The following is an abridged article featured in the December 2020 issue of Healthcare Hygiene Magazine (see page 32).
As a healthcare provider that is part of a Regional COVID-19 response team, I have sadly seen the direct and indirect impacts of the ongoing threat posed by COVID-19. Countless lives have been directly or indirectly impacted including those of many healthcare providers at the front lines and healthcare executives charged with leading their organizations during challenging pandemic times. This ongoing pandemic is not expected to cease anytime soon, and the upcoming fall and winter respiratory infections season could potentially produce a new dilemma with concurrently circulating infectious pathogens such as Influenza, RSV, Rhinovirus, and SARS-CoV-2, the novel coronavirus that causes COVID-19. Due to this concurrent circulation of respiratory viruses during the Fall and Winter, it is all the more important for healthcare facilities to not succumb to infection prevention fatigue and maintain an appropriate level of vigilance to the core practices of infection prevention and control.
The Centers for Disease Control and Prevention (CDC) has identified several core recommendations that can dramatically reduce the potential risk for the transmission of respiratory viruses. Below are several key steps that healthcare providers and infection prevention professionals should take to reduce the transmission of infectious respiratory illnesses:
- Rapid Identification of Infectious Diseases: Healthcare facilities must continue to diligently screen their patients, visitors, and staff for potential infectious illness. This screening process should include temperature, symptoms, exposure history, and also travel history.
- Social Distancing: Social distancing practices continue to provide for an additional element of safety by distancing persons from each other, including while in healthcare settings. Social distancing continues to be recognized as one of the simplest and most effective infection control interventions to curb the spread of COVID-19. All healthcare providers, patients, and visitors should wear masks as a universal source control and in accordance with institutional policies for respiratory protection.
- Occupational Health and Illness Recognition: Remaining home from work when ill and away from other people remains an important component of any healthcare facility infection control program. The facility’s human resources department must create a culture of safety by making it “safe” for ill healthcare workers to remain home from work when ill with infectious illnesses without penalty or punitive action. National Programs such as Just Culture can assist healthcare organizational leaders in creating a culture of safety that rewards best practices for safety.
- Routine Hand Hygiene: Simply washing or sanitizing our hands as healthcare providers remains the single most important infection prevention intervention to reduce the potential transmission of Healthcare-Associated Infections (HAIs) and respiratory viruses. This can be accomplished by either washing the hands with soap and water for at least 20 seconds or the use of an alcohol-based hand rub that contains an alcohol formulation between 60-90%.
- Cleaning and Disinfection: Routine cleaning and disinfection of high touch surfaces using an Environmental Protection Agency (EPA)-registered disinfectant will help reduce the potential for indirect transmission of respiratory viruses from environmental surfaces to both healthcare providers as well as patients. It is important to always utilize an EPA-registered, healthcare disinfectant which has broad-spectrum efficacy for a wide variety of pathogens common in healthcare settings. In addition, because of the ongoing threat caused by the SARS-CoV-2, the EPA has released a new List, List N: Disinfectants for Coronavirus (COVID-19), which specifically identifies all current EPA registered disinfectants that are deemed effective against the SARS-CoV-2. Users must carefully follow the disinfectant manufacturer’s instructions for use to ensure safety and efficacy of the product.
- Proper Use of Personal Protective Equipment (PPE): The CDC has provided updated guidance for mitigating the risk of transmission of infectious respiratory pathogens within the current pandemic. This guidance includes the use of respiratory protection, glove, gowns, and eye protection as clinically indicated based on the pathogen of suspicion. It is imperative that healthcare providers not only have access to high-quality PPE, but also are properly trained on the specific PPE equipment’s use in accordance with the manufacturer’s instructions for use. This includes proper donning and doffing procedures to minimize the potential risk for healthcare personnel and environmental contamination.
Each of the steps referenced above plays a pivotal role in reducing the potential transmission of infectious respiratory viruses, keeping patients and healthcare providers safe, and also ensuring the continuity of clinical care operations. Every stakeholder in the healthcare delivery system must play an active role in recognizing and preventing the spread of these common respiratory pathogens. Through interprofessional collaboration, the use of efficacious infection prevention products such as disinfectants, hand sanitizers, and PPE, we can help effectively curb the transmission of respiratory illnesses.
