The power of light: How hospitals can harness UV energy to reduce HAIs

As hospitals and health systems work to reduce healthcare-associated infections, a number of harmful pathogens, such as Clostridium difficile, may evade traditional disinfectants and manual cleaning processes. To eliminate these pathogens from high-touch surfaces, hospitals can incorporate UV disinfection technology. Today's technology uses a subtype of ultraviolet light called UV-C. Adding treatment with UV-C into cleaning routines can help to effectively kill bacteria and pathogens and reduce HAI rates.

This article is sponsored by Diversey.

Incomplete disinfection drives HAIs
For many hospitals, current cleaning interventions may not completely address the risk of HAIs. A study published in American Journal of Infection Control found patients admitted to rooms that previously held a patient infected with a multidrug-resistant organism were significantly more likely to contract that infection. "This risk could be 1.5 to 3.5-times higher, which supports the fact that the environmentcan play a role in the spread of infection, and for a variety of reasons, healthcare facilities may not be cleaned and disinfected as well as they could be," says Jim Gauthier, senior clinical advisor of infection prevention at Diversey, a Charlotte, N.C.-based cleaning and hygiene product provider.

Incomplete or insufficient cleaning of surfaces most commonly in contact with patients can contribute to infection rates. In fact, it is estimated that 20-40% of HAIs result from transmission of pathogens by a healthcare worker after touching another patient or a contaminated surface, Gauthier says.

HAIs not only threaten the safety of patients and staff, but can also be a significant expense for hospitals due to longer patient stays, more treatment costs and less reimbursement for procedures. In the U.S. alone, HAIs range between $28 billion and $45 billion in annual direct hospital costs, according to a study published in Expert Review of Pharmacoeconomics & Outcomes Research.

Reducing HAIs is especially important in an era of value-based medicine. In 2008, CMS began denying hospitals payment for the treatment of some conditions that occurred during a patient's hospital stay and were not present on admission. Three of the 10 hospital-acquired conditions selected for this policy involve HAIs, according to a study published in Medical Care.

"An increasingly important driver of finance in healthcare, especially in the U.S., is how we perform," Gauthier says. "Performance measures, such as Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile infection (CDI) acquisitions, factor into the reimbursements that are paid to healthcare facilities."

Diversey, which provides cleaning technologies in areas from healthcare to hospitality, offers a framework for hospitals to fight off HAIs through UV-C disinfection programs. The company's portable UV-C machines disinfect hospital rooms, hard surfaces, and noncritical equipment and devices.

When deciding to incorporate this technology into cleaning routines, hospital executives can examine numerous published studies providing understanding of what makes a UV-C disinfection program an effective business move, how UV-C disinfection technology works, what questions to ask when considering UV-C and how to effectively operate UV-C devices.

UV-C disinfection programs eliminate bacteria that manual processes may miss
Infection prevention experts agree: Thorough cleaning and disinfection of environmental surfaces are essential elements of effective infection prevention programs. However, traditional manual cleaning and disinfection practices in hospitals are often suboptimal. Inconsistent manual cleaning processes, time pressure and lack of an auditing process can affect the efficacy of manual disinfection.

To be sure, no-touch disinfection technologies should not replace manual cleaning and disinfection processes. However, adjunct technologies, such as UV-C disinfection machines, can become a critical part of how healthcare settings control HAIs, Gauthier says.

Here are five reasons healthcare settings are adding UV-C disinfection machines to their infection control efforts.

1. Manual cleaning is inconsistent. Hospitals need the right products and reliable disinfection procedures. Manual disinfection can certainly be effective, but the problem is this: no two rooms will ever be cleaned to exactly the same specifications, regardless of how explicit or detailed the standard procedure may be. Human error will always be part of manual disinfection.

"You can never over-emphasize, the importance of evaluating current Cleaning and disinfection protocol and continuous improvement, yet it may not be enough," Gauthier says. By utilizing UV disinfection, the inevitable differences in the disinfection process from room to room become less pronounced, further protecting patients and facilities from healthcare-acquired infections. Healthcare settings can benefit from the additional assurance afforded by the application of UV-C disinfection devices.

