On January 31, 2020, the US Department of Health and Human Services declared the COVID-19 situation a public health emergency.1 Nearly year and a half later in June 2021, the Occupational Safety and Health Administration (OSHA) issued the COVID-19 Emergency Temporary Standard (ETS) CFR 1910.502.2 The ETS requires employers in all healthcare settings to develop and implement a COVID-19 Plan to identify and control COVID-19 hazards in order to protect workers when treating suspected or confirmed COVID-19 patients This blog post will focus on the cleaning and disinfection requirements of the ETS.

Employers must conduct a hazard assessment of the entire workplace to identify and understand where COVID-19 hazards might exist and what controls must be implemented to minimize the risk of COVID-19 transmission. High risk areas, tasks, and occupations must be identified in the assessment. This includes the identification of high-touch surfaces. Facilities are expected to follow both the CDCs “Guidelines for Environmental Infection Control in Healthcare Facilities” for standard practices for cleaning and disinfection of surfaces and equipment as well as the COVID-specific recommendations found in the CDCs “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic”.  The latter guidance calls for the following:

Furthermore, the ETS requires that employers have cleaning and disinfecting policies and procedures. The cleaning frequencies to be included in the policies are outlined below:

To avoid costly citations, you may wish to familiarize yourself with the OSHA Inspection Procedures.3

When will the OSHA ETS end? In all likelihood, when the public health emergency is declared over, the ETS will “end” with the many of the elements being absorbed into other existing OSHA standards such as the general respiratory protection standard.

1. U.S. Department of Health and Human Services. Determination that a Public Health Emergency Exists [internet]. [cited 2021 Aug 21]. Available from https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx
2. Occupational Safety and Health Administration. COVID-19 Emergency Temporary Standard. COVID-19 Healthcare ETS [internet]. [cited 2021 Aug 21]. Available from https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.502
3. Occupational Safety and Health Administration. Inspection Procedures for the COVID-19 Emergency [internet]. [cited 2021 Aug 21]. Available from https://www.osha.gov/sites/default/files/enforcement/directives/DIR_2021-02_CPL_02.pdf

After two long years, we finally got to meet together again. Albeit only virtually, it was great to be in the “same room” with the over 3,300 participants from across the globe - many of whom are new to the profession. This blog post will summarize my top two favorite sessions from the 2021 annual APIC conference.

The Joint Commission (TJC) Office Hours

Speaker:
Sylvia Garcia-Houchins, TJC Director of Infection Prevention & Control (IP&C)

In this practical session, a hierarchical approach to infection control (IC) standards (pictured below) was reviewed. The speaker advised participants, when creating or revising IC-related policies, to apply this hierarchy as it will “always get you to the right answer.”

It was interesting to learn that only three evidence-based guidelines are required and they are 1) CDC or WHO Hand Hygiene, 2) CDC Standard Precautions, and 3) CDC Transmission-based Precautions. Beyond these, healthcare facilities may adopt any other evidence-based guidelines (EBG), national standards, or consensus documents of their choosing. Of note, the speaker stated that to be considered an EBG, that the document must have a reference list.

Last, participants were advised to download a copy of the program-specific Centers for Medicare and Medicaid Services (CMS) State Operations Manual which offers day-to-day operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives. Be thoughtful in regards to facility policy content as TJC will hold facilities accountable during surveys to ensure they are doing what they say they will do. For example, if your policy says you follow Association for the Advancement of Medical Instrumentation (AAMI) standards as opposed to CDCs for high level disinfection, you must be compliant with AAMI standards. Of note. AAMI guidelines have no reference list.

Pre-Conference Workshop: IP&C in Long-Term Care (LTC) - The Future is Now

Speakers:
Deb Burdsall, PhD, RN-BC, CIC, FAPIC; Assistant Adjunct Professor, University of Iowa College of Nursing; Manager, Baldwin Hill Solutions LLC, Infection Prevention for Long-Term Care

Teri Hulett, RN, BSN, CIC, FAPIC; Infection Prevention Consultant, Infection Prevention Strategies LLC

Buffy J. Lloyd-Krejci, DrPH, MS, CIC; Owner, IPC Well, LLC; Infection Preventionist

This day-long session was kicked off by calling out the elephant in the room: IP&C in LTC was an issue before the pandemic. In fact, 82% of LTCFs surveyed between 2013 and 2017 were cited for an IP&C deficiency. Infections are the most frequent cause of transfers and readmissions to the hospital. Two very important topics covered in this workshop were 1) Process surveillance and 2) Enhanced Barrier Precautions (EBP). For more information on the latter, see my June HICPAC Hub blog post. Regarding process surveillance, it is the review of staff practices with the purpose to identify whether staff implement and comply with IP&C policies and procedures. It is also required by CMS. Not only do IPs need to perform outcomes surveillance (e.g., healthcare-associated infections), they need to collect data and act on the findings around processes that can lead to infections. A good example is to observe cleaning and disinfection practices and to provide timely feedback to frontline workers.

At the session closing, new IPs who started in the profession during the pandemic were cautioned to be mindful that the IP&C practices observed were not best practices. Reuse of single-use personal protective equipment is a great example. For more on the CMS infection control requirements for LTCFs, see my blog post titled “New CMS Requirements for Long-Term Care Facilities – Are You Ready?”

I will conclude with a reminder inspired by Simon T. Bailey in the closing plenary session: Never forget that you all are diamonds – created under pressure and it is your time to shine!