For additional information:
To learn more about the EPA List N, visit: https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19.
Dr. Hudson Garrett Jr. is a paid consultant for Clorox Healthcare.
“Adjunct disinfection methods such as electrostatics seem to be gaining in popularity. Is a manual cleaning step always required?”
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 Disinfectants||Active Ingredient||Suggested Use Locations||Contact time||Personal Protective Equipment (PPE)|
|Spore10 Defense™ Cleaner Disinfectant||Sodium hypochlorite||Patient care areas where C. diff is a concern (e.g., terminal cleaning, etc)||5 minutes||Eye protection; Wear other PPE in accordance with Standard Precautions.|
|Total 360® Disinfectant Cleaner1||Quaternary ammonium compound||Patient care areas when C. diff is not a concern||2 minutes||Eye protection; Wear an N95 respirator for prolonged use; Wear other PPE in accordance with Standard Precautions.|
|Anywhere® Hard Surface Sanitizing Spray||Sodium hypochlorite||Non-patient care areas such as offices and conference rooms and anywhere that a food safe product is indicated such as the cafeteria.||2 minutes||Eye protection; Wear other PPE in accordance with Standard Precautions.|
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.
- Kill C. diff with Clorox Healthcare® Spore Defense™ &Clorox® Total 360® Video
- Clorox® Total 360® System Training Video
- Electrostatic Spray Disinfectant Technology & Clorox Healthcare® Spore Defense™ - Clinical Study
- Donskey, C., et al. (2020). Evaluation of an Electrostatic Spray Disinfectant Technology for Rapid Decontamination of Portable Equipment and Large Open Areas in the Era of SARS-CoV-2. AJIC, 48(8), 951-954.
- Clorox® Total 360® Disinfectant Compatibility Chart
- Evaluating Electrostatic Sprayers for Surface Disinfection White Paper
- 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:
- Expand: Infection prevention needs to expand from acute care only to all healthcare and community settings;
- Contain: The mindset needs to change from one of response to one of containment;
- Eliminate: We need to move from the concept of preventing infections to eliminating them.
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.
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.
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.
- The New York Academy of Medicine, “Virtual Summit for Infection Prevention in Nursing Homes”, [cited 12/2/2020].
This is the first of a series of historical blog posts, each of which will cover the life and work of infection control pioneers or celebrate key related events. This post features Sir John Pringle whose original ideas laid the foundation for aspects of infection control that we take for granted today.
On the first day of January 1750, the Philosophical Transactions of the Royal Society published three remarkable articles. The first, titled “Some experiments on substances resisting putrefaction” was followed by two others, both of which described additional experiments on the topic. The articles are notable because they describe the first scientific study on these substances which the author called “antiseptics”, and they represent one of the earliest uses of the word “antiseptic”, a term which some have attributed to the author.
That author was Sir John Pringle. Readers of Infection Control and Hospital Epidemiology (ICHE) may well be familiar with him, as his portrait has graced the front cover of every volume in 2020. He sits at a desk facing the unknown artist, looking as if he’s been interrupted while reading a manuscript, and holds a walking stick in his left hand. He wears the typical dress of a gentleman of his time; black breeches falling just below the knee, white stockings, a long, dark coat, and a fashionable silvery-gray wig. The journal gives a brief description of his achievements but there’s much more to Sir John, physician to the army and the Royal Family, President of the Royal Society, and one of the pre-eminent physicians of his day.
Sir John, it turns out, was far ahead of his time. His pioneering work on antiseptics, combined with his work on his constant aim of “preventing infection, the common and fatal consequence of a large and crowded hospital” perhaps entitles him to be considered not just a founding father of military medicine, but as a pioneer of public health and infection prevention practices.
His experiences on the battlefields during the War of the Austrian Succession in the 1740’s appears to have shaped much of his thinking around transmission and prevention of infectious diseases. His most important work, Observations on the Diseases of the Army, published in 1750 gave, for the first time, a scientific account of the epidemiology, pathogenesis and prevention of hospital cross-infections. He observed that military hospitals with their poor ventilation, unsanitary conditions and overcrowding were a chief cause of sickness and death, citing for instance, the spread of dysentery between patients in the same wards through infectious straw probably used as bedding.
