Hospital Mattresses: A Vector for Spreading Clostridium difficile

Clostridium difficile (C. diff) is known to cause around 250,000 infections per year, as well as a staggering 14,000 deaths. In response to this growing problem, health care workers everywhere have been channeling their efforts into preventing the life-threatening infection in their facilities. One way to do this is by strengthening disinfection efforts, but, as one researcher boldly pointed out at the 5th Annual International C. diff Awareness Conference & Health Expo, one of the biggest vectors for spreading C. diff is largely unrecognized: hospital mattresses.

“You’re at risk for getting C. diff infections if you’re getting antibiotics, on proton pump inhibitors, if people aren’t washing their hands—those kinds of things have been well-recognized. But the big risk to inpatients is the mattress,” Edmond A. Hooker, MD, DrPH, professor in the Department of Health Administration at Xavier University, told Contagion^® in an exclusive interview. “Patients are exposed to the mattress; they’re lying on it for hours on end, and these mattresses cannot be cleaned. With the current cleaning methods being used today, they are not being cleaned adequately enough, and we need to change.”

Even after terminal cleaning, the mattresses are not clean, Dr. Hooker stressed in his presentation, and he listed at least 30 peer-reviewed studies that supported his statement. This research begs the question of why the mattresses are not being disinfected properly. According to Dr. Hooker, one of the answers is time. Many hospitals ask Environmental Services (EVS) workers to turn a room over in just 20 minutes, which, according to Dr. Hooker, makes it impossible to clean all items in the room.

“If you are truly cleaning and disinfecting every part of that room, it takes almost 30 minutes just to clean the bed,” he explained. “You’ve got to wipe the top of the mattress, the sides, the bottom, the bed deck, the handrails, up underneath, the wheels—all of that is potentially contaminated. And [they]’re not doing that; they usually spend about 3 minutes on the bed. Three minutes to disinfect a major piece of equipment.”

Properly cleaning a mattress is a multistep process which requires rinsing, something that health care staff just don’t have time for. “I can tell you right now, there’s not a hospital on the planet rinsing after they clean, then disinfecting, and then rinsing again,” Dr. Hooker said. “Nobody’s doing that; it would take them an hour just to clean the bed. They would be tied up for an hour, and that hospital has patients coming out of the operating room, patients in the emergency room. I had 50 in-patients being held in my emergency room just last week—50.”

The other problem is the chemicals that are being used in hospitals to clean the mattresses.

“Hospital hard surfaces are a lot easier to clean because the chemicals were made for hard surfaces,” Dr. Hooker told Contagion^®. “Unfortunately, the mattress is a soft, porous surface; it was intended to be that to stop all of the bed sores. And so, if you think about a 1970’s car with a vinyl seat—you sat in it, you sweated, and you stuck to it, and that was miserable. Well, that’s not good for a patient either, and that’s what mattresses used to be like.”

Now, mattress developers are using “breathable fabric,” which allows for the moisture to get away from the patient, according to Dr. Hooker. However, the problem with this is, the chemicals that are being used to clean the mattresses were developed to be used on hard surfaces. “All the chemicals that are being used are the wrong chemicals; they don’t work and they damage the fabric, which causes cracks and crevices where C. diff and other nasty bugs can go down and hide,” Dr. Hooker stressed.

To make matters worse, regulatory agencies such as the US Food and Drug Administration (FDA), the US Environmental Protection Agency, and the Centers for Disease Control and Prevention (CDC), appear to be “turning a blind eye” to the issue, according to Dr. Hooker.

“They are great organizations with wonderful people working there, but they just haven’t done anything. The CDC has not updated their guidance since 2008 in the cleaning of mattresses, and the 2008 guidance didn’t really change much from the 2003 guidance. The CDC could say, ‘Effective immediately: clean these beds to a high level every single time,’ but, instead, they call it a noncritical surface; they say it’s noncritical because it doesn’t touch non-intact skin,” Dr. Hooker said. “The last time I checked, every single patient has non-intact skin; they’ve got an intravenous line in; they’ve got dermatitis; they’ve got a pressure ulcer; they just had an operation on their hip—that’s non-intact skin. And yet, we lay the patient on the mattress as if they’re being laid on a perfectly clean space and it's not clean. They put it in the noncritical category which means that you can use low-level disinfection.”