Let’s grab a cup of coffee next year in Indianapolis, Indiana!

About the HICPAC Blog Series

The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal committee that provides guidance on infection prevention practices in US to the federal Department of Health and Human Services and the Centers for Disease Control and Prevention (CDC) in US healthcare settings. As Infection Preventionists, we are all familiar with the HICPAC guidelines including, but not limited to, the Hand Hygiene and the Environmental Infection Control Guidelines. HICPAC meets several times each year, where among other activities, new guidelines are developed and older guidelines are updated. This blog series will highlight the key discussions at these meetings. Because of the lengthy delay from meeting to posting of the minutes, we hope you will find our HICPAC meeting summary blog posts helpful to keep you informed in a timely manner. 

Introduction

In this review of the June 3 2021 meeting, I’ll highlight updates from the Division of Healthcare Quality Promotion (DHQP), the Long-Term Care/Post-Acute Care (LTC/PAC) workgroup, and the Healthcare Personnel Guideline workgroup. Additionally, a draft of the Enhanced Barrier Precautions (EBP) whitepaper was reviewed and a new workgroup to look at transmission-based precautions was kicked off. Over the past year and half, the Committee typically provides a brief status of the pandemic. Interestingly, no COVID-19 update was provided.

DHQP Update

This country’s response to the pandemic is a reflection of how fragile our current systems are. Denise Cardo, MD and director of the DHQP shared what they are working on to address the healthcare challenges which have been highlighted by the COVID-19 pandemic. These include:

As an Infection Preventionist, I am elated that the CDC will address the long over-due needs in for robust IP&C in this countries nursing homes.

Healthcare Personnel Guidelines Workgroup Update

The Healthcare Personnel Guideline was first written in 1998 and addresses health and safety in the workplace for healthcare workers including exposures and illnesses1. The updates to this guideline which have been underway for the past ten years continues. There were no public comments made to the revisions to the four pathogens (pertussis, meningococcal disease, diphtheria, and Group A Streptococcus) posted back in March so these are ready to be posted. Next on deck to watch for public comment period are:

Bloodborne pathogensHerpes SimplexS. aureus (MSSA/MRSA)
Conjunctivitis/AdenovirusParvovirusTuberculosis
CytomegalovirusRabiesViral Respiratory Infections
Hepatitis AScabies and Pediculosis 
 

LTC/PAC Workgroup Update

The awaited first draft of the Enhanced Barrier Precautions (EBP) Whitepaper was shared in the meeting. EBP is a targeted approach to prevent Staphylococcus aureus and MDRO transmission during resident care activities for residents with wounds or indwelling medical devices –regardless of MDRO colonization or infection status. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care. The whitepaper will address the following:

In the event of PPE shortages, EBP should be prioritized for residents with wounds over those with devices alone and for targeted MDROs. Neither the workgroup nor HICPAC indicated when the final Whitepaper will be published.

New HICPAC Workgroup Kicked Off

Finally, Michael Bell, Deputy Director of DHQP and the designated federal officer over HICPAC, announced the formation of a new workgroup to evaluate new approaches to transmission-based precautions. He challenged the committee to consider if there is value in a gradient approach to isolation precautions – similar to EBP. The pandemic has provided the opportunity to update the guidance and has driven some research on how they are thinking about this. Source control will be a very important element of the updated guidance, as will new masks and air quality. Will droplet precautions look differently going forward? We will have to wait to see the hierarchy of controls that this new workgroup will bring forward in coming months.

Summary

The June HICPAC meeting was very productive with lots of important work happening. Be sure to watch for public comment periods on HICPAC guidelines in review as well as for the final EBP Whitepaper. For additional information the HICPAC meeting minutes can be reviewed once they are posted. I hope that you find these meeting summaries helpful in your day-to-day practice. 

References

1. CDC. (2019). Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control. Retrieved on 23 June 2021 from https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html

About the HICPAC Blog Series

The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal committee that provides guidance on infection prevention practices in U.S. to the federal Department of Health and Human Services and the Centers for Disease Control and Prevention (CDC) in U.S. healthcare settings. As Infection Preventionists, we are all familiar with the HICPAC guidelines including, but not limited to, the Hand Hygiene and the Environmental Infection Control Guidelines. HICPAC meets several times each year, where among other activities, new guidelines are developed and older guidelines are updated. This blog series will highlight the key discussions at these meetings. Because of the lengthy delay from meeting to posting of the minutes, we hope you will find our HICPAC meeting summary blog posts helpful to keep you informed in a timely manner.

Introduction

Welcome to the first edition of the HICPAC Hub for 2021. This post will highlight the key topics addressed in the March 4, 2021 meeting which included updates on COVID-19, CDC guidelines, Project Firstline, and the Long-Term Care workgroup.

COVID-19 Update

With the worst of the pandemic behind us (hopefully), the CDC is taking a closer look at which COVID-19 guidance and practices are applicable for future pandemics. They are also investigating the sustainability of both local and regional responses. Issues that have bubbled to the surface are also CDC priorities such as:

With vaccinations underway across the country, the CDC has released updates on post-vaccination activities such as small maskless gatherings with other vaccinated individuals. The CDC did acknowledge that they need to be clearer moving forward to differentiate guidance intended for the public versus that for healthcare workers. A great example was the recent double masking guidance which targeted the general population and not healthcare personnel. The lack of a clearly stated target audience for the guidance caused much confusion among healthcare personnel.