He also recognized that outbreaks of jail fever and hospital fever were the same disease – typhus, reaching this conclusion after observing that deserters with jail fever transmitted the disease to English troops, who then became the source of hospital fever outbreaks. His advice for prevention of flea and lice-spread typhus is as sound today as it was then; burn the clothes of prisoners and executed criminals and give new clothes to prisoners and wash them from time to time. Furthermore, these observations led him to describe interventions to moderate or prevent the contagion including dispersing the sick, preserving pure air in the wards, reducing overcrowding, along with other hygienic measures to combat sepsis.
That idea that pure air could help prevent the spread of infection became apparent in October 1750. After an outbreak of jail fever in Newgate Prison and the law courts of the Old Bailey (the latter had taken the life of the Lord Mayor of London), Sir John joined a committee to investigate. It had a clear objective:
“to inquire into the best means for procuring in Newgate such a purity of air, as might prevent the rise of those infectious distempers, which not only had been destructive to the prisoners themselves, but dangerous to others, who had any communication with them”.
A Royal Society publication of 1753 describes the investigation and the solution which was the installation of a windmill-powered ventilator invented by the leading ventilation expert of the time, the Reverend Dr. Stephen Hales. This device “sweetened” the air in the building by drawing out the foul air from the lower stories to the upper. After installation, deaths in the prison decreased from eight a week to about two a month, but not until seven of the workmen installing the device died of the fever. Two hundred and seventy years later, the importance of good ventilation to help prevent the spread of COVID-19 is becoming very clear.
But back to antiseptics, and a connection to modern day disinfectants. The Royal Society publications describe in meticulous detail, Sir John’s controlled experiments on a range of exotic-sounding substances. His method was simple – add the substance to a small piece of meat in water, cap the tube and keep it warm, then observe whether the meat putrefied or not. Substances that prevented or stopped putrefaction he called “antiseptic”. What the substances were doing was killing or preventing the growth of bacteria that would cause putrefaction.
At this point, it’s worth remembering that although van Leeuwenhoek had observed bacteria through his microscope in 1676, they were virtually ignored for over 100 years and not well known at the time of Sir John’s experiments. In fact, nowhere in the three publications does the word “bacteria” appear.
Of the countless exotic-sounding and common substances tested, he found that alkalis as Spirit of Hartshorn (aqueous ammonia solution derived from the horns of a male red deer) and salammoniac (ammonium chloride) and acids such as vinegar (acetic acid) and lemon juice (citric acid) were effective antiseptics. This is perhaps not surprising to the modern reader with a basic knowledge of antimicrobial mechanism of action. For these substances, or derivatives of them form the basis of many disinfectants today; quaternary ammonium chlorides are essentially ammonium salts; acetic acid when combined with hydrogen peroxide forms peracetic acid, an especially powerful antimicrobial agent. And citric acid is finding its place as an EPA-approved Safer Choice active antimicrobial ingredient.
We have a lot to thank Sir John Pringle for; basic infection prevention measures for hospitals, the idea of fresh air and good hygiene, fundamental research into antiseptics. Well-thought of in his time – there is even a memorial to him in Westminster Abbey – his contributions seem to have been forgotten over time. Thanks to ICHE for bringing him to life in 2020. I’m eagerly waiting to see who’s on the front cover in 2021.
This is the third post of a six-part blog series, Infections Inside Out, by Dr. Kelly Cawcutt. Read part two here.
Biofilms play an important role in the development of hospital-acquired infections (HAIs). In my line of work, I’m often reminded of their presence when handlining central venous catheters or endotracheal tubes, but biofilms can also be present on any environmental surfaces. Biofilms are defined as a complex collection of microorganisms that attach to a surface and create a surface specific ecosystemic on that surface (known as an extracellular polymeric substance [EPS]). Given the complexity, and strong adherence to surfaces, biofilms result in a perpetual conglomerate of microorganisms that may be impossible to fully eradicate, resulting in a difficult, albeit often underestimated cause of infections in healthcare.
