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Wednesday, October 26, 2011

Some Rules Aren't Made for Breaking

I’ll admit there are times when I don’t follow “the rules” and I have been known to push boundaries. At the same time, however, there are situations when I always follow “the rules”, but the only two that come to mind are baking and playing with chemicals. Unlike cooking, where you can simply throw a number of ingredients together and simmer, stew or bake with periodic tasting to adjust for flavor profile preference, baking is almost mathematical in precision. Anyone who bakes knows if you leave out the egg, the baking soda, add too much liquid, over mix or over kneed you can quickly ruin whatever cookie, cake or pastry you were preparing. I happen to know from experience if you leave the egg out of the brownie recipe, no amount of dipping in hot tea or coffee is going to get that thing to soften up!

Like baking, playing with chemicals has very specific rules that need to be followed some are hard rules for safety sake such as do not mix oxidizers together, do not mix chlorine with acids, don’t mix chlorine with ammonia, don’t mix acids and bases together….the list can go on and on. The list of Do’s & Don’ts should also include don’t ignore the label instructions by over or under mixing the cleaners and disinfectants that we intend to use.

As Lee and I have attempted to describe in our blogs, the use of disinfectants takes more than just the consideration of what a product kills. A key consideration is appropriate dilution and with that consideration of a product’s shelf life once diluted. Disinfectant manufacturers provide dilution instructions for a very specific reason, and it is not just to please Health Canada or the US EPA. The dilution instructions provide the ratios and therefore the In Use Solution concentration that a product should be used at. This is the concentration that the product’s efficacy has been tested and approved by the appropriate regulatory body and this is also the concentration that the required toxicity data and subsequent MSDS information is based on. It is also the concentration that the shelf life, once diluted has been determined.

Over diluting of a product means you are using less chemical than necessary to achieve the label kill claim and this leaves you open to the chance that the pathogens you are concerned with are not going to be killed. Inversely under diluting means you are mixing the disinfectant too strongly, and contrary to what many of us believe more is not necessarily better. Additionally, as I hope everyone who uses a concentrate that requires dilution before use knows, once the product has been diluted into a closed container there is a shelf life that has been determined by specific test methodology that needs to be adhered to in order to ensure product efficacy.

This leads to the importance of using test strips to ensure that the disinfectant you are using has been mixed correctly. It is important to understand first and foremost that as chemicals are different in nature so too are the test strips you will use. A QUAT strip cannot be used to test a H2O2 or Chlorine-based disinfectant, so before starting to test, make sure you have the test strip that is designed to test the product on hand. Secondly, know the dilution you are using and what the expected parts per million or ppm of the active chemistry you are testing. Thirdly, know the shelf life. Test strips are NOT designed or intended to extend the shelf life of a product beyond that recommended by the manufacturer regardless of what the test strip reading is. Fourth, is your intention to use the test strips to verify the product has been diluted correctly, use them to verify that the solution is the bottle is still appropriate to use or a combination of both and then determine the frequency with which you intend to test.

For registration purposes, a manufacturer has to provide data to support the shelf life claims so the “hard work” so to speak has been completed for you and many facilities simply choose to spot check dilution systems to ensure for dilution accuracy (more about that next week from Lee). However, there are times, as specified by Best Practice Guidelines or Public Health Inspectors where products are to be tested daily (such as in an outbreak situation) or hourly (such as in a three-sink sanitation system in a restaurant). There is no hard and fast rule that must be followed, simply put, you want a method to validate for quality control purposes, you want a program that suits the needs of your facility and if required you want a program that meets the needs of your local public health inspector to avoid citations.

That leads me to the last point, if you are using a Ready-To-Use Liquid, the expiry date that needs to be followed is that listed on the bottle. There is no need to test the concentration. If you are using a wipe, again follow the expiry date listed on the bottle. You cannot test the product concentration of a wipe – and yes, I have been asked how to use a test strip to determine if a wipe is still at the appropriate concentration…..

Bugging Off!

Tuesday, October 18, 2011

Just DO it!!! Cleaning Saves Lives!

Consider the following scenario: a young woman is raced to the hospital in serious heart failure. Over the following two days it is clear she will need surgery to repair a badly infected heart valve. A surgical team works late into the evening and although it was touch and go for a while, they are satisfied that her new valve is working well. She is transferred to the intensive care unit on antibiotics and rapidly improves to the point that she can be moved to the surgery floor 4 days later. Unbeknownst to her, she was moved into a 4-bedded room that 2 weeks ago had been used to cohort patients with C. difficile. The room had been cleaned many times since then; however housekeeping resources had been cut back on that unit several weeks ago and the staff were also facing considerable pressure from the ED to turn around rooms quickly.

Three days after her move she developed abdominal pain. Initially this was thought to be a normal postoperative ileus, but when she developed diarrhea the next day, C. difficile was considered. By the time her positive test result came back, her blood pressure had dropped and she needed to be transferred back to the ICU. She got worse over the next two days despite more antibiotics and had to be taken back to the operating room to remove her colon. Sadly, her already weak heart could not tolerate the shock of a second surgery and she died during the operation.