CDC also announced that there will be a work group assembled to focus on rethinking the respiratory illness isolation precautions.

CDC Guideline Updates

Several guidelines for neonatal intensive care units (NICU) as well as the Infection Control in Healthcare Personnel guidelines continue to be updated. On March 8th, HICPAC reopened the public comment period for the following sections of the Healthcare Personnel guidelines:

                                

Project Firstline Update

CDC’s Project Firstline was launched late last year to educate frontline staff on the fundamentals in infection prevention and control (IP&C). This 2-year pilot intends to address gaps in IP&C knowledge and aims to provide the rationale behind the recommendations. Topics will be timely and will cover the fundamentals, as well as grounded in adult learning theory and provided in bite-sized formats. For example, there are some great short videos on cleaning and disinfection including why it matters and about contact times. Currently, materials are available in English, with Spanish versions to follow. CDC does recognize the need for the materials to be available in other languages too.

Long-Term Care Work Group Updates

The Long-Term Care (LTC) Work Group continues to make progress on its White Paper to address the new enhanced barrier precautions guidance for MDRO infections (EBP). Multidrug-resistant organism (MDRO) infections disproportionately affect LTC residents. They contribute significantly to morbidity and mortality for residents and high costs for the healthcare system. Standard Precautions are inadequate to prevent transmission of MDROs and Contact Isolation Precautions are impractical in this setting. In comes EBP which fall somewhere between Standard and Contact Precautions. Essentially, with EBP, gown and gloves are recommended for certain residents infected or colonized with novel or targeted MDROs or who have wounds or indwelling medical devices during specific high-touch care activities such as bathing or providing wound care. Gowns, gloves, and alcohol-based hand sanitizer should be available outside of every resident room. While there will be costs up front to implement EBP, savings should be realized through prevention of healthcare-associated infections.

Summary

A few action items for IPs include 1) take a moment to review the section of the Healthcare Personnel guidelines that is open for public comment, 2) check out the resources available from Project Firstline, and 3) watch for more to come on EBPs for LTC settings. For additional information the HICPAC meeting minutescan be reviewed once they are posted. We hope that you find these meeting summaries helpful in your day-to-day practice.

Introduction

While the COVID-19 pandemic appears to be slowing down, the next pandemic is knocking at our door – infections caused by antibiotic resistant organisms (ARO). The post-antibiotic era isn’t coming – it’s here.1 According to Dr. Arjun Srinivasan with the Centers for Disease Control & Prevention (CDC), “The COVID-19 pandemic has created the perfect storm for antibiotic resistance. Prolonged lengths of stay; crowding; and infection control challenges, such as training gaps and shortages in PPE, all contribute.”2 It is estimated that in the next 30 years, deaths caused by AROs will surpass those caused by all cancers combined.3

The two AROs we’ll focus on are Candida auris (C. auris) and Clostridioides difficile (C. diff), both of which are considered urgent threats, according to the CDCs most recent Antibiotic Resistance Threats Report. What these two pathogens hold in common is their ability to cause severe infections, survive in the environment for prolonged periods, and spread easily between hospitalized patients and nursing home residents. In 2018, there were only 323 known clinical cases of C. auris.1 As of November 2020, the total has climbed to 1,595 which represents a nearly 400% increase in just two years.4 Moreover, to demonstrate how quickly the C. auris yeast can spread, in March 2017, a single case of C. auris was identified on a ventilator unit in Chicago. Sixteen months later, C. auris prevalence on the unit was 71%.5

Regarding C. diff, while we have made progress in reducing healthcare-onset rates in recent years, some studies show that these rates may have increased during the pandemic.6 But there are also studies that show a decrease.7,8,9 With the CMS reporting waivers during the pandemic, we may never know the true impact, at least not for a while. Regardless, C. diff remains the most common cause of healthcare-associated infections, more than half of which occur among recently hospitalized long-term care facility residents.1

Deviations from recommended infection control practices during the pandemic, fueled by fear of a novel pathogen, staffing challenges and supply chain challenges may have contributed to outbreaks of these two pathogens. For example, at one facility, a C. auris outbreak involving 35 patients was attributed to such deviations. In addition to missed hand hygiene opportunities, the CDC investigators found incorrect use of PPE and inconsistent disinfection of mobile computers and medical equipment between uses. . However, one of the control measures that helped in stopping this outbreak was enhanced cleaning and disinfection practices.10

Take Action to Prevent the Spread

The importance of infection prevention and control measures cannot be over-emphasized. The strategies to control these two pathogens are similar and include antibiotic stewardship, surveillance, diagnostic testing, transmission-based precautions, hand hygiene, inter-facility communication, and cleaning and disinfection of environmental surfaces and medical equipment. In this final section, we will focus on cleaning and disinfection.

Both of these contact-spread pathogenscan survive for prolonged periods on surfaces.  C. auris can survive for weeks and C. diff can survive up to 5 months making cleaning and disinfecting an imperative practice.11,12 Below are some key points around cleaning and disinfection when C. diff or C. auris are present:

Conclusion

These two urgent threat pathogens have many factors in common, which include an affinity for environmental surfaces, including medical equipment and for causing outbreaks. Robust cleaning and disinfecting programs are a key infection control measure.

