Doe Kley, Infection Prevention Fellow within Clorox Healthcare’s Clinical and Scientific Affairs Team, recently sat down with Professor Didier Pittet of the University of Geneva, Switzerland and Chair of Clean Hospitals to discuss new research, Clean Hospital’s mission and how healthcare professionals can limit the spread of healthcare-associated infections.

With these topics top of mind worldwide, play the video above or keep reading to hear their thoughts.

Please note this is an abridged version of the interview edited for brevity and clarity.

What Is Clean Hospitals?

Doe Kley: Hello, everyone. My name is Doe Kley. I'm an infection prevention fellow with Clorox Healthcare's Clinical and Scientific Affairs Team. I'm a little bit starstruck today because I'm joined by Dr. Didier Pittet to discuss his current work with Clean Hospitals, all the way from Geneva, Switzerland. Welcome, Dr. Pittet. Would you like to introduce yourself and the Clean Hospitals Initiative?

Professor Didier Pittet: Thank you, Doe. It’s a pleasure to be with you today. I'm Professor Didier Pittet from the University of Geneva in Switzerland, and we started the Clean Hospitals initiatives several years ago as a way to partner together to improve patient safety and reduce healthcare associated infections and patient harm in hospitals.

Leveraging the Clean Hands Initiative Framework  

Doe Kley: That is awesome. I know that you led the team with the World Health Organization that revamped the hand hygiene guidance. I'm really excited to see what Clean Hospitals accomplishes. I'm curious, was there something that you learned from your hand hygiene work that led you to this next initiative?

Professor Didier Pittet: Absolutely. In fact, the Clean Hospitals Initiative is built on the model that we use for the so-called Clean Hands initiatives or the Clean Hands Save Lives.

First, we did a review of the literature. Is healthcare environmental hygiene important? The answer is yes. You could look at our systematic review that we published a few years ago, that revisited all the studies in the literature, and we paid attention in this review to exclude studies where hand hygiene was promoted. Why? Because we know that if you succeed at promoting hand hygiene, then it would be difficult to monitor the impact of improving healthcare environmental hygiene in reducing infections.

But this systematic review was the first deep research of the Clean Hospital Initiative. [It] was there to help raise awareness about the importance of the role of healthcare environmental hygiene. Then we developed instruments that we already developed for hand hygiene. You probably know the hand hygiene self-assessment framework that we developed in 2009, and we launch globally all over the world.

We have been developing the healthcare environmental hygiene self-assessment framework that we will be launching at the next Clean Hospitals Day worldwide on the 20th of October this year. These are instruments that we used for hand hygiene promotion that we are using in the model of the Clean Hospitals Initiative.

Doe Kley: That's awesome. I'm super excited to get my hands on that self-assessment and share it with some of our customers. I am very familiar with the hand hygiene assessment [and I] used it at my last hospital. It's really incredible to hear about this impactful and inspiring work. Thank you for tackling this important patient safety topic.

The Recipe for Environmental Hygiene

Doe Kley: Beyond what you just shared, I also know that Clean Hospitals champions high-quality products, processes for environmental hygiene. Can you talk just a little bit about this? For example, what does your research show as it relates to the importance of environmental hygiene and patient outcomes or HAIs?

Professor Didier Pittet: If you succeed at implementing a healthcare environmental model program that improves the practices by using not only the right product but the right procedures and sometimes the right people — or training the right people to use the right procedures — you could demonstrate a very significant impact on healthcare associated infections, but also on the transmission of multi resistance, multi resistance and bacteria or multi resistant organism.

This was very revealing of the importance of a multimodal approach for improving healthcare environmental hygiene, something that we know very well in infection control. That's what Clean Hospitals is working on in order to spread this strategy all over the world, using the best partners from all around the world.

Doe Kley: Thank you for that. And I can very much resonate with the multi-modal strategy, especially when you touched on antimicrobial resistant pathogens. We put so much focus and emphasis on antimicrobial stewardship, [it’s] very, very important, but I think we overlook that a clean environment is equally as important. I also think that we are not entering — I think we are in the post antimicrobial era. So even more important now, more than ever before. Thank you for this work and thank you for touching on that.

Ready-to-Use Disinfectants

Doe Kley:  Do you have thoughts on ready to use disinfectants in terms of patient safety and [the disinfecting] process?

Professor Didier Pittet: Yeah, of course. The [Clean Hospitals] strategy is a worldwide strategy. So of course, the recommendations may vary from one region of the world to another. Not that bacteria are changing, but that resources are not the same. Sometimes we have only resources that are very simple, but at least we need to make sure that the procedures, the process of cleaning is at the top.

Staff Training

Professor Didier Pittet: That's why we are always adapting the strategy to the level of care and to the resources that are available. Today, we have many approaches to clean the environment. The most important is how are you doing it: with what product, with what technique, and who is doing it. Making sure that people who are performing those processes understand those processes very well. But we need to adapt the technique. The education should be adapted to anybody applying the technique. For us at Clean Hospitals, this is extremely important.

Clean Hospitals Self-Scoring System

Doe Kley: I could not agree more. You know, at Clorox Healthcare, we are huge advocates for compliance, effective [and] efficient cleaning and disinfection. We know it starts with education, training and competency. I think competency is the piece that often gets overlooked. Do you have any thoughts on approach towards achieving competency in our in our cleaning staff?

Professor Didier Pittet: Yes. We have developed a scoring system that will be launched at ICPIC, the Congress in Geneva, but then launched worldwide on Clean Hospitals Day. When you look at the scoring system, it is appreciating. It’s a self-scoring system where you can appreciate the level of your institution. How ready is your hospital? Is your healthcare institution able to have [the] environmental hygiene program adapted to your institution?

In the scoring system, we are looking at the product, we are looking at the process, we are looking at the education. Of course, all of these help us to actually redirect or help the way people can teach, the way people are learning, the way people are implementing. As you know today, infection prevention and control implementation is extremely important.

I know at Clorox you are making sure the implementation of the good product and the good process is a reality and that's extremely important for this. You can use all sorts of techniques, but the most important is to make sure that you are working on the way to implement the best strategies and the best product.

What to Expect at ICPIC

Doe Kley: Perfect. I'm sure that these topics are going to be a focus at this year's International Consortium for Prevention and Infection Control, or the ICPIC conference that you mentioned. Can you share a little bit about Clean Hospitals presence at ICPIC.

Professor Didier Pittet: Clean Hospitals partners [Clorox] will be at the Clean Hospitals booth, where we will show our activities [and] promote our next activities. We will speak about the activities around upcoming Clean Hospitals days.

We will share about our knowledge in the field of healthcare environmental hygiene. There will also be a Clean Hospitals symposium, because at ICPIC we want people to understand the Clean Hospital initiatives and we ask our best international experts from around the world to come and deliver a lecture. We will also have four poster sessions in the field of healthcare and hygiene.

We will have more than 200 posters just in these fields of hand hygiene, healthcare environmental hygiene, from more than 60 countries around the world. Last but not least, Clean Hospitals partners will be there to share and share and share, which is so important for us today in our field.

Doe Kley: I couldn't agree more. It is so exciting to see the increase in activity in the science and the protocols that go into environmental planning and disinfection. I think Clean Hospitals has already started to make a great impact there. Thank you for helping to elevate the hard work. Do you have any final thoughts that you'd like to share with us all Dr. Pettit?

Professor Didier Pittet: We have been saving lives all over the world with the Clean Hands initiative — between 5 and 8 million lives every year around the world — but we know that we can save even more lives. [It’s] so good to have partners like Clorox, among the best partners around the world, being with us in this Clean Hospitals initiative; it's a pleasure and a privilege.

