaning needs to be done right the first time, and that cleaning saves lives. Looking back through history, Florence Nightingale, during the Crimean War (1853 – 1856), identified the link between overcrowding, hygiene and poor patient outcome and by instituting a cleaning program and increasing the space between patients, saw a marked decrease in infection transmission. 

In June 2012, a guest blogger, Rick Wray’s blog “Complexities of cleaning a paediatric hospital environment” talked to the fact that achieving optimal cleaning requires an understanding of the complex interplay of chemistry, human factors and behavioural science involved in cleaning processes. He further discussed a program they had at their facility where assorted hospital staff were partnered with a member of our cleaning staff to learn from and to work with them to clean patient rooms. One senior leader became aware of the pride and diligence of the staff member with whom he was partnered. She was reluctant to let him do the cleaning; not because it was a job beneath his usual position but because he wouldn't do it well enough and she would have to clean up behind him.  

In December 2014, in my blog “Hey! Hey! Ho! Ho! Apathy has to go!” when it comes to cleaning and disinfection there are just as many people who believe they cannot affect change so they do nothing, and just as many people again that plainly think cleaning and disinfection is someone else's responsibility.  However, based on another review of published literature by Donskey to determine if we had sufficient evidence to prove that improved cleaning and disinfection could reduce HAIs, the conclusion was that, "Although the quality of much of the evidence remains suboptimal, a number of high-quality investigations now support environmental disinfection as a control strategy. Based on these data, current guidelines for pathogens such as C. difficile, MRSA, VRE, and norovirus emphasize the importance of environmental disinfection as a control measure." 

These are but a few examples of the work the infection prevention community has completed to link the importance of cleaning and disinfection to the reduction in HAIs. The work has investigated best practices to ensure the cleaning processes used will meet the needs of our healthcare facilities and there are several studies that highlight the importance of providing training to our EVS staff and elevate them to a higher level to support the fact that they are a crucial part of our infection prevention program.

In reviewing this study, we have proven yet again that cleaning when completed effectively by skilled and trained staff, can directly impact the lives of patients.  If we know it, and if we have proven it time and time again, why can’t we get the C-suite or the wallet holders to understand the importance of cleaning and disinfection and the importance of having a skilled environmental services team? How do we get them to understand that this investment will save money and more importantly save lives?

Bugging Off!

Nicole