References

  1. CDC. (2019). Antibiotic Resistance Threats in the United States. [online]. [cited 2021 Mar 13]. Available from https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf.
  2. Medscape Nurses. (2020). CDC Doc Addresses Today’s Pandemic and the Next. [online]. [cited 2021 Mar 13]. Available from https://www.medscape.com/viewarticle/941169.
  3. WHO. [2019]. New Report Calls for Urgent Action to Avert Microbial Resistance Crisis. [online]. [cited 2021 Mar 13]. Available from https://www.who.int/news/item/29-04-2019-new-report-calls-for-urgent-action-to-avert-antimicrobial-resistance-crisis.
  4. CDC. (2021). Tracking Candida auris. [online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html
  5. Chicago Department of Public Health. (2018). 23rd Annual Infection Control Conference: Candida auris Emergence and Containment Efforts in the Chicago Region. [online].[cited 2021 Mar 14]. Available from https://www.chicagohan.org.
  6. Lewandowski K, Rosołowski M, Kaniewska M, Kucha P, Meler A, Wierzba W, et al. Clostridioides difficile Infection In Coronavirus Disease (COVID-19): An Underestimated Problem? Pol Arch Intern Med. 2021 Feb 26;131(2):121-127.
  7. Assi M, Doll M, Pryor R, Cooper K, Bearman G, Stevens MP. Impact of COVID-19 on Healthcare-Associated Infections: An Update and Perspective. Infect Control Hosp Epidemiol. 2021 Mar 12:1-9.
  8. Bentivegna E, Alessio G, Spuntarelli V, Luciani M, Santino I, Simmaco M, et al. Impact of COVID-19 Prevention Measures on Risk of healthcare-Associated Clostridioides difficile Infection. Am J Infect Control. 2020 Oct 5:S0196-6553(20)30891-9.
  9. Ponce-Alonso M, Sáez de la Fuente J, Rincón-Carlavilla A, Moreno-Nunez P, Martínez-García L, Escudero-Sánchez R, et al. Hospital-Onset Clostridioides difficile Infections During the COVID-19 Pandemic. J.Infect Control Hosp Epidemiol. 2020 Sep 8:1-5.
  10. CDC. (2021). MMWR Vol. 70: Candida auris Outbreak in a COVID-19 Specialty Care Unit – Florida, July-August 2020. [online].[cited 2021 Mar 15]. Available from https://www.cdc.gov/mmwr/volumes/70/wr/mm7002e3.htm
  11. Fekety R, Kim KH, Brown D, Batts DH, Cudmore M, Silva. Epidemiology of antibiotic-associated colitis; isolation of Clostridium difficile from the hospital environment. Am. J. Med. 1981; 70:906–908.
  12. CDC. (2019). Candida auris: Healthcare Professional FAQ.[online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-health-qa.html  
  13. CDC. (2020).Infection Prevention and Control for Candida auris. [online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html#disinfection.
  14. EPA. (nd). Pesticide Product and Label System. [online]. [cited 2021 Mar 19]. Available from https://iaspub.epa.gov/apex/pesticides/f?p=PPLS:1.
  15. CDC. (2019). Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities. [online]. [cited 2021 Mar 15]. Available from https://www.cdc.gov/hai/prevent/cdi-prevention-strategies.html.
  16. Donskey C, Cadnum J, Jenscon A, Livingston S, Li D, Redmond S, et al. (2020). Evaluation of an electrostatic sprayer disinfectant technology for rapid decontamination of portable equipment and large open areas in the era of SARS-CoV-2. AJIC, (48):951-954.

A Little About Me

I have been a nurse since 1993 and have worked as an Infection Preventionist (IP) for the past 20 years. Throughout my infection control career, I’ve faced challenges such as the potential weaponizing of smallpox after 9/11, the SARS outbreak in 2003, the H1N1 pandemic in 2009, and the Ebola outbreak in 2014 (just to name a few). I have seen a lot of tragedy and hardship, most of which I never would have dreamed of seeing in a million years.

In 2018, I made a big change in my infection control path. I was afforded an opportunity to join the Clorox Healthcare team as a Senior Infection Preventionist. After completing my first year in my new role, the COVID-19 pandemic was just beginning – a monumental pandemic that we will likely never see again in our lifetimes. In a matter of a few months, COVID-19 spread like wildfire to nearly every continent. We spent most of 2020 in lockdown, and infection prevention became more relevant than ever.

My COVID-19 Pandemic Story

In March of 2020, as part of the emergency response to COVID-19, California Governor Gavin Newsom released an executive order allowing the state of California to commandeer hotels and medical facilities to treat COVID-19 patients. This was termed “Project Roomkey 2 and local counties were tasked with manning these shelters.1

In my local county, some of these hotels are being used as temporary isolation housing for unsheltered residents. The intent is to reduce transmission in the community from infected persons who are experiencing homelessness or live in congregate or over-crowded settings (e.g., prisons, etc.). Meanwhile, some of the hotels (named Safer Ground sites) are designated for medically fragile persons who meet the above criteria and have not been diagnosed with COVID.2 

The other hotels (named Operation Comfort sites) serve as shelters to quarantine or isolate COVID-positive or COVID-exposed individuals who meet the criteria listed above. Project Roomkey takes referrals from hospitals, clinics, prisons, emergency shelters, and homeless outreach teams.

Last summer, I learned through a friend that our local county public health department was looking for nurses to replace the public health nurses at the shelters, who were desperately needed by the county to return to their usual public health roles. With a full-blown pandemic underfoot, I had been chomping at the bit to be able to put my IP skills to work and contribute in a substantive way. I was hired part-time to supervise nurses at the COVID-positive shelters. Since July 2020, I have been working every other weekend with medically fragile COVID-positive individuals in the hotels in an underserved area of East Oakland, California.