Given the increase usage of ventilators for the treatment of severe COVID patients, I thought now was a particularly good time to drive awareness about this complex, Jello-like matrix filled with microorganisms such as bacteria.
Biofilms contribute to many infectious diseases. Some classic examples are endocarditis, prosthetic joint infections and Clostridiodes difficile (C. diff) along with device-related infections such as central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs) and ventilator-associated pneumonia (VAP), among others. In the era of COVID-19, the impact of biofilms on HAIs may be more prominent due to the high device utilization in the intensive care units (ICUs) and long length of stays.
Considering the impact of biofilms, there are many details to keep in mind. First, given the capacity for biofilms to form on any surface, preventing microorganisms from attaching to a surface is a key intervention. The prevention of infection is multifaceted, and echoes the importance of infection control measures such as hand hygiene, device stewardship, aseptic technique, maintenance of devices and equipment, and environmental cleaning. Beyond this, patients may have additional risk factors that contribute to their likelihood of biofilm development which can include diabetes, kidney disease and immunosuppression. The risk factors are associated with decreased innate immune responses that normally fight the development of biofilms, so when a disease impacting the innate immune system is present, there is less of our individual capacity to prevent the build-up of that "gunk" on my patient’s endotracheal tube. Recognizing the role comorbid conditions, especially those that are very common (like diabetes and kidney disease) may play in such infections is essential as we strive to beat biofilms and prevent HAIs.
There are many human pathogens that are described to comprise, and grow within, biofilms can result in infection, including, but not limited to, Staphylococcus aureus, Pseudomonas aeruginosa and Legionella pneumophila. Candida species, including both Candida albicans and Candida auris (C. auris), are known to also cause biofilms. The known presence of these organisms has resulted in innovative devices, such as central venous catheters, impregnated with antimicrobial agents to prevent microbial attachment to the catheter, and therefore biofilm development. Such catheters have demonstrated decreases in HAIs, specifically in this scenario, CLABSI.
Although individual patient infection control measures must be followed, environmental sources of biofilm cannot be ignored. One specific rising concern in the infection control world is C. auris, which was first detected in 2009, and subsequently has spread throughout the world. Infections secondary to C. auris are significant due the life-threatening nature of these infections, combined with both the resistance to several antifungal medications and the capacity to spread within healthcare facilities. C. auris has been described to cause surface biofilms in patient rooms that may be difficult to eradicate, therefore be a conduit for infections. C. auris may be contracted from a patient, or their environment (including equipment that may be used for multiple patients), in as little as 4 hours, therefore effective disinfection is critical. Chlorhexidine-based regimens for patient asepsis may not be as effective as povidone iodine and environmental disinfectants, such as ethyl alcohol and quaternary ammonium, may be less effective than hydrogen peroxide or sodium hypochlorite. We must understand which infection control strategies, including the chemicals used, are effective against pathogens, or we will miss the opportunity to prevent HAIs!
Beyond the patient and physical environment, biofilms with infectious pathogens (such as Pseudomonas aeruginosa and Legionella pneumophilia) can form in water sources and clear guidance exists from the CDC on how to assess, and decrease the risk, of water-based biofilm as a source for transmission of infection within hospitals. Examples of where such biofilms could occur is within faucets, ice machines, showers, toilets and drains.
Given the near impossibility of eradicating biofilms, further research into prevention of biofilms is of paramount importance. Specifically, the roles of antimicrobial impregnated devices and surfaces (such as the central venous catheter device mentioned above), and optimal patient asepsis and environmental disinfection. Our best offense continues to be adherence to infection control practices and engaging the entire healthcare team in the one-two punch required to beat biofilms. Our patients are depending on us!
Kelly Cawcutt, MD, MS, FACP is a paid consultant for Clorox Healthcare.