As per current practice in hospitals, unless a patient has documented multidrug-resistant organisms or C. difficile, they get ‘normal’ cleaning, which is a 1-step process using a quaternary ammonia cleaner. “Quaternary ammonium compound is the most commonly used disinfectant; it does not work for C. diff. It has been shown not to work for C. diff on hard surfaces, and it clearly isn’t going to work on soft surfaces,” Dr. Hooker explained.

Dr. Hooker reminded conference-goers of the chemicals that do work against C. diff; these are mainly bleach (for log 3 to log 5 reductions) and H₂O₂/Peracetic acid (for log 4 reduction). He pointed out that use of UV light only yields a log 1 reduction. Hydrogen peroxide vapor is another option that gives a log 5 reduction, but it takes hours to do. And, again, the chemicals available to kill C. diff only work for hard-porous surfaces. So, how do you kill C. diff on soft, porous surfaces, such as hospital mattresses?

Dr. Hooker discussed the use of a launderable mattress cover known as the Trinity Guardion Patient Barrier System, which is made of knit polyester fabric with a polyurethane coating on the patient side—the same breathable materials used in high-end mattresses. The cover was designed to prevent the penetration of bodily fluids and microorganisms, and, according to Dr. Hooker, it’s cost-effective, easy to use, and it works against C. diff.

“You need a verifiable process that’s repeatable and doesn’t depend on workers doing things right or wrong,” Dr. Hooker explained.

Here’s how it works:

• Put the cover on the mattress. This takes about 30 seconds to 1 minute. The cover is reverse-rolled, so that patient contact surface is inside, which means nothing touches the mattress.
• When the patient leaves, roll it up, and take it to the laundry. There are multiple health care laundries around the United States now, and they can all do this. You clean it, you rinse it, and then you wash with chlorine. “We wash with chlorine, which is normally dangerous for mattress surfaces, but it’s not in this case because we rinse it off and we use lower concentrations of it,” Dr. Hooker explained. “Chlorine works, even at that lower 150 ppm; this means that I’m not putting that 5,000 ppm all over the mattress.” Then, you rinse it again.
• Dry it with heat. Heat makes chlorine much more effective, according to Dr. Hooker, and bacteria do not like heat. The heat also works to kill the bacteria.
• Inspect every mattress, every time. “Just like operating room linens are inspected because we can’t have cracks in those, this is the same idea,” Dr. Hooker explained. The cover is barcoded, which means workers can tell how many times it has been used and when it’s at the end of its life (“We’ve shown that we can run it through at least 150 times without degradation”), where it’s going, and where it’s supposed to be.
• Repeat.

The mattress cover is made for each specific manufacturer’s bed and it has clips to ensure that it stays in place; it can even be used on emergency room or operating room stretchers. “They cost about $450 dollars. And so, if you say 150 uses, that’s about $3 a turn—that’s not bad. It costs about $5 to $6 to clean them because they’ve got to be cleaned well. Obviously, you don’t want to just take them and wipe them off. Then, you’ve got the same problem that you had before,” Dr. Hooker said.

Dr. Hooker and colleagues conducted a recent study to test the effectiveness of the mattress covers in 2 different long-term acute care hospital settings—one facility had 74 beds, the other had 30 beds. The investigators changed the cover after each patient and then laundered them using hot water, detergent, and chlorine. They proceeded to compare C. diff infection rates by using Poisson regression between the 16 months before using the covers and the 14 months after using them. The results? Use of the mattress covers helped reduce C. diff infections by 47.8% in the first hospital, and 50% in the second.

“The mattress is the highest touch point in the room; you lay on that thing 23 hours a day or more, and yet we clean the toilet better than we clean what you lay on,” Dr. Hooker stressed. “And the sheet won’t protect you; the bacteria can go right through a sheet; blood can come right through a sheet; C. diff can come right through a sheet.”

Launderable mattress covers may provide a potential solution to an ongoing problem faced by health care facilities everywhere. One thing is for certain—the current cleaning methods leave much to be desired, and so, something needs to change.