Challenges from the Front Lines

Since an “isolation/quarantine” hotel had never been created or utilized in modern times, we’ve had to continuously learn and adapt to new situations. This often means that our protocols, along with the CDC guidance for COVID-19, is also continuously evolving. Furthermore, as is often the case in public health nursing, we are with faced limited resources. This includes things as simple as having a consistent supply of environmental surface disinfectants.  Just about every time I report for duty, we have a different disinfectant which means having to learn the instructions for use, including the contact time.  Also, with the supply chain shortages, it means we have to remember to save our empty bottles and trigger sprays for refilling.

As if fighting COVID-19 were not enough, we’ve also had to address the complicated health and social issues our patients face on a daily basis outside of the pandemic, such as mental health and/or substance abuse disorders. My fellow nurses and I must simultaneously monitor our patients’ COVID symptoms as well as any withdrawal or suicidal ideation indicators. Some of our patients also have complex health issues (e.g., diabetes) so we work diligently to coordinate the appropriate care.

Additionally, patients at Project Roomkey come from all types of socioeconomic backgrounds. For low-income community members, having to quarantine for 14 days or stay isolated at a hotel could mean missing a paycheck or risking the next meal for their family. Meeting these patients’ social or other medical needs is not easy when your patient also has an infectious disease like COVID-19. I quickly realized that it’s not the same as working in the hospital outside the pandemic where virtually every resource you need to do your job is on-hand.

In addition to our patients, our nursing staff also come from a variety of backgrounds, which range from new graduates to veteran caregivers. Clinical backgrounds include hospital (ICU, OR, and Medical-Surgical), long-term care, home care, infection prevention and control, behavioral health, public health, and even nurses from academia. What I appreciated this past year was that no one used their specialty to appear superior to anyone else. We simply leaned on each other’s strengths and got the work done.

Finding Inspiration Among the Hardship

Since this work takes place in addition to my regular “day job” with Clorox Healthcare, I’ve had to find inspiration to keep showing up every other weekend. Fortunately, this did not prove to be too difficult as I’ve found great inspiration in both my patients and my coworkers. The most vulnerable in our community needed us during this historic event and as a nurse, I felt that it was my duty to help.

Like me, many of my fellow hotel coworkers took on this work in addition to their “day jobs.” Their dedication motivates me to keep showing up week after week. These amazing individuals not only give their time and skills, but they often donate items to these families in need - things like winter clothing, children’s toys, and games to keep them occupied during quarantine. In addition to nurses, the healthcare team includes nurse practitioners, physicians, mental health providers, substance abuse providers, and pharmacists. Meanwhile, we couldn’t do any of this without the relentless work of the facilities team, housing support staff, housekeepers, cooks and security guards in the hotels. The team collaboration and the comradery of this group has been truly something amazing to be a part of. 

Finally, I would be remiss if I didn’t recognize the inspiration provided by all of my fellow IPs out there wherever they have been working during this pandemic. Your dedication to our profession is nothing short of remarkable.

Relief is in Sight

When both the Moderna and Pfizer vaccines were granted Emergency Use Authorization (EUA) from the Federal Drug Administration in December 2020, I was beyond elated to help run the staff vaccination clinic.3 Along with a few of my coworkers, we administered nearly 140 first doses to our fellow shelter workers, which included nurses, medical assistants, housing support staff, housekeepers, cooks, and security guards. I was more than happy to do it all over again four weeks later, too. Being able to offer hope through a vaccine has brought me such joy that I have volunteered to administer vaccinations to the general public as well.

As public health officials, healthcare workers, and members of our community continue to come together to help fight the spread of COVID-19, I’m grateful for the resilience I’ve witnessed first-hand over the past year. This virus is not done with us yet and we are not done fighting, but I have hope for the future. Before the pandemic struck, 2020 had been designated the International Year of the Nurse in honor of the 200th anniversary of Florence Nightingale’s birthday.4  While this may have been lost in the chaos of the pandemic, we nurses will never forget the additional meaning behind this past year.

References

  1. Alameda County Public Health Care for the Homeless. Isolation Housing for COVID-19 [nternet]. [cited 2021 Mar 7]. Available from: https://www.achch.org/isolation-housing.html
  2. Office of the Governor Gavin Newsom. Governor Newsom Issues New Executive Order Further Enhancing State and local Government’s Ability to Respond to COVID-19 Pandemic [internet]. [cited 2021 Mar 7]. Available from: https://www.gov.ca.gov/2020/03/12/governor-newsom-issues-new-executive-order-further-enhancing-state-and-local-governments-ability-to-respond-to-covid-19-pandemic/
  3. Federal U.S. Food & Drug Administration. COVID-19 Vaccines [internet]. [cited 2021 Mar 7]. Available from: https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-vaccines
  4.  World Health Organization. Executive Board Designates 2020 as the “Year of the Nurse and midwide.” [internet]. [cited 2021 Mar 7]. Available from: https://www.who.int/news/item/30-01-2019-executive-board-designates-2020-as-the-year-of-the-nurse-and-midwife-

Guidelines from several government and professional organizations lead one to believe that the use of spray disinfectants in healthcare settings is “taboo”.  The primary rationale cited for this is concern for the production of aerosols and also for contaminated solutions. In true Infection Preventionist form, I decided to take a closer look at the evidence that informs these guidelines. The bottom line is that I could not find much evidence to support NOT using sprays disinfectants when appropriate, at least nothing current.  Let’s take a closer look.