Stories like this are all too commonplace in our healthcare system although it is rare that we can pinpoint when a patient acquired the organism that will later result in a healthcare associated infection. Healthcare workers will go to extraordinary lengths to save a life, including learning the latest procedures and lobbying for the best technology, yet underpinning this drive to provide the best possible care, is the assumption that all the “basics” have been taken care of. Experience has taught us however that many basics such as equipment sterilization and environmental cleaning are far from perfect. Environmental cleaning in particular has frankly suffered from a general lack of appreciation of the importance of this function. Indeed, the recent attention being paid to healthcare worker hand hygiene and antimicrobial stewardship may have led some to believe that improving these alone will dramatically improve patient safety, yet as the above story illustrates, they may be necessary, but they are not sufficient.

Essentially all significant healthcare associated bacteria, including methicillin resistant Staphylococcus aureus (MRSA), Clostridium difficile, Vancomycin resistant enterorcocci (VRE), and multidrug resistant gram negatives (MDRGN) all have the ability to live in the healthcare environment for days, if not weeks to months. Multiple studies have shown that colonized or infected patients readily shed organisms into their environment where they can then take up home on surrounding surfaces such as bedrails, call bells, curtains, bedside furniture, and multiuse equipment such as blood pressure cuffs and pulse oximeters. Once present, all it takes is a touch for the organism to move to the next patient. It should come as no surprise that having a roommate increases ones chance of acquiring a hospital “superbug” and that staying in a single room will considerably decrease this risk.

Healthcare settings are not hotels. Not only must the healthcare environment look clean, but pathogenic organisms also have to be removed before the next patient shows up. People worry about the cleanliness of bedspreads in hotels, but if they knew that they were about to be admitted to a bed that had previously held a patient with C. difficile, I am sure they would be far more concerned.

Several improvements are necessary to ensure that our buildings and the equipment therein are not making our patients sick. Housekeeping staff need to recognize how important their job is, and their central role in keeping patients safe. Further they need the clear support of administrators and clinicians to be empowered to do the best job they can: this means providing them with the resources to do what is necessary. Until relatively recently, there was a lack of clear guidelines to map out what cleaning needs to be done, including where, what and how often. Now that these exist however, it is relatively straightforward to determine what resources are required. We need to move from thinking of environmental cleaning as an easy to scale back program in times of fiscal restraint to realizing that it is a service essential to patient safety. Patients shed and become colonized with pathogenic organisms 24 hours a day, seven days a week yet we continue to view environmental cleaning as very much a nine to five service.

Quantity isn’t enough: patients also need quality. Environmental services staff must know what needs to be cleaned and how to clean it with appropriate attention to detail. Furthermore, the choice of cleaning/disinfecting agent is also crucially important. Clostridium difficile is likely the best example of an organism that will frequently continue to spread unabated unless attention is paid to cleaning and disinfecting surfaces with an agent that can kill bacterial spores. In my experience, it is the widespread use of sporicidal agents more than any other intervention that leads to the control of runaway C. difficile outbreaks.

If we go back to the story at the beginning, think of the effort and money that went into saving a life, only to have it end tragically. Simply put, good environmental cleaning saves lives.

Dr. Michael Gardam

Dr. Michael Gardam is the Medical Director, Infection Prevention and Control, University Health Network and Women's College Hospital and Medical Director, Tuberculosis Clinic Toronto Western Hospital. As an Infectious Diseases Consultant, Dr. Gardam has provided support at the provincial, national and international level and is known internally as a Positive Deviance guru. As an “early adopter” he is always at the forefront of change within the medical community and is never one to shy from controversial questions. Dr. Gardam has published over 60 scientific paper and book chapters where his research interests focus on mitigating the spread of infectious diseases in both the hospital and community setting.

Thursday, October 13, 2011

Surfaces and Wipes - the secrets of maintaining a monogamous relationship

Cleaning is often overlooked as a simple process that does not require much thought or support with respect to education, formal or informal. In many ways as the number of university or college graduates increases so does our belief that cleaning is a mundane task that takes virtually no education or expertise. This belief is fostered from a young age as we witness our parents, primarily our mothers, cleaning dishes, cleaning the house, the laundry and even us! Certainly as we mature, we are taught how to clean up after ourselves and for many your allowance may have been based on the unpleasant task of cleaning your bedroom before you were allowed to watch Saturday morning cartoons. How did we clean? We were given one cloth and whatever cleaning solution was to be used and told to go at it! Sorry mom, you were wrong…….so, so wrong…..

Cleaning and the knowledge surrounding cleaning techniques that need to be used in healthcare facilities is far more complex than we give credit. Like the cleaning of surgical instruments, cleaning of environmental surfaces requires meticulous attention to detail with a well defined and ordered set of procedures. One of the most important concepts that housekeeping and nursing staff need is the knowledge that bugs can be transmitted from surface to surface. Studies have in fact shown that bugs can be transferred from surface to surface with cleaning cloths.