Doe Kley: Thank you. That privilege is all ours. Thank you for inviting us in.

While it may have been 107°F in Dallas, the hottest topic at the 2023 Exchange Conference was emerging and high-consequence pathogens. The conference hosted each year by the Association for the Healthcare Environment (AHE), allows for the exchange of evidence-based best practices and solutions. With emerging pathogens continuing to be a top concern for healthcare facilities, staying up to date is critical for Environmental Services (EVS) leaders and Infection Preventionists (IPs) to effectively eliminate the environment as a source of infection. I was fortunate to have the opportunity to present on the implications of cleaning and disinfecting against emerging pathogens in a session titled “Know the Enemy: Deepening Your Understanding of Environmentally Spread Emerging Pathogens.” In this post, I will share some of the key takeaways from this practical session.

6 Challenges with Emerging Pathogens

Emerging pathogens come with their own set of unique challenges. Global changes in recent decades have resulted in increased spill-over from animal to human hosts, often catching us under-prepared. Because of the diagnostic and treatment challenges inherent with a novel pathogen, transmission can go unchecked resulting in outbreaks. Finally, there can be implications for cleaning and disinfecting against a novel pathogen.

Cleaning & Disinfection Implications

Some general considerations as they relate to cleaning and disinfecting against emerging pathogens include:

• Product: For emerging pathogens, it’s imperative to select appropriate disinfecting products. However, because the pathogen is novel, it is not likely that any disinfectant on the market will have claims against it — at least not right away. Adding new claims to an existing product does not happen overnight. It takes about a year to get these claims approved by the US Environmental Protection Agency (EPA). Additionally, some disinfecting chemistries may be more effective than others against a given pathogen. For example, disinfectants with quaternary ammonium compounds (e.g., “quats”) as the only active ingredient have not been found to be effective against Candida auris.¹
• Training: Staff will need to be educated, trained, and competent to safely and effectively clean and disinfect against a new pathogen. Consider having a dedicated cleaning team to respond to these pathogens. In addition to Centers for Disease Control and Prevention (CDC) guidance, the National Emerging Special Pathogens Training and Education Center (NETEC) is another great resource.
• Process: There is the need to identify a process for managing the pathogen. For example, protocols should include the personal protective equipment (PPE) to be worn to enter the room, the appropriate disinfectant to be used, and the cleaning frequency. Again, see CDC and/or NETEC guidelines and resources.
• EPA: As the regulatory body over disinfectants, it is essential to be aware of any specific policies, requirements, or resources as they relate to novel pathogens. Some examples include the EPAs Emerging Viral Pathogen Policy and the EPA Disinfectant Lists that should be leveraged to find appropriate products.

Leveraging the Hierarchy of Pathogen Kill by Disinfectants

As guidance from the CDC and EPA may not be immediately forthcoming in the early weeks of the emergence of a new pathogen, it is imperative to have a plan. In the interim before the EPAs Emerging Viral Pathogen policy is activated, I recommend using a sporicidal, like bleach, because it is broad-spectrum against hard-to-kill pathogens. I also recommend creating job action sheets specific to the emerging pathogens of concern. These should describe the roles and responsibilities for each discipline. For example, an EVS Job Action Sheet for Candida auris could include the precautions to be taken and which disinfecting product to use (e.g., EPA List P).

Understanding the EPAs Emerging Viral Pathogen Policy and List Q

It is important to note that the EPA’s Emerging Viral Pathogen policy only applies to viruses. It does not apply to emerging bacteria, fungi, or other pathogens. This policy is activated once the CDC declares an outbreak of the emerging virus. This means that products meeting EPA’s List Q criteria can be used - unless there is a more targeted list – for example, EPA’s List L for Ebola. Many disinfectant manufacturers already have the EPAs Emerging Viral Pathogen claim on some or all of their products, so it is ready to go in the event of a novel virus.^2,3

List Q is unique from the other EPA Lists because it does not target a specific pathogen. With this List, the user searches for eligible products for use against an emerging pathogen by selecting the appropriate tier based on virus type. To navigate List Q, the user will need to know whether the emerging pathogen is:

• An enveloped virus (tier 1- the easiest of the 3 types to kill),
• A large non-enveloped virus (tier 2), or a
• A small non-enveloped virus (tier 3 - the hardest of the virus types to kill).

Lastly, it is important to understand that because a given product from List Q meets the criteria for use against one emerging virus (e.g., Mpox), it does not mean this product will be effective against any future emerging viruses. It is designed to be used on a pathogen-by-pathogen basis.⁴

The 21st century world is being impacted by emerging infectious diseases on an unprecedented scale.⁵ Preparedness is key to control and containment. Attendance at conferences such as AHE Exchange is one way for EVS leaders and IPs to stay one step ahead of the next new pathogen. We need to be better prepared than we were for COVID-19. Robust and adaptable protocols for cleaning and disinfection are a great place to start.

References

<sup>1. Centers for Disease Control and Prevention. Infection Prevention and Control for Candida auris [Internet]. [cited 2023 Aug 14]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html
2. US Environmental Protection Agency. What is an Emerging Viral Pathogen Claim [Internet]. [cited 2023 Aug 14]. Available from https://www.epa.gov/coronavirus/what-emerging-viral-pathogen-claim
3. US Environmental Protection Agency. Guidance to Registrants: Process for Making Claims Against Emerging Viral Pathogens Not On EPA-Registered Disinfectant Labels [Internet]. [cited 2023 Aug 14]. Available from https://www.epa.gov/pesticide-registration/emerging-viral-pathogen-guidance-and-status-antimicrobial-pesticides
4. US Environmental Protection Agency. Disinfectants for Emerging Viral Pathogens (EVPs): List Q [Internet]. [cited 2023 Aug 14]. Available from https://www.epa.gov/pesticide-registration/disinfectants-emerging-viral-pathogens-evps-list-q
5. Ambat A, Vyas N. Assessment and preparedness against emerging infectious disease among private hospitals in a district of South India. Open Access: Med J Armed Forces India [internet]. 2022;78(1):42-46.</sup>

Is it true that healthcare disinfectants must have a tuberculocidal (TB) claim? It’s an age-old belief held by many infection preventionists (IP) that healthcare disinfectants must have a TB claim. We did some digging and have published our findings in our latest white paper.

I recall a time when the manufacturer of the disinfectant we used at my hospital had removed the TB claim from the product. The corporate IP informed us that we must find a replacement product that had a TB claim. When I queried as to why, I was told it was a requirement. Knowing how disruptive it can be to switch products and being a very inquisitive and evidence-based IP, I started on a quest to find this “regulation”. I looked at both the local and federal government level and after an exhaustive search, I found no such requirement. After starting in my new role at CloroxPro, I shared this experience with my colleagues which started us on down a discovery path to identify this source of this misinformation. A white paper on this topic is the culmination of our research.

The purpose of a TB claim on surface disinfectants is not for the prevention or control of transmission of tuberculosis, an airborne-spread disease, which is not transmitted via contaminated surfaces or fomites. Rather its purpose is to serve as a benchmark of disinfectant antimicrobial efficacy. This is because Mycobacteria (the genus which TB belongs to) are notoriously difficult to kill with disinfectants. Disinfectants that have a TB claim are considered intermediate-level disinfectants. Yet, according to the Spaulding scheme, no greater than low-level disinfection is necessary for environmental surfaces and non-critical medical equipment (e.g., equipment that only contacts intact skin).