2. Manual disinfection isn't 100 percent efficacious. Numerous studies show standard manual cleaning or disinfection of surfaces can reduce, but often does not eliminate, important pathogens such as C. diffcile and MRSA. Of 1,917 patient rooms cleaned using standard processes and detergent, nearly 25 percent still contained strains of MRSA, according to a 2014 study in BMJ Journals. This finding suggests hospitals cannot rely on manual cleaning alone to fully eradicate pathogens and deter HAIs.

3. Antibiotic resistant organisms can survive on surfaces for weeks to months. "Even viruses, such as noroviruses, can survive on surfaces outside the body for seven to 14 days without much difficulty," Gauthier says. Research into UV-C's ability to eliminate antibiotic-resistant organisms is promising. There are numerous studies supporting the efficacy of UV-C in reducing the viability of a broad range of problematic pathogens, particularly antibiotic resistant strains. For example, a 2017 study published in the Journal of Applied Microbiology subjected antibiotic resistant strains of Escherichia coli (E. coli) to UV energy, and found UV disinfection processes dramatically reduced the survival of antibiotic-resistance genes of E. coli. Hospitals can use UV energy as a disinfecting technology in addition to manual cleaning and disinfection to help eliminate the particularly robust organisms that cleaning wipes and disinfectants may not reach.

4. UV-C helps cover surfaces wipes and chemicals may miss. UV-C machines work to fill the gaps that wipes and chemicals miss when cleaning a patient room, which can help hospitals achieve the best possible cleaning practices. UV-C machines, which serve as a 'no touch' method of room decontamination, can reduce key pathogens on surfaces in patient rooms, according to a study published in Current Opinion in Infectious Diseases. The study authors recommend using a 'no touch' system for terminal room disinfection after discharging patients to reach areas of patient rooms that are not easily accessible for cleaning via wipes and chemicals, such as keyboards, monitors and workstations on wheels. State of the art UV-C technologies offer portability and compact footprints facilitating terminal cleaning and daily use, helping to minimize the buildup of pathogens over time.

5. UV-C can help meet patient expectations for cleanliness. When asked what impressed them most about the healthcare industry, the greatest number of respondents chose a visible commitment to infection prevention, according to a survey of 1,000 patients conducted by the Health Industry Distributors Association.

"Cleaning and disinfection is something that is very important to patients," Gauthier says. "Utilizing a UV system is a very visible way of showing patients and families that the hospital is committed to reducing infections as best they can."

How UV-C technology works
Before hospitals add UV-C technology to their cleaning routines, there are several components to understand about how UV-C machines work.

To combat HAIs, healthcare staff can implement what Rick Dayton, Chief Architect of Diversey, calls the "1-2 Punch."

"The 1-2 Punch is the combination of the right chemical and manual cleaning solutions and the addition of a robust UV-C technology that can really help to fight HAIs. And, of course, the 1-2 Punch is best delivered by a well-trained EVS staff," Dayton says.

UV-C technology works by UV-C energy penetrating through the cell walls of bacteria, viruses and bacterial spores and into the DNA strand to ultimately disrupt the cell's ability to replicate. After exposure to UV-C energy, the pathogen is unable to replicate itself. "It's an environmentally friendly, effective and non-chemical approach to preventing infection," Dayton says.

To properly apply the UV-C portion of the "1-2 Punch", hospital staff must understand the two primary factors that make or break the application of UV energy: the angle at which UV is applied and the distance between the object being disinfected and the UV source.

To properly address these key criteria, Diversey's MoonBeam™3 UV-C disinfection device has three individual UV lamps on adjustable arms. These arms can be positioned at nearly any angle to target UV-C light, and users can position the heads of the device to optimize UV-C dosing. Finding a system that is fast and simple to operate helps enable consistent usage of the system, and the Diversey technology provides fast cycle times, typically three to ten minutes, and a simple operating system that can be used by almost any staff member.

Dayton frequently demonstrates the physics supporting why it is important to apply UV energy at the correct angle. "With UV energy, when you're applying light directly onto the surface, that's when you maximize the amount of energy applied to that surface, enabling faster kill of pathogens."

