Hospital room decontamination: 5 questions with an infection prevention expert

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Hospital room and surface decontamination has become an increasingly important point of focus for infection preventionists, but that wasn't always the case.

A manuscript published in the Annals of Internal Medicinein 2015 noted a "longstanding debate over the relative role the environment plays in the transmission of healthcare-associated infections … both cultural shifts and new studies have elicited virtually polar opinions about the role of the environment in HAI transmission and the role of disinfection in reducing hospital infections."

Last year, the CDC called for a research agenda to focus on cleaning and disinfecting patients' rooms, since recent studies show that surfaces in the patient's room such as bedrails, bedside tables and call buttons play a role in the transmission of infection from one patient to another, but there is little agreement on best practices for reducing contamination.

Here, Ann Marie Pettis, RN, BSN, director of infection prevention at the University of Rochester (N.Y.) Medical Center, answers five questions about how healthcare facilities can approach the issue of room decontamination.

Note: This content is sponsored by Maquet. Responses have been edited for length and clarity.

Question: What challenges do healthcare facilities face when it comes to room decontamination?

Ann Marie Pettis: Room decontamination has become a very important focus in the effort to prevent health care associated infections. When I became an infection preventionist more than 30 years ago we taught people to not worry much about the environment. But because of a preponderance of scientific evidence we now know that indeed, the patient's environment does represent a risk in terms of HAI.

Traditionally room decontamination relies on the work of human beings. From a human factors engineering standpoint, we know that even when people struggle to achieve perfect results, they often are forced to take shortcuts — it's always well-intentioned, but they get rushed. Despite giving their best effort it is inevitable that areas that should be cleaned will get missed altogether or not receive thorough cleaning.

You can have excellent training of environmental services staff, but since they are often the lowest paid in the organization it is a challenge to find other methods of motivation.  This can also result in high turnover, creating a constant need for onboard training.  

No matter how good your environmental services staff are, there will be areas missed during cleaning, so we must add technology to fill in the gaps. Technology, however, often brings a whole other set of challenges to the equation.

Q: What steps can healthcare facilities take to improve room decontamination practices?

AMP: You've got to address the gaps you know exist. In all likelihood it's not going to be one thing but rather a variety of things required to improve the outcome.

You can't forget about traditional cleaning, however. In addition to staff training, competency checks should be considered. ATP or florescent gel can be used to quantify or qualify what kind of job was done. You might be able to increase motivation of EVS staff by tapping into their competitive spirit by coming up with a contest such as who has the lowest ATP scores for the month. Make it fun for them.

Even when you do these things you might also need to look at novel technology such as no-touch surface disinfection to address the gaps. Episodic ultraviolet surface disinfection is an example of an effective technology which is now being implemented in many health care facilities; however, it presents its own set of challenges. It's difficult to use it for daily cleaning, since the patient can't be in the room while the light is in use, so it is more frequently used for terminal cleaning.

When it comes to preventing HAIs, it's usually not one thing but rather many things that need to be considered. You sometimes "have to throw all the mud up against the wall" and take a bundled approach for interventions. There are usually specific challenges presented with each strategy, and each gap identified may require a specific approach. It requires a lot of footwork to address all of that.

Q: What promising new technologies are available to assist in this effort?

AMP: There is UV light disinfection for both episodic and continuous disinfection. The UV lights that work continuously have the advantage of being safe to operate while patients and staff are in the room and are often used in operating rooms.

There are also new surfaces being touted for HAI prevention such as copper or silver as well as textiles in the room treated with copper, silver or other chemicals.

There is even a paint you can use that reportedly aids in the fight against germs, increasing light reflectivity to aid UV robots to work more effectively.

There are always new chemicals coming out on the market for low and mid-level disinfection; which is another thing infection preventionists really need to pay attention to.

Q: What advice would you give to healthcare facilities when evaluating these technologies?

AMP: An infection preventionist has to create a business case by developing a cost-benefit analysis to present to the C-suite. The bottom line is that new strategies and technology often cost more money in the short run but the prevention of HAI can more than make up for the increased cost.

Infection preventionists should review the literature to evaluate the efficacy of new technology or chemicals. You must be aware of the impact on operations and how [the technology] might slow things down….especially if it is going to affect throughput of patients. One example is hydrogen peroxide fogging to eliminate difficult-to-kill organisms such as Clostridium difficile from patients' rooms. It's more effective than UV light but it takes considerably more time and air intakes and exhaust must be blocked off during use.

Some of the things that have to be considered when advocating for a new product or technology include material compatibility, storage of any machine, and what support you'll receive from the vendor and sales rep.

Then you must develop a good training program and a system to communicate the change to key stakeholders such as nursing, EVS, admitting, etc. You really have to do your due diligence. Talk to colleagues who have previous experience with whatever you're implementing. I often ask the vendor rep to provide me with contact information of other customers who had a successful experience with the product. Or you might ask for a free trial like I did when we considered initiating UV surface disinfection due to an increased incidence of C. diff.

Q: What other factors contribute to effective room decontamination?

AMP: When you're thinking about bringing in a new tool, try to create a buzz around the product or technology. Present it so all staff understand that if we do our job right — which we know we all want to do — we're going to be saving lives. Have a clear message about why we're all doing this.

Share HAI data on a routine basis to those on the front lines — EVS, nursing, admitting, all the people doing the hard work — to make sure they see when they're making a difference…or not. It's key to continue to motivate people.

Sometimes when you bring new technology in, it can feel like you're adding to staff's work, and you are, but present the benefits of the new tools as a way they can make a difference in people's lives. That resonates with all of us in healthcare — environmental services, doctor or nurse. That has to be an ongoing part of your education or training.

Because of employee turnover, training can't be one and done. Constantly interface with stakeholders. Creating relationships by having face-to-face interaction with all staff is incredibly important.

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