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Friday, April 25, 2014

RUST - the new cost of doing business?

The fodder of many of the Talk Clean To Me blogs are based on comments, questions, emails and conversations Lee and I have with the infection prevention and control community from around the world. The impetus of this is that the conversation we are having at that point in time is not likely an isolated occurrence but that others are asking or pondering over the same question. So when I saw a question posted on an infection prevention chat room about rust on furniture in the OR, it seemed a perfect topic for this week's blog.

So, what is rust?  Most of us would describe rust as a reddish or yellowish-brown flaky coating on a surface and generally associate it with corrosion of metal surfaces. Technically, it is iron oxide that has formed on iron or steel by oxidation, especially in the presence of moisture.  Similar to a cut or abrasion on our skin, once rust has formed there is no protection to the underlying iron. From a surface integrity, this loss of protection can lead to further deterioration, but most importantly, rust cannot be disinfected and provides the perfect habitat to harbour pathogens.

So why is rust becoming a concern to Infection Preventionists?  Well, as in our earlier blogs "Unintentional Consequences of Improving Infection Prevention" and "Is the EPA condoning the use of Steroids" in our efforts to strive for ZERO HAIs and annihilate all germs from the environment we are unwittingly causing an epidemic of degrading surfaces.

For some, targeting zero means using sporicidal agents such as bleach and peracetic acid every day, everywhere. While some facilities may attest that this movement has lead to a reduction in HAIs (C.diff in particular) and thereby a perceived savings in terms of HAIs, what costs have been incurred from a perspective of replacement of medical equipment, furniture and environmental surfaces? 

Choosing a disinfectant is a balancing act. Infection Preventionists must balance the need for an effective disinfectant to minimize HAIs with the safety of the product from an occupational health and safety, materials compatibility and environmental impact perspective.  Chlorine (bleach) solutions are by nature highly corrosive. They should not be used on surfaces that are prone to rust. Metal surfaces are prone to rust.  Metal surfaces are found in virtually every room in a hospital; bed frames, wheel chairs, stretchers, the arms of OR lights etc, etc...

As one IP stated (and correctly so) "rust on equipment cannot be disinfected".  But perhaps a more important consideration is what will Joint Commission or CMS think?  Well, as at least one facility found out, CMS does not care for rust. In fact if they find it, they will cite you for it and perhaps more importantly will require you (okay, your facility) to replace, clean or repurpose all equipment that has rust on it. 

As we know, infection prevention and control is multifactorial.   There is no single solution or silver bullet that will solve our HAI woes.  Hand hygiene, antibiotic stewardship and environmental hygiene all play a role in an effective and successful infection prevention program.  We talk about building a business case for infection prevention programs, and while for most we talk to the cost savings in terms of reduction of HAIs, we cannot ignore incremental costs.   Our business cases may include the justification for increased costs for improved environmental hygiene due to their associated impact on HAIs, however, we cannot forget to consider the incremental costs for replacement or refurbishing of medical devices, equipment, furniture or environmental surfaces.

The "KIS" or "Keep it Simple" principle of one product for everything, while seemingly simplistic, does have unintended consequences.  It works if you are only weighing the cost of HAIs, however, if you or your facility has a problem with rust or other visually deteriorating surfaces and are not willing to include replacement costs for surfaces, devices and equipment in your annual budget...really, who wants to talk about spending $25,000 on a hospital bed or $5000 - $12,000 on replacing rusty OR lights as part of the consequences of using a corrosive chemistry everywhere, every day. If you're not willing to have that chat as part of your business case, then you may want to consider a multifactorial approach to disinfection by choosing a broad-spectrum disinfectant that can kill the pathogens (bacteria & viruses) that cause the majority of our outbreaks for daily use and a sporicidal agent for targeted use against C.diff. 

Maybe you'll find the best of both worlds?  No rust, no deteriorating surfaces, decreased costs from occupational injury associated with disinfectants AND a significant reduction in HAIs. Now that would be a Win-Win!

Bugging Off!

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