One way to set up UV-C devices in a patient room is to have two devices — one on either side of the patient's bed. If UV-C is being used in the OR, the device can be placed at the foot of the operating table. "You want to have the ability to directly impact the surfaces with direct light for the fastest cycle and greatest efficacy," Dayton says.

It is also critical to get the energy as close to the surface as possible, Dayton says. "The bulb output may be constant, but the farther away you get, the lower the applied energy. The energy actually decreases by the square of the distance from the bulb. It is not a linear relationship for electromagnetic energy."

10 questions hospital executives should consider when choosing UV-C technology
Given that no two healthcare settings operate in exactly the same way, from number of employees and patients to discharge times and room organization, hospitals can assess the different aspects of UV-C technology to ensure it is a good fit for their facility.

Here are 10 questions to consider when choosing UV-C technology.

1. Will the turnover time associated with using UV-C fit the facility's peak needs so patients do not have to wait a long time for rooms to be cleaned?
2. How many patients are discharged each day at the facility?
3. Where will UV-C machines be used? For example, will they be used in the operating room or areas that are constantly occupied, such as the intensive care unit?
4. How many machines should our facility purchase?
5. Where are the machines most needed in the hospital?
6. What does the cycle of completion, maintenance and audit look like for the machines?
7. Does the organization need to increase staffing to operate UV-C technology?
8. What types of education and training does staff need?
9. When is the best time to optimize UV-C disinfection? For example, should it be used after discharges during the day or in procedure rooms and operating rooms at night?
10. How will the machines affect workflow in the system?

8 tips for effectively operating UV-C devices
After understanding how UV-C devices fight HAIs and considering how this technology can fit in to a given healthcare setting, hospital staff may need to address several challenges when operating the devices.

Here are eight tips for effectively getting the most from your UV-C devices.

1. When considering the importance of having a short distance between the UV source and the object as well as the correct angle, EVS staff should be well aware of the areas of greatest importance — the high frequency of touch surfaces (as defined by the CDC). This allows the greatest intensity of UV exposure to be applied in the shortest amount of time, Dayton says.

2. Ensure the availability of technology as close to the point of need as possible. Significant time can be wasted porting the devices from one end of the hospital to the other. The reality is that if a UV device is not used because of logistic challenges, the benefit won't be realized.

3. To ensure cleaning schedules are consistent, create a spreadsheet listing who cleans what — e.g., who is responsible for cleaning the different pieces of equipment. This is often not established clearly.

4. To know what works for a given setting, hospitals can work with the UV-C machine manufacturer to evaluate the hospital's traditional workflow practice. In this way, hospitals can better identify how different types of rooms can incorporate UV disinfection.

5. Most manufacturers of UV devices have tested disinfecting results. Hospital staff can read these manufacturers' white papers to compare quality and determine the efficacy of each machine's ability to reduce pathogens. There is currently no standardized testing methodology for UV technology, so white papers need to be scrutinized for where the test organisms were placed in relation to the bulbs of the machine being used. Distance from surfaces and angle of incidence are two of the most important factors influencing UV-C efficacy.

6. To measure how the device is reducing the formation of bacterial colonies, hospital staff can complete a swab and culture test before and after EVS staff manually disinfect a room, and then complete the same test after applying UV. Staff can analyze changes between these results.

7. UV is a surface-only technology and is not an effective solution for soft surfaces, such as curtains. These surfaces still require a separate disinfection process.

8. Hospital staff should monitor the life cycle of their UV light bulbs. The machine may or may not provide a warning when the bulb has been utilized for a long time and is approaching the end of the effective life of the bulb. Some systems operate even with burned out bulbs providing an ineffective disinfection cycle.

Conclusion
In the battle against HAIs, UV-C technology can help hospitals increase the strength of their cleaning system, promote safety and satisfaction for patients and curb the financial burden of lengthy patient stays.

"No one is perfect. We can train our staff to go in and do the best possible manual clean, but there are a lot of areas that may be missed, and bacteria that could be left behind," Gauthier says. "There are a lot of surfaces within a healthcare setting where an adjunct technology can help dot that last 'i' in 'disinfection' in terms of taking care of organisms that could make patients sick."

For more information on Diversey's MoonBeam™3 UVC disinfection device, visit www.sdfhc.com.

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