Why is it important to understand that a TB claim is not a requirement? Because two of the leading properties of an ideal disinfectant are a short contact time and good surface compatibility. Harder to kill pathogens, like Mycobacteria (e.g., TB) require tougher disinfectants, which often have longer contact times and less-than-desirable compatibility with surfaces and equipment. Achieving a TB claim also increases the cost of the product. Insisting on a TB claim limits your disinfectant options. Many manufacturers opt not to pursue this unnecessary claim given these downsides as well as the fact that harder-to-kill pathogens like C. difficile are now available for testing.

But where did this misbelief of requiring a TB claim come from? We learned that it came into being in the early years (and fears) of the HIV epidemic, before the causative agent had been identified, and before we knew how easy (or hard) it was to kill with disinfectants. However, the Cleaning Industry has come a long way over the past 40 years. Many, if not most, of today’s EPA-registered healthcare-grade disinfectants have kill claims for the bloodborne pathogens of most concern (e.g., HIV and Hepatitis B and C viruses) negating the need for the TB claim. In fact, these enveloped viruses are among the easiest pathogens to kill. As a result, OSHA revised their definition of an appropriate disinfectant for blood and body fluid clean up to include those with HIV and Hepatitis B kill claims.

Figure 1.

It’s time for this now debunked belief that a TB claim is required to be put out to pasture once and for all. Learn more from our white paper titled “Clearing up the confusion: why a tuberculocidal claim on surface disinfectant is no longer needed."

Environmental service (EVS) professionals play a crucial role in infection prevention and control by eliminating the environment as a source of infection. Continuing education helps EVS leaders bring their “A-game” and help their teams perform at the highest level possible. Because of this, Clorox Healthcare® is happy to introduce a new best-in-class microlearning module that is part of our CloroxPro HealthyClean^® online learning platform. EVS professionals will benefit from this interactive course created to deepen understanding of healthcare-specific cleaning and disinfection. We collaborated with instructional designers to ensure that the needs of adult learners are met. No products are promoted in this short training — it includes only the essentials on what busy EVS professional need to know.

Because healthcare operations are incredibly complex, continuing education is a given for professionals working in healthcare. Healthcare EVS have a very serious mission: keeping patients, visitors, and healthcare workers free from exposure to infection-causing pathogens. Healthcare EVS must understand how pathogens are transmitted within their facilities — including from contaminated environmental surfaces. Cleaning healthcare spaces, like operating rooms and isolation rooms, requires a very specialized skill set that can only be achieved through ongoing education and training. Time spent on education and training is never in vain. The benefits include improved skills and possible career advancement. When an employee adds skills to their “toolbox”, their value to their employer is increased. Additionally, relevant certificates demonstrate to future employers skills that the competition may not have.

What will participants learn in this new training titled “An Introduction to Cleaning and Disinfection in a Healthcare Setting”? Available in both English and Spanish, this course addresses both the need and the nuances of cleaning and disinfecting in this specialized setting and includes some of the different types of cleaning (e.g., occupied, terminal, isolation, etc.). Additionally, participants are pointed to several great resources and there are even a few case studies to help the learner to apply the lessons learned. More specifically, participants will learn:

• What infection prevention and control (IPC) is
• The role that EVS play in IPC in a healthcare setting
• What a healthcare-associated infection (HAI) is
• The standard precautions and transmission-based precautions used to prevent HAIs
• Best practiced when cleaning and disinfecting patient areas

This module meets many of the same quality training standards that the Centers for Disease Control and Prevention (CDC) has established for their trainers and educators.¹ This includes content that is accurate and relevant and that provides opportunities for learner engagement. Upon completion of this training and passing a short quiz, the participant will receive a certificate of completion. Course completion can be added to one’s resume and the certificate can proudly be displayed in an office or even on LinkedIn for all to see. And if interested, we also offer a HealthyClean Trained Specialist course for frontline EVS that is accredited by the ANSI National Accreditation Board (ANAB).

For a limited time, you can access the New Healthcare Microlearning Module at no cost by registering here and entering promo code 0323 at checkout. If you have any question or need any help registering, contact the CloroxPro HealthyClean Certificate Program Team at cloroxpro.healthyclean@clorox.com.

References

^{1. Centers for Disease Control and Prevention. Training Development: Quality Training Standards [Internet]. [Cited 2023 Feb 13]. Available from CDC.}

It has been over 3 long years since the Association for the Healthcare Environment (AHE) Annual Exchange Conference was held in-person. AHE is the professional organization for healthcare environmental services (EVS) professionals and the Annual Exchange Conference gathers these EVS leaders for knowledge sharing, exchange of best practices and ideas, and connecting with peers. Despite an ongoing pandemic and a category 3 storm (Hurricane Ian), nothing was going to stop over 400 of us from attending this year’s event in Orlando, Florida! I can’t express the joy in seeing the smiling faces of old friends and colleagues again. Together we partook in fun social events, ate good food, strolled a right-sized exhibitor hall, and networked. And not to forget, there were some great educational sessions including topics as such as:

• Pathogens of interest (e.g., Clostridioides difficile (C. diff) and Candida auris)
• Emergency preparedness
• Future of EVS
• Continuous survey readiness
• Cleaning and disinfection (of course!)

A common theme heard from an overwhelming majority of attendees was the staffing challenges as a result of the Great Resignation. Keynote speaker DeDe Halfhill, a leadership expert, shared that we are seeing burnout at levels we have never seen before. She advised EVS leaders to be vulnerable and lead with love through staff engagement. Leaders should communicate to connect at a human level, not simply to direct. Keynote speaker, Kim Seeling Smith, a future-of-work and talent retention expert, informed attendees that 80% of workers would choose a caring boss over a 20% pay increase. People must be in the center, and we can do this through respect, trust, collaboration, communication and inclusiveness.

Ms. Seeling further reported on some the causes of the worker shortage including self-employment, competition, and retirement. Baby Boomers are retiring at a rate that exceeds the younger generations entrance into the workforce and this is not expected to correct until 2030. Today’s workforce has become more empowered and to retain them, we need to help them to achieve their goals - all while still getting the work done. People come to work to add value. As leaders, it’s our job to help them understand that what they do is meaningful – they help to keep patients healthy and alive through the provision of a sanitary environment cleaned to acceptable healthcare standards. I really appreciated this hiring tip provided by Ms. Seeling:

Several attendees shared the creative ways in which they are recruiting workers. One facility reported hiring high school students part-time, while another facility developed a re-entry program for veterans and recently released incarcerated persons.

Once you have the right people in place, you need to get them up-to-speed quickly through education and training. A well-trained staff is an efficient machine so checkout some of our short Clorox Healthcare training videos:

• Occupied Patient Room Cleaning
• Discharge/Terminal Patient Room Cleaning
• Operating Room Between Case Cleaning
• Operating Room Terminal Cleaning

As a leader, it is important to stay current with your own education so I recommend checking out our new CloroxPro™ HealthyClean™ online learning platform for best-in-class education and training. HealthyClean™ offers the only industry-wide certificate course designed for the commercial cleaning industry to be accredited by the American National Standards Institute National Accreditation Board (ANAB). 

Other time-saving tips include the use of ready-to-use one-step cleaner-disinfectants. These products save your staff time while eliminating the risk of dilution errors. Additionally, there are no secondary bottles to label and to have to clean, disinfectant, and dry after each use as recommended by the CDC.

Thanks for reading and I hope to see you all in Dallas at the 2023 AHE Annual Exchange Conference! In the meantime, be on the lookout for our new healthcare-specific HealthyClean™ training coming soon!