Within the past three months, there have been more and more articles written about “Sanitization or Hygiene Theater.”1 The concept is based off “Security Theater,” a term which was used post-9/11 to describe the increased TSA measures that, arguably, did little to prevent future attacks.2 The comparison is founded on the notion that all the pandemic-induced cleaning, sanitizing, and disinfecting may be completely unwarranted and even wasteful in terms of time and money. In August 2020, Dr. Emanuel Goldman, a Professor of Microbiology at Rutgers University published a commentary based on comprehensive scientific literature review in The Lancet stating that “the chance of [SARS-CoV-2] transmission through inanimate surfaces is very small, and only in instances where an infected person coughs or sneezes on the surface, and someone else touches that surface soon after the cough or sneeze (within 1–2 h) [is there a risk].” Dr. Goldman goes on to say that “although periodically disinfecting surfaces and use of gloves are reasonable precautions especially in hospitals, I believe that fomites that have not been in contact with an infected carrier for many hours do not pose a measurable risk of transmission in non-hospital settings.”3
As a Public Health Professional, I cannot help but pause to contemplate this perspective. On one hand, the CDC confirms that “COVID-19 is thought to spread mainly through close contact from person-to-person, including between people who are physically near each other (within about 6 feet).” Though guidance still encourages “routinely clean[ing] and disinfect[ing] frequently touched surfaces.”4 On the other hand, I have been advocating for better disinfection practices in both healthcare and private settings for my entire career. I see this new world mindset as an incredible public health achievement. Infection Prevention is no longer a term isolated to the four walls of the hospital — we, now more than ever, are all more aware of the need for disinfection within our businesses as employees (or owners), as consumers, and even in our own homes. If you were to travel back to pre-pandemic times (possible via a quick Google search), illnesses such as the flu, common colds, and stomach bugs (gastroenteritis) were already a substantial burden in terms of absenteeism, diminished productivity, and increased healthcare costs.5 Influenza infections in adults alone resulted in an estimated $87 billion per year in terms of healthcare costs, projected lost earnings, and loss of life.6
Even knowing all of this, prior to the pandemic, employees and customers accepted a certain level of risk when it came to the safety of our shared public spaces. Post-pandemic, that accepted trust in the world around us is gone. Deloitte recently published a Safety and Cleanliness Survey7 which demonstrated that in addition to wearing masks and providing hand sanitizer, the top interventions businesses can take to rebuild trust are:
- Surfaces cleaned after each interaction (62%)
- Extra cleaning precautions & preventions taken (59%)
- Regular spraying/fogging to disinfect shared furniture spaces (57%)
- Regular cleaning of equipment and shared space by a cleaning service (64%)
- Regular spraying/fogging to disinfect shared furniture spaces (60%)
Source: Deloitte Safety & Cleanliness Survey, Deloitte Consulting LLP, 2020
Not only are these practices what we should have been doing all along, it is evident that the public is now looking for consistent displays of safety and cleanliness to trust businesses moving forward. However, as highlighted in the recent CloroxPro blog, Smart Disinfection: Making the Most of Your Disinfectants, it is important to develop a plan for using disinfectants efficiently and effectively. There is undoubtedly a balance that businesses need to find, and “hygiene theater” cannot be the only public health protocol put into practice. Any cleaning and disinfection efforts need to be used in combination with other CDC recommended initiatives, including social distancing, mask wearing, handwashing, staying home when sick, and improving indoor ventilation.4 The idea of Dr. James Reason’s 1990 “Swiss Cheese Model” still holds true today. The safeguards recommended represent the multiple layers needed to protect consumers and employees, alike. As pointed out by the Cleveland Clinic, “when used together consistently, the holes (or weaknesses) in any single layer of protection should be offset by the strengths of another layer of intervention.”8 We have to address every area of potential spread to truly create a safe and healthy environment for all.
