Challenges to Disinfecting Hospital Rooms to Prevent C. difficile—Part 2

Clostridium difficile (C. diff) is one of the biggest causes of health care-acquired infectious diarrhea, which, in turn, can lead to lengthier hospital stays, increased financial burden, and higher morbidity and mortality rates among those infected. Therefore, the use of appropriate, thorough disinfection practices is critical in health care facilities. However, in the haste to turn over rooms quickly after patient discharge, effective disinfection can fall through the cracks, allowing C. diff spores to remain in the room for the next patient.

Maureen Spencer, RN, BSN, MEd, CiC, FAPIC, director of clinical implementation at Accelerate Diagnostics, sat down with Contagion^® for an exclusive interview at this year’s international C. diff Awareness Conference & Health Expo in Las Vegas, Nevada, to discuss surface contamination in hospitals. There are many challenges in the disinfection of hospital rooms and health care workers need to know how to prevent the spread of C. diff.

Contagion^®: Can you share some statistics regarding surface contamination?

Spencer: Years ago, Phil Carling, MD, did a study that included 23 acute care hospitals where he used a fluorescent gel that he had developed. He solicited the infection preventionists (IPs) in these hospitals to stamp high-touch surfaces in patient’s rooms, such as bed rails, bedside tables, commodes, [and] bathrooms. The IPs returned the next day and used a black light to see whether the fluorescent gel was still there, or if it had been removed by environmental services (EVS). What they found was that, overall, only approximately 49% of the surfaces in the hospitals were cleaned.

There are a couple of reasons for that. We don’t have enough EVS workers in hospitals; it’s not uncommon for that position to get downsized when hospitals are having financial issues. We also don’t have well-trained EVS workers. Many of the hospitals don’t even have training programs or manuals available on how to clean and disinfect unless they’re outsourced to a company that is a cleaning company. And so, we have rooms that are not being cleaned and disinfected; in fact, if you are admitted to a room where a prior occupant had any of the following multidrug-resistant organisms (MDROs)—methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter, Pseudomonas, C. diff—your risk of picking up the infection from just being in the room increase 2- to 4-fold. That’s our challenge.

For prevention interventions, we use a lot of innovative EVS equipment—some of it’s really cutting edge and new, while others, like ultraviolet robots, have been around for a while. Hospitals are looking at that technology to treat the room after C. diff patients are discharged.

There’s also technology that is purifying the air—that’s really new over the last 2 years—we never really had that before. This is especially important because we know that C. diff spores can be aerosolized. We have new light fixture technology that disinfects the air using filters and UV that purify the air 24/7. That’s a future goal for a lot of vendors, to create technology for self-disinfecting rooms to help in our battle against environmental issues and the fact that we don’t have enough workers to clean the rooms.

Contagion^®: Disinfection practices are important when it comes to preventing C. diff transmission in health care facilities. More often than not, health care workers are trying to turn over rooms quickly in order to get another patient in the room. As a result, disinfection practices can suffer. Can you speak to that a little bit?

Spencer: When a decision is made to discharge a patient, the physician must come in to write the order, see the patient, and then discharge them. Then the patient has to wait for family members to come and pick them up. That usually happens anywhere from late morning to afternoon. Typically what happens is that all the discharges are done on the evening shift, and they have very limited people on that shift; sometimes it’s just 1 person doing all of the discharges.

If the cubicle curtains have to be changed, they have to get a guy—most of them want to use a man—to climb up on a ladder and unhook all of the cubicle curtains, especially in precaution rooms. That’s another delay in that room, preventing a new patient from inhabiting the room. Also, sometimes the rooms can’t get cleaned on the night shift and they’re left all night long until the next day. Those are some of the challenges that we have with getting the rooms cleaned.

Health care workers do cut corners; I’ve done a lot of observational studies of room turnovers. A couple of things happen if they’re using sani cloths they don’t use enough of them, and they don't change them as often as they should. I saw one situation where a person took 1 cloth and used it to wipe the whole backside of the bed, the lights, and then went over to try to do the bed before I had to stop them and say, ‘No, you have to keep changing your cloths.’ You also have to have the appropriate contact time; If you’re using a cloth that requires 3 minutes of contact, the worker has to keep the surface covered with disinfectant for 3 minutes—which is a long time in health care.

On top of that, they have to clean all of the walls, the bathrooms, and the floor. Terminal cleaning of a discharge can be pretty intensive—a lot of work—and if you don’t have the staff to do it or the staff is in a rush, they’re going to cut corners. This is what Dr. Phil Carling showed in his study that I mentioned earlier, why approximately only 50% of rooms are getting disinfected.

Contagion^®: How can health care workers still adequately disinfect a room in a short period of time?

Spencer: In 2010, the Centers for Disease Control and Prevention published a guideline on environmental monitoring, and they have a page dedicated to cleaning the environment, which is based on their original 2008 environmental cleaning and hygiene standard that they came out with to direct health care facilities on appropriate cleaning.

The health institution should have an assessment program that uses some type of a monitoring system, like the DAZO [Fluorescent Marker Method] that Dr. Carling developed—which is available from a company—and perform DAZO sampling. That would be completed by the supervisors to monitor their staff. The other is adenosine triphosphate (ATP), where they can take a swab and put it into a meter, and it gives them the units of how many bacteria have been killed or are still alive; however, sometimes it’s difficult to interpret the results.

There’s also something as simple as Glo Germ that you can buy. It’s a powder or a lotion with fluorescent dye in it. Also, you can purchase on Amazon what are called glo pens, which are fluorescent pens, and they have a little black light that you can just, in a very inexpensive way, put your initials onto a high-touch surface, come back the next day, and see if they’re there.

That’s what should be put into the program, some sort of an assessment; a built-in assessment program, not done by the infection preventionists, but done by the EVS supervisors, since they’ll be supervising the staff who are not cleaning the rooms adequately.

Stay tuned for Part 3 of the Q & A, which will touch on how reducing antibiotics may be the key to preventing C. diff infections (CDIs). Read the first part of the interview on preventing and controlling CDIs in hospitals, here.