Introduction

Healthcare facilities have many options when it comes to surface disinfectant selection. While no one product checks off all of the boxes of the ideal disinfectant (Figure 1), I will share why I think bleach is B.E.S.T. in this article. I will start with a brief history of bleach, tackling tough pathogens, responsible bleach use, and the critical moments for bleach use.

The Joint Commission recommends that healthcare facilities limit the number of disinfectants to 2-3 products with at least one having a sporicidal claim, like bleach.¹ Sodium hypochlorite (the active ingredient in bleach), has withstood the test of time since its discovery in the late 1700s (Figure 2)². This is because it is relatively inexpensive, readily available, and has efficacy against a broad range of pathogens.

B.E.S.T. Use Indications for Bleach

Innovative chemists have developed lower-level sodium hypochlorite products that offer good surface compatibility, low odor, and acceptable contact times while still being sporicidal. Our compatibility program has endorsements from key equipment manufacturers. See Appendix A for a range of bleach products to address different needs. While these improved bleach formulations are gentle enough for everyday use, shared here are some of the most critical moments for its use. The mnemonic B.E.S.T. will help you to remember these key moments (Figure 3).

• Bloodborne Pathogens:
  • For cleaning and disinfection of blood or body fluid spills, the CDC recommends a 1:100 (small spills) or 1:10 dilution (large spills) of 5% bleach.³ The EPA Master Label for pre-diluted ready-to-use bleach-based disinfectants should provide information on the products dilution ratio.
• Emerging and Re-emerging Pathogens:
  • Bleach is often the go-to disinfectant active for emerging or re-emerging pathogens. Examples include:
    • COVID-19: While products with the EPA-approved emerging viral pathogen claim (List N) are expected to kill SARS-CoV-2, there were supply chain issues during the pandemic. Bleach to the rescue! Many facilities relied on “jug” bleach diluted in accordance with CDC recommendations.⁴
    • Novel Influenza strains: I specifically recall the H1N1 pandemic of 2009. Since this was before the EPA had implemented their Emerging Viral Pathogens policy, the CDC had recommended use of bleach until more was learned about killing this viral strain.
    • Carbapenem-resistant Acinetobacter baumanii (CRAB): According to CDC special report earlier this year, the incidence of CRAB increased 78% during the pandemic.⁵ This problematic emerging pathogen is difficult to eradicate due to its ability to survive for prolonged periods in the environment. The CDC recommends enhanced cleaning and disinfection. A recent of outbreak of CRAB in a South Korea hospital was eventually contained when twice daily disinfection with bleach was implemented.⁶ 
    • Ebola: While historical Ebola outbreaks have mostly been contained to the African continent, the current outbreak in Uganda, again raises concerns for imported cases. Emergency preparedness means having appropriate products on-hand. The CDC recommends the use of an EPA-registered hospital disinfectant from List L.⁷ I am particularly proud of the fact that the Clorox Company is the only disinfectant manufacturer with EPA-registered label claims against the Ebola virus. 
  • The above examples are all viral. Please note that the EPA Emerging Viral Pathogens Policy only applies to viruses. It will not apply should the next emerging pathogen be a bacterial or fungal in nature. For this reason, it’s a great idea to ensure that you always have bleach on-hand.
  • For additional reassurance against these troublesome pathogens, consider use of adjunct disinfection such as electrostatic technology to ensure that all surfaces and nooks and crannies are covered. You will need to ensure that the product is EPA-approved for use through electrostatic sprayers.
• Special Pathogens — Two of the most troublesome pathogens that call for enhanced infection control measures to control their spread, are outlined here:
  • Clostridiodes difficile (C. diff):
    • C. diff remains one of the most common causes of healthcare-associated infections.⁸ The hardy spores can persist in the environment for many months and are very difficult to kill (see Figure 3 above). These spores can be picked up on the hands of healthcare workers and transmitted to other patients. Until recently, bleach was the only sporicidal disinfectant available to kill C. diff spores. With the use of bleach and other infection prevention efforts, the HO-CDI standardized infection ratio (SIR) has decreased from 0.85 in 2016 to 0.48 in 2021.^8,9 There is an abundance of studies demonstrating the effectiveness of bleach in reducing HO-CDI rates (Appendix B). While we have made recent strides in reducing HO-CDI rates (hooray bleach!), we must remain vigilant as community-acquired C. diff incidence is on the rise.¹⁰ As these patients seek medical attention, the pathogen can get re-introduced into our facilities. Click here for a great C. diff Terminal Cleaning Protocol & Checklist. 
  • Candida auris (C. auris):
    • This emerging threat is a very worrisome multidrug-resistant yeast with a mortality rate between 30-60%. During the pandemic, HAIs caused by C. auris increased an alarming 60% (Figure 4).⁵ Because this pathogen is transmitted by the contact (or touch) route and because it persists in the environment for prolonged periods, it spreads rapidly in healthcare settings. It can be very difficult to eradicate and outbreaks often result. Several outbreaks documented in the literature reported enhanced cleaning and disinfection with bleach successfully contained the outbreak.^11,12 In fact, the CDC recommends using an EPA-registered hospital-grade disinfectant effective against C. auris or C. diff spores, including bleach.¹³  Click here to learn more from my C. auris webinar (free CE’s!).

COVID-19 Impact on Antimicrobial Resistance in the U.S.

• Terminal Cleaning:
  • Several studies have shown that patients admitted to rooms previously occupied by individuals infected or colonized with MDROs or C. diff  are at up to three times higher risk  of acquiring these pathogens.¹⁴ CMS requires that after a patient vacates a room, all visibly or potentially contaminated surfaces are thoroughly cleaned and disinfected.¹⁵ Each patient deserve the highest level of surface cleaning and disinfection, therefore I recommend, at a minimum, using a bleach-based cleaner-disinfectant for all discharge and isolation cleanings.

Responsible Bleach Use

After nearly 3 years of dealing with pandemic, including staffing and supply chain issues, practices may have drifted from our written protocols. For example, are staff being compliant with bleach use when it’s indicated? It’s now time that we reassess our cleaning and disinfection programs.

The Centers for Medicare and Medicaid Services (CMS) requires a clean and sanitary healthcare environment to maximize the prevention of infection and communicable disease.¹⁵ Evidence-based cleaning protocols, such as those provided by the Centers for Disease Control and Prevention (CDC), should be followed. This means the use of EPA-registered healthcare-grade disinfectants. To ensure compliance of these requirements, CMS surveyors will be on the lookout for the following:

• Environmental surfaces are regularly cleaned and disinfected following an established schedule (e.g., at least daily),
• Spills and visibly contaminated surfaces are promptly cleaned and disinfected, and
• High-touch surfaces are cleaned and disinfected more frequently than minimal-touch surfaces.¹⁵

CMS further requires that disinfectants are used in accordance with the manufacturer’s instructions for use.¹⁵ When used correctly, EPA-registered disinfectants, including bleach products, can be expected to be safe when used as directed. In fact, following label direction is required by law.¹⁶  The responsible use of any disinfectant entails the following:

• People:
  • Education and Training – Ensure that staff are adequately education and trained. Clorox Healthcare offers best-in-class education and training materials (see our HealthyClean™ Program as one example).
  • Competency — no education and training is complete with competency assessment.
• Product:
  • Perks of Ready-to-Use products:
    • Safer
    • No mixing required
    • No risk of dilution error
    • Saves time
  • Contact Time:
    • Consider using the shorter contact time for your bleach products when sporicidal activity is not necessary. For example, Clorox Healthcare® Spore¹⁰ Defense™ Cleaner Disinfectant has a contact time of 1 minute for most pathogens, 3 minutes for C. auris, and 5 minutes for C. diff. This product can be used at one minute when sporicidal kill is not needed (which is likely most of the time). Spore Defense can also be used through an electrostatic sprayer. This will go a long way with surface compatibility.
• Practice:
  • Always follow the manufacturer’s directions for use.
  • Adhere to evidence-based cleaning and disinfection protocols such as those provided by the CDC.