- 1. Thompson D. Hygiene Theater Is a Huge Waste of Time: People are power scrubbing their way to a false sense of security. [Internet]. The Atlantic. 2020 [cited 2020 Oct 6]. p. 1–8. Available from: https://www.theatlantic.com/ideas/archive/2020/07/scourge-hygiene-theater/614599/
- 2. Judkis M. Deep cleans and disinfecting mists might not keep us from getting the virus , but they sure make us feel better [Internet]. The Washington Post. 2020 [cited 2020 Oct 6]. Available from: https://www.washingtonpost.com/lifestyle/style/deep-cleans-and-disinfecting-mists-might-not-keep-us-from-getting-the-virus-but-they-sure-make-us-feel-better/2020/09/05/f428b8ee-e965-11ea-97e0-94d2e46e759b_story.html
- 3. Goldman E. Exaggerated risk of transmission of COVID-19 by fomites [Internet]. Vol. 20, The Lancet Infectious Diseases. 2020. p. 892–3. Available from: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30561-2/fulltext
- How COVID-19 Spreads [Internet]. Centers for Disease Control and Prevention (CDC). 2020 [cited 2020 Oct 6]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html
- 4. Bramley TJ, Lerner D, Sames M. Productivity losses related to the common cold. J Occup Environ Med. 2002.
- 5. Keech M, Beardsworth P. The impact of influenza on working days lost: A review of the literature. PharmacoEconomics. 2008.
- 6. Safety and cleanliness – make it or break it. [Internet]. Deloitte Consulting, LLP. 2020 [cited 2020 Oct 6]. p. 1–5. Available from: https://www.deloittedigital.com/content/dam/deloittedigital/us/documents/offerings/offering-20200626-safety-cleanliness-covid.pdf
- 7. Return to Work Amid COVID-19 [Internet]. Cleveland Clinic. 2020 [cited 2020 Oct 9]. p. 5. Available from: https://my.clevelandclinic.org/-/scassets/files/org/employer-solutions/covid-19-returning-to-work-guide.ashx
Many infection preventionists regularly utilize clinical guidelines to guide their daily practice, but have you ever wondered how these national guidelines are developed? Many of the policies and practices that are used in infection prevention and control are developed by multidisciplinary groups whom create evidence-based guidelines. The Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion is primarily responsible for authoring evidence-based guidelines and guidance documents specifically to assist healthcare facilities and providers in reducing Healthcare-Care Associated Infections (HAIs). To aid the CDC in developing evidence-based guidance to the healthcare community, CDC and the Department of Health and Human Services (HHS) maintain the Healthcare Infection Control Practices Advisory Committee (HICPAC), which is a group of federally appointed healthcare experts who are charged with providing the CDC staff with strategic guidance on a wide variety of infection prevention and control challenges across the healthcare continuum of care. In addition to the voting members of the committee, there are also representatives from 21 clinical organizations which do not hold voting power. A senior member of CDC’s staff, the Designated Federal Official, serves as the official committee Secretary and official government representative to the group. This committee provides input not only to the CDC, but also to HHS. HICPAC is an extremely influential body that has tremendous impacts on the infection prevention and control community through the release of guidelines, guidance documents, and position statements that are viewed as the gold standard for both clinical practice as well as liability. These documents and recommendations are used widely in the infection prevention field and serve as the basis for many policies and procedures used in both inpatient and outpatient healthcare facilities.
As an infection preventionist, it’s critical to closely monitor the ongoing work that is being performed by HICPAC. Most HICPAC documents are sent out for official public comment prior to being finalized by the committee, and all healthcare professionals are encouraged to submit written comments along with supporting evidence. Engaging in this guideline creation and review process is a core responsibility of every infection prevention professional.
HICPAC typically meets 3–4 times per year formally, but members of the committee regularly interact through working group meetings. The in-person meetings are hosted at the CDC Headquarters in Atlanta, Georgia and the meetings are open to the public. All infection preventionists should attempt to participate in HICPAC meetings remotely by registering for the webcast of the event. Space is limited for the webcast, so it is imperative to register early to secure your reservation for each meeting. All of the HICPAC presentations as well as minutes are published on the HICPAC website within ninety days of the meeting concluding. The many documents produced by HICPAC are routinely used by other regulatory and accreditation agencies to define standards of care and for documentation of compliance of the current CDC recommendations.
Dr. Hudson Garrett Jr. is a paid consultant for Clorox Healthcare.
This is the second post of a six-part blog series, Infections Inside Out, by Dr. Kelly Cawcutt. Read part one here.