The Evidence

What evidence was used to inform these guidelines? For their recommendations around use of spray disinfectants in healthcare settings, the Centers for Disease Control and Epidemiology (CDC) Guidelines cite four studies ranging from 21-49 years old with little relevance to spray disinfectants.1 As I chased the evidence trail, the studies just got older and older. The most curious finding was the lack of relevance of these studies. The guideline authors are generalizing results from studies that looked at floor care and vacuuming with outdated and faulty equipment, construction activities, use of porous insulation in buildings as a source of pathogens, and prevention of opportunistic infections in stem cell transplant patients to support their stance on not using spray disinfectants.

As for the guidelines from the key professional organizations, most simply cite the CDC’s guidance. Take for example the Association for periOperative Registered Nurses (AORN) Perioperative Practice Guidelines which recommend against the use of spray bottles in the operating room.2  AORN cites the CDC guidelines and states that “sprayed disinfectants produce more aerosols compared to other formats”.2 They also provide the rationale that “if the cleaning solution is contaminated, spraying may provide a route for airborne transmission which may contaminate the surgical wound, sterile supplies, or the sterile field”.2

With today’s pre-diluted, ready-to-use (RTU) sprays and liquids, the chance of contaminated product is virtually zero3. I would also like to call out that we should not be carrying out environmental cleaning tasks when the patient with a surgical wound or sterile supplies are present anyway - regardless of the disinfectant format used!

The Association for the Healthcare Environment (AHE) Practice Guidance provides no rationale or evidence for their recommendation to “apply chemicals using pour spouts, rather than sprayers”.4 Like AORN, AHE recommends “no spraying or misting bottles in the OR as they may aerosolize the disinfectant”.  The source for this guidance? AORNs guidelines which point to the CDC Guidance addressed above. As you can see, we are traversing quite the rabbit hole!

Most importantly, I could find no mention on use of spray disinfectants from the Association for Professionals in Infection Control & Epidemiology (APIC) or from the Centers for Medicare & Medicaid (CMS), the latter of which is a regulatory agency.

The basis for non-use of sprays largely centers on the concern of contaminated disinfectants made from concentrate. While this may be possible, this can eliminated with the use of RTU sprays, and the risk decreased by emphasizing the need to clean and dry spray bottles rather than “topping off”.

Modern Day Sprays

Some of today's manufactures have engineered sprayers that create larger droplets rather than an aerosolized mist which would reduce the risk that spray bottles aerosolize microorganisms or pose an occupational hazard. So if we connect the dots of what we have learned so far, spray disinfectants do have a place for use in healthcare settings.

Think about conducting a risk assessment to determine when and where in your facility that the use of spray bottles might be appropriate. Some examples might include: vacant spaces such as operating rooms between patients or at end of the day, waiting rooms, public restrooms, conference rooms, and public spaces to list a few. When considering a spray disinfectant, include the following in your assessment:

  1. The conditions in which it would be appropriate to use spray disinfectants.
  2. Information provided in the Safety Data Sheet (SDS).
  3. Product instructions for use (IFUs), including personal protective equipment (PPE).  

Summary

A reassessment of the evidence from past studies is needed. But in the meantime, we must remember that these are guidelines and not regulations and that healthcare facilities can conduct their own risk assessments and implement the appropriate use of spray disinfectants.

References

  1. Centers for Disease Control & Prevention (CDC). (2003). Environmental infection Control Guidelines from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html.
  2. Association for periOperative Registered Nurses (AORN). (2020). Guidelines for periOperative Practice from https://www.aorn.org/guidelines/about-aorn-guidelines (subscription required).
  3. Weber, D., Rutala, W., Sickbert-Bennett, E. (2007) Outbreaks Associated with Contaminated Antiseptics and Disinfectants. Antimicrobial Agents and Chemotherapy, p. 4217-4224.
  4. Association for the Health Care Environment (AHE). (2020). Practice Guidance for Health Care Environmental Cleaning, 3rd edition from https://www.ahe.org/ahe-publications-home (subscription required).

This post is part of our “Ask The Pros” blog series for which our internal panel of experts address the latest questions from industry professionals. This month’s query,

“Adjunct disinfection methods such as electrostatics seem to be gaining in popularity. Is a manual cleaning step always required?”

Introduction

Because Infection Preventionists have oversight of all cleaning and disinfection practices within their facilities, it’s really important to keep current on emerging disinfectant technologies, including new adjunct disinfection technologies. One such technology in high demand given the “new normal” is electrostatic sprayers. In addition to getting disinfectant into nooks and crannies, these devices can disinfect large areas in a very short time. This blog post will provide a brief overview of the technology, how best to employ its use within a healthcare facility, and safety considerations.

Electrostatic Sprayer Technology 101

Despite its growing popularity, electrostatic technology is actually not new. It’s been used for many years in other industries such as agriculture, automotive painting, and spray tanning. In healthcare, this adjunct technology is a new way to apply familiar disinfectants. The device charges the disinfectant droplets as they exit the nozzle where the disinfectant is attracted to the surface/object like a magnet. The end result is a uniform coating of disinfectant that wraps 360 degrees around targeted objects. This makes for a fast and efficient disinfecting process.

Incorporating Electrostatic Sprayer Technology into Current Processes

A study conducted by Bhalla et al (2004) showed that only 50% of healthcare surfaces were properly disinfected with manual cleaning1, creating the need for supplemental disinfectant technologies such as electrostatics. Electrostatic sprayers are intended to be an adjunct to routine manual cleaning and disinfection.