In conclusion, these past few years have shown us that the pathogens are playing to win. Emerging pathogens and MDROs are coming at faster than ever before but with few new treatment options on the horizon. The good news is that we have some great weapons in our arsenal. I, for one, will be keeping bleach on my team!

References

<sup>1. The Joint Commission. Environmental Infection Prevention: Guidance for Continuously Maintaining a Safe Patient Care and Survey-Ready Environment [Internet]. [Cited 2022 Oct 23]. Available from https://store.jcrinc.com/assets/1/7/nexclean_environinfectionprevention_%28002%29.pdf.
2. Encyclopedia.com. Sodium Hypochlorite [Internet]. [Cited 2022 Oct 17]. Available from https://www.encyclopedia.com/history/biographies/benelux-history-biographies/sodium-hypochlorite.
3. Centers for Disease Control & Prevention. Healthcare-Associated Infections (HAI) – Environmental Cleaning Procedures [Internet]. [Cited 2022 Oct 18]. Available from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html.
4. Centers for Disease Control and Prevention. COVID-19: How to make a 0.1% Chlorine Solution to Disinfect Surfaces in Healthcare Settings [Internet]. [Cited 2022 Oct 18]. Available from https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/make-chlorine-solution.html.
5. Centers for Disease Control and Prevention. 2022 Special Report: COVID-19 US Impact on Antimicrobial Resistance [Internet]. [Cited 2022 Oct 21]. Available from https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf.
6. ContagionLive Infectious Disease Today. Containing an Outbreak of Carbapenem-Resistant Acinetobacter baumanii in a COVID-19 Isolation Unit [Internet]. [Cited 2022 Oct 29]. Available from https://www.contagionlive.com/view/containing-outbreak-carbapenem-resistant-acinetobacter-baumannii-covid-19-isolation-unit.
7. Centers for Disease Control and Prevention. Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus [Internet]. [Cited 2022 Oct 18]. Available from https://www.cdc.gov/vhf/ebola/clinicians/cleaning/hospitals.html.
8. Centers for Disease Control and Prevention. Data Summary of HAIs in the US: Assessing Progress 2006-2016 [Internet]. [Cited 2022 Oct 17]. Available from https://www.cdc.gov/hai/data/archive/data-summary-assessing-progress.html.
9. Centers for Disease Control and Prevention. COVID-19 Impact on HAIs in 2021 [Internet]. [Cited 2022 Oct 17]. Available from https://www.cdc.gov/hai/data/portal/covid-impact-hai.html#:~:text=First%20quarter%20standardized%20infection%20ratios,hospitalizations%20to%20all%2Dtime%20highs.
10. Fu Y, Luo Y, Grinspan A. Epidemiology of community-acquired and recurrent Clostridioides difficile infection. Therap Adv Gastroenterol. 2021. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141977/.
11. Schelenz S, Ferry H, Rhodes J, Abdolrasouli A, Chowdhary A, Hall A. First Hospital Outbreak of the Globally Emerging Candida auris in a European Hospital. Antimicrobial Resistance and Infection Control. 2016;5:35.
12. Austin L, Guild P, Rovinski C, Osman J. Brief Report: Novel Case of C. auris in the VHA and in the state of South Carolina. Am J Infect Control. 2022;50(11): 1258-1262.
13. Centers for Disease Control and Prevention. Infection Prevention and Control for Candida auris [Internet]. [Cited 2022 Oct 21]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html.
14. Suleyman G, Alangaden G, Bardossy A. The Role of Environmental Contamination in the Transmission of Nosocomial Pathogens and Healthcare-Associated Infections. Curr Infect Dis Rep. 2018;20(6):12.
15. U.S. Dept. of Health & Human Services. Guidance Portal: Hospital Infection Control Worksheet [Internet]. [Cited 2022 Oct 23]. Available from https://www.hhs.gov/guidance/document/hospital-infection-control-worksheet.
16. United States Environmental Protective Agency. About Pesticide Registration [Internet]. [Cited 2022 Oct 21]. Available from https://www.epa.gov/pesticide-registration/about-pesticide-registration.</sup>

Appendix A

Range of bleach products offered by Clorox Healthcare to address different needs:

• Clorox Healthcare^® Bleach Germicidal Disinfectant maintains fast disinfection efficacy while improving surface compatibility and residue profile to meet the needs of a changing healthcare environment. Built to kill nearly 60 microorganisms in 3 minutes or less, including C. diff and C. auris, these cleaners are ready to use and proven to be effective in the battle against HAIs.
• Clorox Fuzion^® Cleaner Disinfectant uses a revolutionary technology to eliminate the chemical reaction that can damage surfaces and leave a residue. The solution contains sodium hypochlorite and a neutralizer that, when combined, form hypochlorous acid. The result is a highly effective disinfectant with broad surface compatibility and little to no residue. Fuzion^® kills 53 microorganisms in two minutes or less, with a two-minute kill time on C. diff spores.
• Clorox Healthcare^® Spore Defense™ Cleaner Disinfectant kills C. diff in 5 minutes, C. auris in 3 minutes, and 45 additional bacteria and viruses in 1 minute. The patented light bleach formula balances the need for strong efficacy with safety by using low levels of bleach, anti-corrosion ingredients and lower pH levels to ensure safety for surfaces and users facility-wide, and can be used through electrostatic devices.

Appendix B

The use of bleach on surfaces to address HO-CDI and surface contamination.

In Part 1 of this blog series, we highlighted the challenges that make cleaning and disinfection in the LTC setting different from acute care settings. This blog (part 2) will provide some solutions to tackling these challenges head-on with confidence.

Now that we understand the risks to LTC residents and the challenges, how should we approach cleaning and disinfection in this setting? A great starting point for establishing an effective and efficient program is the CDC’s Core Components of Environmental Cleaning and Disinfection as shown in Figure 3. This guidance takes into consideration that the healthcare environment is a reservoir to a diverse population of microbes, many of which are continuously shed into the environment.

Focusing on the product selection component, CMS requires that EPA-registered healthcare-grade disinfectants are used.¹ The LTC IP has oversight for the environmental cleaning and disinfection program so he or she should be involved in product selection and approval. Other product considerations include:

• Ensuring that the product has kill claims for the pathogens of interest for the facility. Examples of key LTC pathogens include the SARS-CoV-2 virus (e.g., COVID-19), Influenza, Norovirus, bloodborne pathogens, Clostridioides difficile and MDROs — including but not limited to MRSA, VRE and Candida auris.²  
• The product should also have kill claims for the most common HAI pathogens specific to your facility.
• Limit the number of disinfectants to 2 or 3 with at least one of these being a sporicidal agent such as bleach. Product standardization makes the right thing the easy thing to do.