A very integral part of training for Housekeeping and Nursing Staff in healthcare facilities is the importance of moving from clean to dirty with the understanding that surfaces furthest away from the patient should be the cleanest while the surfaces closest to the patient are the dirtiest – just think of all the blood, mucous, pus, vomit, diarrhea that a patient can excrete! This is where the monogamous surface-wipe relationship comes to play. While the areas furthest away are the cleanest…it in no way means they are free from bugs. The area to be cleaned should be viewed as a series of zones. As an example, if cleaning a private room, consider the entry way as zone 1 – door handle, light switch etc should be cleaned with one cloth then move to zone 2 which could be the window area, visitor seating, patient closet etc and clean with a new cloth. Before going to zone 3 the hand hygiene sink &/or nurses storage area, grab a new cloth. Cleaning needs to take place in almost a circular fashion around the perimeter of the room before you move into the “Dirty Zone” – the patient space which includes the bed, over bed table etc. If there is a bathroom or commode leave it until the end and NEVER clean the toilet first! The toilet or commode is the Holy Grail when it comes to the Dirty Zone!!!

Cleaning is a tedious and laborious task and one that has far too many opportunities for cheating and taking short cuts. A nurse or doctor may be breathing down the neck of the housekeeper to speed things up and ready the room for the next patient so the concept of moving from clean to dirty can be thrown out the window and with it, the importance of changing cloths between zones. We shudder at the images that CNN and other networks have shown with undercover videos of housekeeping staff at hotels wiping glasses down with the same cloth they have used to clean the toilet. In an environment where we know that bugs exists and the economic burden of HAIs do we really want to foster a culture where taking short cuts is acceptable when we have the science to prove we can cause harm by doing so? I think not.

Make “1 surface, 1 wipe” your facility mantra!

Bugging Off!

Friday, October 7, 2011

“Wax On...Wax Off. Spray On...Wipe Off.” Mr. Miyagi’s Guide to Cleaning and Disinfection.

I think we all remember the scene from Karate Kid where Mr. Miyagi teaches Daniel-san the basics of karate/kung-fu by using the principles of waxing a car or painting a fence. Wax On...Wax Off! However, when was the last time your cleaning staff were educated on the appropriate method for cleaning and disinfecting surfaces? I bet if you surveyed your hospital or long term care home’s cleaning staff, each individual would have their own preferred method. Spray On...Air Dry! Spray On...Wipe Off! Wipe On...Wipe Off! Most likely, some prefer to spray the disinfectant or cleaner on the surface while others prefer to wipe it on the surface. So what are the potential advantages or deficiencies in spraying vs. wiping a disinfectant on a surface?

While applying a disinfectant or cleaner via spritzing or spraying onto a surface may be convenient and something we’ve all witnessed on a television commercial advertising the latest consumer cleaning product, it may not be the best way to effectively clean and disinfect a surface. It is widely recognized that cleaning – the removal of organic and inorganic soils from a surface or device – is an integral part of the disinfection process. By removing surface contaminants we allow the disinfectant to more effectively address the microbial pathogens that may inhabit the surface. Unfortunately, surfaces or devices cannot be cleaned without mechanical friction which assists in the removal of soil and contaminants. Simply spraying a cleaner or disinfectant onto a surface does not assist in this removal, but rather deposits the solution on top of the soil. Likewise, spraying does not ensure thorough, even coverage of the solution on the surface. As a result, pockets of the applied surface may NOT come into contact with the disinfectant at all. Clearly, the end result is a surface that has been incompletely disinfected and may harbour pathogens that can be transmitted to the next person that comes into contact with it.

If we apply the disinfectant or cleaning solution with a wipe or saturated cloth, we are combining the much needed mechanical friction with the detergency attributes of the chemical to achieve optimal results. The process of wiping the surface with the cleaning or disinfectant solution not only assists in removing surface contaminants – allowing the disinfectant to address any pathogens left behind – but it also ensures that the surface has been more thoroughly covered with the solution. The end-result is a surface that one can confidently state has been appropriately disinfected.

Aside from direct product performance, spraying of a disinfectant or cleaning solution also has a couple of other negative side effects. First and foremost, the spraying of cleaning and disinfectant products has been linked to occupational asthma and other respiratory disorders. Spraying of the chemical atomizes the chemistry making it much easier to breathe deeply into the lungs. Regardless of the safety of the cleaner or disinfectant in use, this can cause irritation and potential long term effects. Several best practice guidelines including PIDAC’s Best Practices for Environmental Cleaning for the Prevention of Infections strongly recommend that cleaning and disinfectant products are NOT to be applied via spraying for these reasons. Lastly, it is very difficult to control precisely where the disinfectant or cleaning solution is being applied when sprayed onto a surface. Hence, neighbouring surfaces that should not come into contact with the solution may be exposed inadvertently and collateral damage may occur.

So in summary, the application of disinfectants or cleaning solutions via a wipe or cloth is likely to provide the best results while mitigating or eliminating some of the negative side effects of spraying disinfectant or cleaning chemicals.

How do your cleaning staff apply their products? Has anyone ever trained them on this most basic of practices?

Hasta la vista!

Lee – The Germinator