For example, consider using an electrostatic sprayer as a finishing step for terminal cleaning of C. diff, COVID, or other isolation rooms. Other considerations include terminal cleaning of operating rooms, waiting rooms, and transport equipment such as wheelchairs and gurneys.

With that said, much like we use hand sanitizer for much of our hand hygiene opportunities and reserve hand washing for specific times such as removing visible soil or C. diff spores from our hands, we can consider using an electrostatic sprayer in a similar way.

If a surface is not visibly soiled or the area did not house a C. diff patient, a manual cleaning step is not required prior to disinfection so consider using electrostatic sprayer technology in these instances. Consider that operating rooms (OR) are manually cleaned multiple times during the day (e.g., after each procedure), so why couldn’t terminal cleaning of the OR be completed using an electrostatic sprayer to apply the disinfectant?

Additionally, consider objects or areas that are likely not getting cleaned and disinfected as often as we would like because they are large spaces, or difficult to clean, such as waiting rooms or wheelchairs. Electrostatic sprayers are a great option and the Donskey study (2020) provides great evidence to support this. Keep in mind, however, just like our hands, we do still need to periodically perform manual cleaning.  

Electrostatic Sprayer Safety

First and foremost, be sure to select EPA-registered products approved for use through an electrostatic sprayer. Use of a disinfectant or sanitizer in a non-approved manner is a violation of federal law. It’s equally important to adhere to the manufacturer’s directions for use (DFUs), including contact time.

Be sure to wear personal protective equipment (PPE) according to both the manufacturer’s DFUs for the selected product and also per Standard Precautions.

We often get asked if it’s safe to use an electrostatic sprayer when other people are in the area being disinfected. In addition to following the manufacturer’s DFUs for both the device and the disinfectant, we recommend that only the operator be present in the room while the device is being used. Another question that frequently gets asked is “what is the room re-entry time after applying the disinfectant?”  The answer: there is none!

The Clorox® Total 360® System

Clorox Healthcare offers an electrostatic sprayer technology called the Total 360® System. The table below is quick overview of the current products in our portfolio that can be used with the Total 360 electrostatic sprayer.

Total 360 DisinfectantsActive IngredientSuggested Use LocationsContact timePersonal Protective Equipment (PPE)
Spore10 Defense™ Cleaner DisinfectantSodium hypochloritePatient care areas where C. diff is a concern (e.g., terminal cleaning, etc)5 minutesEye protection; Wear other PPE in accordance with Standard Precautions.
Total 360® Disinfectant Cleaner1Quaternary ammonium compoundPatient care areas when C. diff is not a concern2 minutesEye protection; Wear an N95 respirator for prolonged use; Wear other PPE in accordance with Standard Precautions.
Anywhere® Hard Surface Sanitizing SpraySodium hypochloriteNon-patient care areas such as offices and conference rooms and anywhere that a food safe product is indicated such as the cafeteria.2 minutesEye protection; Wear other PPE in accordance with Standard Precautions.
 

Summary

Adjunct disinfection technologies such as electrostatic sprayers can be a great addition to your current cleaning and disinfection routines. The technology has been around for many years and it is both safe and efficient.

Related Resources


References

  1. Bhalla A., Pultz N.J., Gries D.M. et al. “Acquisition of Nosocomial Pathogens on Hands After Contact With Environmental Surfaces Near Hospitalized Patients.” Infection Control Hospital Epidemiology. 2004 Feb;25(2): 164–7

The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal committee that provides guidance on infection prevention practices in the U.S. to the federal Department of Health and Human Services and the Centers for Disease Control and Prevention (CDC) in US healthcare settings. As Infection Preventionists (IPs), we are all familiar with the HICPAC guidelines including, but not limited to, the Hand Hygiene and the Environmental Infection Control Guidelines. HICPAC meets several times each year, where among other activities, new guidelines are developed and older guidelines are updated. For a more detailed overview, please see our HICPAC 101 blog post by Dr. Hudson Garrett.

Participating in HICPAC meetings puts context and rationale to the recommendations. Furthermore, as an IP, your voice can be heard or questions answered during the public comment period of the meeting. Because of the lengthy delay from meeting to posting of the minutes, we hope you will find our HICPAC meeting summary blog posts helpful to keep you informed in a timely manner.  

Lessons Learned from the COVID-19 Response

Dr. Denise Cardo from the CDC’s Division of Healthcare Quality Promotion presented on the gaps across the healthcare delivery system, the critical needs in post-acute care (PAC), and health equity and access issues that the COVID-19 pandemic has unmasked. There is a huge need to integrate infection prevention across the entire healthcare continuum to be as robust as it is in acute care settings. For example, if you have watched the news in recent months, you have seen the challenges that nursing homes have faced during this time. In fact, 42% of all COVID-19 deaths have occurred in nursing homes.1

This pandemic has certainly highlighted the need for policies for accountability. Dr. Cardo identified three cultural changes that need to happen:

While we may not know exactly how this culture change will take place, it’s reassuring to know that the CDC is keenly aware of these issues and will be working on providing guidance to facilities.

Project Firstline

Dr. Mike Bell, Deputy Director for the CDC talked about the Project Firstline, a new national training collaborative for healthcare infection prevention and control for frontline healthcare and public health workers. The project was kicked off at the end of October 2020 with a key objective to effectively communicate infection prevention messaging directly to frontline workers.