Regarding where and when to clean in the LTC setting, CMS regulations require routine cleaning and disinfection of LTC environmental surfaces.¹ Because CMS does not define “routine,” this is left to the facility to determine and define in their policies. However, the CDC does have a Cleaning Frequency Risk Assessment to help in determining the right frequency by space in a facility. Cleaning frequencies should be based on 3 factors:

1. Probability of contamination (e.g., low, moderate or heavy contamination),
2. Vulnerability of the population to infection (e.g., less vs more susceptible), and
3. Potential for exposure (low-touch surface vs. high-touch surfaces).

While our focus should be on horizontal surfaces and high-touch surfaces (Figure 4), truly all touch surfaces should have a schedule for routine cleaning and disinfection. In general, the CDC recommends daily cleaning at a minimum but also recommends more frequent disinfection of high-touch surfaces as compared to those surfaces with minimal hand contact.²³ Additionally, the CDC recommends that public and shared restrooms and isolation rooms are cleaned at least twice daily.²² Shared medical equipment should be cleaned and disinfected after each use.²³ Disposable disinfecting wipes will greatly increase compliance and should be readily available at the point-of-use such as the entrance to resident rooms. At a minimum, these wipes should be available at the entrance to isolation or enhanced barrier precautions rooms. If there are resident safety concerns, a risk assessment can be conducted.

Summary

The LTC setting has its own unique challenges to cleaning and disinfection, but these can be overcome with a robust cleaning and disinfection program. Environmental cleaning and disinfection can stop transmission of many of the pathogens responsible for HAIs in this setting. Bottom line — it’s a low-cost, high-yield, “just-do-it,” evidence-based intervention that eliminates the environment as a source of infection.

References

<sup>1. CMS. State Operations Manual-Appendix PP – Guidance to Surveyors for Long-Term Care Facilities, 2017. [Internet]. [Cited 2022 July 16]. Available from https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf
2. Richards M. Causes of infection in long-term care facilities: An overview [Internet]. [Cited 2022 May 1]. Available from https://www.uptodate.com/contents/causes-of-infection-in-long-term-care-facilities-an-overview.
3. CDC. HAIs: Environmental Cleaning Procedures. [Internet]. [Cite 2022 May 25]. Available from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html</sup>

Americans are living longer, and the population is rapidly graying. Baby Boomers, who currently make up 21% of the US population, will be 65 or older by 2030. As a result, the number of persons living in nursing homes is expected to double. For the first time ever in this country, there will be more older adults than children. Most of these older adults will need long-term care (LTC) services at some point in their lives.^1,2,3

Currently, about 8.3 million people live in the country’s nearly 66,000 regulated LTC facilities.⁴ These residents are at high risk for infection due to their frailty, waning immune systems, multiple chronic conditions, prolonged healthcare stays, and over-exposure to antibiotics.⁵ Compounding this risk is the congregate nature of LTC living with shared rooms and common spaces. Unfortunately, there is no requirement to report healthcare-associated infections (HAIs) in LTC settings — at least not yet. Without this data, it is unclear just how many HAIs occur in this setting, but it estimated to be somewhere between 1 to 3 million per year.⁶ The environment is an important reservoir for HAI-causing pathogens - many of which can survive for prolonged periods in the environment where they can be picked up on the hands of healthcare workers and then transmitted to residents. However, cleaning and disinfection can stop transmission as shown in Figure 1. Part 1 of this 2-part blog will highlight some of the challenges in regards to cleaning and disinfection that LTC facilities face. Part 2 will provide actionable solutions.

Figure 1. Cleaning and Disinfection Stops Transmission.

Challenges to Cleaning & Disinfection in LTC Settings

Long-term care is different as compared to acute care settings and here are some reasons why. First, hand hygiene alone, while important, is insufficient to control the spread of pathogens. Effective and consistent cleaning and disinfection is essential to reducing HAI incidence. While the same sanitation principles apply, simply adopting acute care environmental cleaning and disinfection protocols and practices does not address the challenges that LTC facilities face as shown in Table 1.

Table 1. Acute Care vs LTC Setting Differences that Impact Cleaning and Disinfection.

Some of the setting differences include:

• Milieu or Environment: The hospital is a more “sterile” environment, while the LTC facility is the resident’s home, often including personal furnishings and many belongings.
• Length of Stay (LOS): Residents tend to stay indefinitely and for long periods of time, whereas the LOS in the hospital is more on the order of a couple of days.
• Congregate Setting: In the hospital, patients tend to stay in their room with the exception of diagnostic procedures. The opposite is true in LTC which is very much a congregate and social setting. Residents dine together, gather for activities, and even spend their days together visiting or hanging out in the TV room. The more people gather, the higher the risk of pathogen sharing and disease transmission.
• Isolation Precautions: In the hospital, patients harboring epidemiologically important pathogens are placed in isolation precautions. This is a little trickier in the LTC setting. Isolation is often impractical. Additionally, the Centers for Medicare and Medicaid Services (CMS) requires use of the least restrictive precautions possible. Resident’s safety must be balanced with quality of life. The CDC’s new enhanced barrier precautions helps LTCs find the right balance.
• Budget and Resources: LTC tends to lean-in to more generic products and dilutable disinfectants but the trade-off can be efficacy, efficiency, and surface compatibility. Concerns with dilutable products include the risk of dilution error, product contamination, and the need to clean, disinfect, and dry buckets and spray bottles after use. Any remaining diluted product must be discarded at the end of each shift which can be wasteful.

In addition to setting differences, a recent study found that residents touch surfaces in shared areas on average 12 times per hour and staff contact these surfaces 26 times per hour.⁷ Consider this in light of another new study that found that 90% of surfaces across 11 LTC facilities tested positive for fecal pathogens.⁸ Not surprisingly, multidrug-resistant organisms (MDROS) are highly prevalent in LTC facilities. Studies show that over half of residents are colonized with an MDRO. The cases we see - the active infections - are only the tip of the iceberg. Asymptomatic carriage contributes to silent spread. Several studies have reported that 93%-100% of surfaces in LTC facilities are contaminated with MDROs.^9-11 It’s vital to prevent MDRO transmission as treatment options are limited.

As if these challenges are not enough, there are staffing issues. The new CMS regulatory requirement calls for LTC facilities to have a designated and trained IP.¹² This coupled with the Great Resignation, has resulted in many new IPs in this setting. On average, these IPs spend less than 9% of their time on cleaning and disinfection which makes becoming proficient in this area a challenge.¹³ IPs are not the only ones who are under-staffed. There are shortages in nursing and environmental care staff (EVS) as well. While turn-over has always been high in the LTC sector, the pandemic has dramatically exacerbated the issue. With so many new hires, it can be difficult to ensure that everyone is cleaning in a standardized way.

Another challenge that LTC facilities face are disparities in their environmental cleaning and disinfection programs. A recent CMS pilot project found that 80% of LTC facilities had the following gaps:¹⁴

• A lack of training and documented competency,
• Failure to adhere to disinfectant instructions for use (IFUs),
• Failure to audit cleaning practices, and
• A lack of policies for cleaning medical equipment, particularly between residents.

Cleaning Failures: Improper cleaning contributes to pathogen transmission. Studies show that we miss more than half of surfaces that should be cleaned. Additionally, researchers have identified a significant increase in risk to the next patient to occupy a room previously occupied by an infected patient to acquiring that pathogen. Environmental surfaces, objects, and medical devices can serve as reservoirs for pathogens that can be transmitted by the hands of healthcare workers to patients. In fact, hands have been implicated in 20–40% of HAIs. This failure rate of both hand and environmental surfaces cleaning leaves much room for improvement. Figure 2 is a nice infographic that summarizes this section on cleaning failures.^15-18

Figure 2. Improper Cleaning Contributes to Transmission of Pathogens.

In closing, the LTC setting has its own unique challenges to cleaning and disinfection but these can be overcome with a robust cleaning and disinfection program. This brings us to Part 2 of this blog: Solutions to Cleaning and Disinfection Challenges in LTC Settings.

References

<sup>1. The Checkup. Long-Term Care Statistics 2022. [Internet]. [Cited 2022 May 20]. Available from https://www.singlecare.com/blog/news/long-term-care-statistics/
2. US Census Bureau. Older People Projected to Outnumber Children for First Time in US History. [Internet]. [Cited 2022 May 20]. Available from https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html#:~:text=%E2%80%9CBy%202034%20(previously%202035),decade%20for%20the%20U.S.%20population.
3. NIH. Supporting Older Patients with Chronic Conditions. [Internet]. [Cited 2022 May 20]. Available from https://www.nia.nih.gov/health/supporting-older-patients-chronic-conditions.
4. Consumer Affairs. Long-term care statistics [Internet]. [Cited 2022 Mar 20]. Available from https://www.consumeraffairs.com/health/long-term-care-statistics.html#:~:text=There%20are%20about%2065%2C600%20regulated,people%20in%20assisted%20living%20facilities
5. Infection Prevention Guide to Long-Term Care. 2nd ed. Arlington, VA: APIC; 2019
6. CDC. HAI Data Portal, 2021. Available from https://www.cdc.gov/hai/data/portal/index.html
7. Pineles L, Perencevich E, Roghmann M, Gupta K, Cadena, J, Barocco G, et al. Frequency of Nursing Home Resident Contact with Staff, other Residents, and the Environment outside Resident Rooms. Infection Control & Hospital Epidemiology. 2019;1-3. https://doi.org/10.1017/ice.2019.117.
8. Cannon JL, Park GW, Anderson B, Leone C, Chao M, Vinje J, et al. Hygienic Monitoring in LTCFs using ATP, crAssphage, and Human Norovirus to Detect Environmental Surface Cleaning. AJIC. 2022; 50: 289-294.
9.     McKinnell J, Miller L, Singh R,  Walters D, Peterson E, Huang S. High Prevalence of MDRO Colonization in 28 NHs: An Iceberg Effect. JAMDA. 2020;21(12):1937-1943
10.  Cassone M, Wang J, Lansing B, Mantey J, Gibson K, Gontjes K, et al. Proceeding from SHEA 2022. Poster: Diversity and persistence of MRSA and VRE in NHs: Environmental screening and whole-genome sequencing. ASHE. 2022;2:s80.
11. McKinnell J, Singh R, Miller L, Kleinman K, Gussin G, He J, et al. The SHIELD Orange County Project: MDRO Prevalence in 21 NHs and LTACHs in So Cal. Clin Infect Dis. 2019;69(9):1566-1573.
12. CMS. State Operations Manual-Appendix PP – Guidance to Surveyors for Long-Term Care Facilities, 2017. [Internet]. [Cited 2022 July 16]. Available from https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf
13. Landers T, Davis J, Christ K, Malik C. APIC MegaSurvey: Methodology and Overview. AJIC. 2017; 1;45(6):584-588.
14. Ogundimu, A. Proceedings from APIC 2019: Association for Professionals in Infection Control and Epidemiology on Infection Prevention and Control (IPC) Practices in Nursing Homes: Findings from a CMS Infection Control Pilot Project. Philadelphia, PA.
15. Carling PC, Bartley JM. Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients. AM J Infect Control. 2010;38:S41-50
16. Chemaly R, Simmons S, Dale C, Ghantoji S, Rodriguez M, Gubb J, et al. The role of the healthcare environment in the spread of MDROs: update on current best practices. Ther Adv Infect Dis. 2014;2(3-4), 79-90.
17. Haenen A, Greeff S, Voss A, Liefers J, Hulscher M, Huis A. Hand hygiene compliance and its drivers in LTCFs; observations and a survey. Antimicrob Resist Infect Control. 2022; 11(50)
18. Suleyman G, Alangaden G, Bardossy A. The Role of Environmental Contamination in the Transmission of Nosocomial Pathogens and HAIs. Curr Infect Dis Rep. 2018; 20:12</sup>

The importance of environmental hygiene has never been greater than it is today. With our focus on a single pathogen over the past two years, other pathogens have gotten away from us. The U.S. lost a decade of progress in the reduction of healthcare-associated infections (HAI), including Clostridioides difficile and multidrug-resistant organisms (MDROs).¹ Candida auris, an emerging threat, saw an 85% increase in clinical cases in 2020 from the previous year.² This particular pathogen has a very high mortality rate, persists in the environment, and has proven to spread rapidly in and between healthcare facilities. With nearly 80% of all infectious diseases being spread by contact (or touch), addressing environmental transmission of pathogens is as important as any other patient safety activities, including the implementation of bundles and stewardship programs.³ This article will introduce a new framework, highlighting the importance of environmental hygiene and elevating it to that of well-established bundles and stewardship programs.

So, what is a bundle? The concept of bundles was developed in 2001 by the Institute for Healthcare Improvement (IHI) as an improvement tool. The earliest bundles targeted prevention of central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). A bundle is a core set of accepted evidence-based practices that when implemented together result in significantly better outcomes (e.g., HAI rates), than when implemented alone. Bundles are just one strategy among many towards preventing patient harm.⁴

Other strategies for patient safety are stewardship programs. Stewardship means “to take care of something.” A stewardship program is a set of key principles to guide improvement efforts. Two of the most common stewardship programs are antimicrobial stewardship and diagnostic stewardship — both are intended as a means to combat antimicrobial resistance. For example, antimicrobial stewardship programs aim to preserve antimicrobials for future use by preventing over- and inappropriate use. We saw during the pandemic resources being redirected from stewardship to COVID-19 related activities. But with increases in HAIs and MDROs during this time, we must again prioritize our stewardship efforts.

This brings us to the new framework which I call the “Stewardship Triad” (see figure). Part of this 3-pronged bundle of stewardship programs is a new stewardship program: Environmental Hygiene Stewardship. The key evidence-based practices for this program include:

• Provision of a clean and sanitary facility,
• Purchasing cleanable equipment and furnishings,
• Selection of the right products,
• Use of evidence-based cleaning policies and protocols,
• Provision of education, training, and competency assessment,
• Adherence to disinfectant instructions for use (IFUs) and also equipment care guides for cleaning and disinfection,
• Cleaning performance and quality monitoring, and
• Use of no-touch disinfection technologies.

Stewardship Triad to Reduce Environmentally Spread Pathogens (including MDROs & C. difficile)

A stewardship bundle for the post-antibiotic era

*NEW* Environmental Hygiene Stewardship Core Elements

• Provision of clean and sanitary facility
• Purchasing cleanable equipment and furnishings
• Selection of the right products
• Use of evidence-based cleaning policies and protocols
• Provision of education, training and competency assessment
• Adherence to disinfectant IFUs and also equipment care guides for cleaning
• Monitoring cleaning performance and quality
• Use of no-touch disinfection technology

Antimicrobial Stewardship Core Elements

• Dedicate program resources
• Appoint program leaders with clear goals and objectives
• Engage key staff members
• Have expertise in pharmacy practices
• Identify interventions, then implement, audit and solicit feedback
• Educate prescribers, pharmacists, nurses
• Monitor prescribing practices and outcomes
• Reports antibiotic usage and resistance on a regular basis to inform stakeholders

Diagnostic Stewardship Core Elements

• Draft SOPs to guide good lab practices
• Order appropriate tests at the right time
• Collect, store, transport and reject specimens in timely manner
• Report test results in an accurate and timely manner
• Identify pathogen to inform correct and timely treatment
• Develop and implement antibiograms
• Train and educate MDs, pharmacists, nurses on best practices

High compliance with environmental hygiene stewardship means breaking the chain of infection and by doing so, lessening the need for antimicrobial and diagnostic stewardship. Environmental hygiene stewardship not only elevates the importance of cleaning and disinfection but also our hard-working environmental services professionals.