The educational materials and tools provided to targeted audiences are short, convenient, and provided in easily accessible formats such as videos and podcasts. And to help make the messaging stick, the rationale behind the recommendations is strongly emphasized. Keep an eye on the Project Firstline website as the portfolio continues to expand. IPs can follow this initiative on Facebook or Twitter or sign up for email updates.

Work Group Update: Long-Term Care/Post-Acute Care

HICPAC members JoAnne Reifsnyder and Michael Lin provided an update from the Long-Term Care (LTC)/PAC Work Group. This group is working to move from a culture-based to a task-based risk for determining precautions and personal protective equipment (PPE) in LTC and PAC settings. For example, PPE decisions would be based on patient care tasks, like bathing or wound care, rather than on what is growing (or not growing) in a specimen culture.

This comes on the coat tails of the new set of precautions, Enhanced Barrier Precautions, introduced last year. With the lessons learned from the pandemic, this work group is in the process of drafting a white paper on how nursing homes should implement PPE used for resident care activities. The workgroup plans to employ human factors engineering to design their recommended interventions.

Summary

            Because we understand how difficult it is for busy IPs (especially during a pandemic!) to attend HICPAC meetings, we hope that you find these meeting summaries helpful in your practice. Don’t forget to check out Project Firstline and be on the lookout for the CDCs Enhanced Barrier Precautions white paper (final title to be determined). For additional information, the HICPAC meeting minutes can be reviewed once they are posted.

References

  1. The New York Academy of Medicine, “Virtual Summit for Infection Prevention in Nursing Homes”, [cited 12/2/2020].

This post is part of our "Ask The Pros" blog series for which our internal panel of experts address the latest questions from industry professionals. This month's query,

"It seems like we have a new disinfectant product every week and it's hard to keep up with how and where to use the products. What strategies do you recommend for as little disruption as possible to our current process?"

Introduction

The year 2020 has certainly been a challenging one thus far. The COVID-19 pandemic has created supply challenges in this country that we could not have anticipated that range from U.S. Mint coin shortages to personal protective equipment (PPE) for healthcare workers.  The disinfectant manufacturing industry has also been challenged to keep up with an extraordinary increase in demand.  While production facilities are operating 24/7, supply continues to fall short of demand due to production capacity and raw material shortages.  As a result, many healthcare facilities are having to adjust and adapt to new disinfectants products, whether that means different formats, applications, or actives.  While this may be frustrating, healthcare teams are resilient and they know how to triage.  In response to disinfectant shortages, changes in product and potentially in protocols, we will apply the methodology of triage to the use of disinfectant products in formats that may differ from our usual product. A plan of action can then be developed for the appropriate use of the environmental disinfectants available.

Risk Assessment

The first step when an issue is identified is to assess the risks involved and the potential consequences.  In this case, the issue is that our usual product(s) may be temporarily unavailable, or in limited supply. I recommend downloading and adapting a risk assessment tool from the Centers for Disease Prevention and Control (CDC). Considerations with the risk assessment are:

Once the risk assessment has been completed, the next step is to formulate a plan to mitigate and determine what, if any, safeguards should be put into place.  Your plan should include goals and objectives to tackle high-risk issues. Note that your plan should also address how you will swiftly communicate the change in product and educate staff as the new products come in to your facility. Your vendors may be able to help!

Product Prioritization

Much like the CDC has recommended a strategy to prioritize the use of PPE to preserve supply, consider doing something similar in regards to disinfectants.  I am not proposing cleaning less frequently, but rather to prioritize which products will be used where and by whom.  If you have a limited supply of disinfectant wipes, but you also have some spray bottles of disinfectant, consider prioritizing disinfectant wipes for critical departments, or equipment.  For example, you wouldn’t want to use the spray disinfectant in the ICU where you have patients on a ventilator, so this would be a department in critical need of disinfectant wipes. Another example might be to take the large format disinfectant wipes that Environmental Services (EVS) often use and distribute them to nursing staff for use on the units.  EVS is more accustomed and likely more equipped to utilize different formats of disinfectants such as spray disinfectants, dilutable chemistries and microfibers so consider reserving these formats for them.

If you need help getting started with how to prioritize your products, check out this flow chart (also pictured below) and associated blank and completed risk assessments for reference.

Instructions for Use

Through all of this, it is imperative that the product instructions for use (IFU’s) are reviewed, staff is educated on the IFU’s, and compliance is monitored and enforced by leadership. Healthcare-grade disinfectants registered by the U.S. Environmental Protection Agency (EPA) undergo stringent testing requirements in order to prove their efficacy and safety. For the best results, users should follow the product IFU’s.

For example, Clorox Healthcare® Fuzion, a next-generation sporicidal bleach disinfectant, has an engineered dual-chambered nozzle that combines the active ingredients at the point of dispensing (or spraying).  While highly efficacious, this product is most effective when applied directly to the surface from the bottle itself. If concerned about using sprays but that is all that is available, a better approach would be to consider where use of sprays might be more appropriate, such as in public or common areas after-hours. Finally, until this pandemic is behind us, be sure you are selecting products approved as being effective against SARS-CoV-2, the virus responsible for COVID-19 disease.  You can find these products on the EPA’s List N.

Posts for the Ask The Pros blog series are published every other month. Please submit your cleaning and disinfecting questions to AskThePros@clorox.com for consideration to be addressed in a future edition.

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