References

<sup>1. Weiner-Lastinger LM, Pattabiraman V, Konnor RY, Patel PR, Wong E, Xu SY, et al. The impact of COVID-19 on healthcare-associated infections in 2020: A summary of data reported to NHSN. Infection Control & Healthcare Epidemiology. 2020; 1-14.
2. Centers for Disease Control and Prevention. Tracking Candida auris. [Internet]. [cited 2020 Feb 15]. Available from https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html.
3. Tierno, P. The Secret Life of Germs. New York, NY, USA: Atria Books, 2001.
4. Resar R, Griffen FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality, 2012 [Internet]. [cited 2022 Feb 15]. Available from http://www.ihi.org/resources/Pages/IHIWhitePapers/UsingCareBundles.aspx.</sup>

Over the past two years, with our attention singularly focused on COVID-19, facility outbreaks with other pathogens have been particularly problematic. In a systematic review, Thoma et al (2022) identified 17 outbreaks of multidrug-resistant pathogens, most caused by Candida auris and carbapenem-resistant Acinetobacter baumannii (CRAB) with an overall mortality rate of 35%.¹ With resources diverted to pandemic-related activities pathogens such as these and others have gone undetected. Additional contributing factors including staffing shortages and pandemic fatigue have led to breaches in standard infection prevention and control (IPC) practices.

Outbreaks are a serious threat to patient safety and can also damage a facility’s reputation. Management of outbreaks is costly and resource intensive. Because outbreaks are an infrequent occurrence in any given facility, it’s crucial that infection preventionists (IPs) understand how to promptly identify and control outbreaks.

 4 Simple Steps to Outbreak Management

The definitions for levels of disease, including outbreaks, are provided in Table 1. Ideally, we want to identify cases early before we have a full-blown outbreak on our hands.

^{Adapted from CDC’s Principles of Epidemiology in Public Health Practice (2012).2}

Outbreaks are often first noticed by an astute clinician. Should such a clinician reach out to you, take the time to investigate. Sometimes the concern is unfounded or coincidental but too often it’s found to be valid. Also, trust your gut. If you are concerned over what you are seeing in your surveillance activities, then investigate. I recall a single day when I identified not one, but two patients who had respiratory isolates growing the same Penicillium species. Since the patients were on separate units, I took a wait-and-see approach. The next day, two additional patients were identified. Despite being a new IP, I knew this was a problem. But where does one start? Let’s take a look at the 4 key steps to managing an outbreak:

Step 1 — Verify the Existence of an Outbreak:

• Are you seeing an uptick in cases? In my Penicillium example, I had never seen this pathogen before in my microbiology reports so my “spidey senses” were up. Ensure that the increase is not for reasons such as improvements in testing or changes in the population. This happened to me once when we improved our testing process for C. difficile. It’s also important to note that small numbers of cases or even a single case of an epidemiologically important pathogen such as C. auris, CRAB, or carbapenem-resistant Enterobacteriaceae (CRE) is cause for investigation.
• Verify the diagnosis: This is critical. In my Penicillium example, after speaking with the patient’s physicians, I was able to learn that none of them exhibited signs or symptoms of fungal disease. The physicians were managing the cases as contaminants. My next thought was contaminated petri dishes, but after a visit to the hospital laboratory, this was ruled out.  
• Look for commonalities among the patients. In my Penicillium example, I had four cases on two units, all on the same floor all of the hospital. Two of the patients were on a ventilator.
• Summarize cases: Graph the number of cases by time (date). Much can be learned from analyzing frequency distributions using a histogram.

Step 2 — Develop a Case Definition:

A case definition is a set of objective and measurable criteria for deciding whether an individual should be classified as a case. It should be restricted by person, place, and time. A common mistake is to include the exposure or risk factors of interest. For example, in my Penicillium example, it was tempting initially to limit my definition to only patients on the units where positive patients resided. Consider having case definitions for confirmed, probable, and possible cases. As you gather more information, your definition may change. Note: no case definition is perfect – some mild cases may be excluded while others with similar symptoms but a different illness may be included. For an example of a case definition based on my Penicillium example, see Table 2.

^{Adapted from CDC’s Principles of Epidemiology in Public Health Practice (2012).}

Step 3 — Develop and Test Your Hypothesis:

The hypothesis is a proposed explanation for the outbreak made with limited evidence as a starting point for further investigation. It may address the source, transmission mode, and exposures of the pathogen. To test the hypothesis, compare it with the facts such as the clinical, laboratory, environmental, and/or epidemiologic evidence. In my Penicillium example, I hypothesized that the source of the pathogen was a flaw in the HVAC system. To test my hypothesis, I had the facility engineering staff inspect the HVAC duct servicing the effected floor. They found that the HEPA filter was too small for the HVAC duct. This allowed unfiltered outdoor air — where mold spores are ubiquitous — to enter the building. I further hypothesized that if the incorrect filter was replaced with the correct one, we should see no further isolates growing Penicillium. I was right. With the outbreak confirmed, I promptly notified my facility leadership. Also, since most state require reporting of outbreaks of any disease or the occurrence of any unusual disease, be sure to notify local public health authorities.

Step 4 — Implement Control Measures:

In my pseudo-outbreak example, placement of the correct HEPA filter immediately resolved the problem. I was very fortunate as most outbreaks do not resolve this simply and more often than not, the root cause is never identified.

Once you have identified the culprit and understanding its epidemiological traits such as reservoirs and mode of transmission, consider ways in which the chain of infection can be broken. Ensure compliance with basic IPC protocols such as hand hygiene and environmental cleaning and disinfection. Because many pathogens can persist in the environment for prolonged periods, environmental contamination can play a key role in outbreak management. For example, environment surfaces — particularly portable medical equipment — have been implicated in many of the C. auris outbreaks.³

 Key Take-Aways

Be sure to add this article as a tool for your IPC toolbox. Trust your gut — you likely know more than you think you do! Take the time to investigate concerns but always verify that there is indeed a problem. Graph the frequency distribution and develop a case definition. Test your hypothesis. Once you have confirmed the existence of an outbreak, promptly implement IPC measures. Last, be sure to document your outbreak “story” in a report for facility recording purposes.

References

<sup>1. Thoma R, Seneghini M, Seiffert SN, Vuichard G, Scanferla G, Haller S, et al. The challenge of preventing and containing outbreaks of multidrug-resistant organisms and Candida auris during the coronavirus disease 2019 pandemic: report of carbapenem-resistant Acinetobacter baumannii outbreak and a systematic review of the literature. Antimicrob Resist Infect Control. 2022 Jan 21;11(1):12.
2. Centers for Disease Control and Prevention. Principles of Epidemiology in Public Health Practice — Lesson 6: Investigating and Outbreak [Internet]. [Cited 2022 Feb 5, 2022]. Available from https://www.cdc.gov/csels/dsepd/ss1978/lesson6/section2.html#step11.
3. Centers for Disease Control and Prevention. Infection Prevention and Control for Candida auris [Internet]. [Cited 2022 Feb 5]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html.</sup>