Hospital-acquired infections (HAIs) are infections acquired during medical care and are often directly related to the use of medical devices or procedures, along with lapses in critical infection control practices such hand hygiene, and appropriate cleaning and disinfection. Every day in the U.S., approximately 1 in 31 patients will suffer from a HAI. These infections can include central line associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections (SSIs), ventilator-associated pneumonia (VAP) and development of Clostridiodes difficile infection (CDI). The Centers for Disease Control and Prevention (CDC), along with State and county health departments, along with individual hospitals, monitor these closely via reports to the National Healthcare Safety Network, which assesses outbreaks and monitors progress towards future prevention efforts — with a goal of elimination of HAIs in the future of medicine.
The impact of COVID-19 on HAIs may ultimately be profound due to the use of antibiotics for possible bacterial co-infection and prolonged ICU stays, including the use of multiple invasive devices placing these vulnerable patients at risk for CLABSI, CAUTI, VAP, CDI. Additional factors clearly impacting HAIs during this pandemic include lack of appropriate resources and supply chain issues (such as personal protective equipment and testing supplies), combined with varying rates of infected healthcare workers and risk of burnout impacting the available workforce. Finally, there is ongoing concern that fear amidst this pandemic may negatively impact adherence to infection control practices. Never has prevention of HAIs been more critical given the burden of COVID-19 on healthcare around the world.
Prevention of HAIs
Prevention of HAIs is comprised of several key concepts: avoid both device placement and antibiotic use unless clearly indicated, remove devices and stop antibiotics as soon as possible, and follow infection control measures for the healthcare workers and environment (such as standard and transmission-based precautions, hand hygiene and environmental and equipment cleaning).
With the clear impact of HAIs, there are several different guidelines focusing on how to prevent HAIs. A few critical recommendations and guidelines are:
- The Society for Healthcare Epidemiology of America’s compendium of strategies to prevent HAIs
- CDC guidelines for preventing HAIs
- WHO guidelines for infection prevention
Anyone within the healthcare field, including the patient, is accountable to help prevent HAIs. This is truly a multidisciplinary effort!
In the end, we are all patients and, as mentioned above, can play a role in prevention of HAIs. There are several key actions anyone can take to keep ourselves, and our loved ones, safe from these infections. Practicing excellent hand hygiene, watching closely for signs of developing infection, remembering to only take antibiotics when your healthcare team feels it is necessary and remaining an advocate for safety throughout your hospital stay (such as reminding healthcare workers to perform hand hygiene). (Here is a quick video on five tips to prevent HAIs as a patient.)
There are many invasive devices that are frequently used for patient care, and once they are in place for at least 48 hours, those devices carry the risk for a possible reportable HAI to develop. Some patients require infusions of medications or frequent access to blood draws and monitoring, therefore may have a central venous catheter placed, thereby creating a simultaneous risk for developing CLABSI. Certain patients will have trouble urinating, or need very close monitoring of urine output due to impaired kidney, so an indwelling urinary catheter is inserted and, with that, the risk for CAUTI arises. Patients with severe lung disease, such as those with respiratory failure from COVID-19, may require invasive mechanical ventilation, as provided via an endotracheal tube. Much like the two catheters listed above, with insertion and use of the endotracheal tube, the risk for development of VAP evolves.
In essence, all of these devices are inserted through a potential non-sterile source and therefore carry a risk for bacteria to create a biofilm on the external surface of the catheter, or have bacterial inoculated on the internal surface during cares, increasing the risk of a possible life-threatening HAI. Understanding appropriate indications, insertion techniques, maintenance and prompt removal, once no longer indicated, is of paramount importance.
Infections can spread within the healthcare setting, including based on inadequate environmental cleaning. CDI is one such infection, which is highlighted below. Additionally, there are many aspects of the environment to consider, such as the high touch surfaces at risk for contamination based on lack of hand hygiene. Air-based contamination are based on infectious aerosols (which may additionally occur via coughing, sneezing, flushing a toilet, procedures for a patient that may generate aerosols such as suctional or intubation) or mold secondary to construction or other damage. Water-based contamination can be found in ice machines, faucets, drains and with equipment that utilizes water but is not maintained or cleaned via manufacturer instructions-for-use (IFUs).
All of these simple components around us can serve as conduits for infection. Although this may be top of mind for many during this pandemic and tempt us to focus only on COVID-19, the more ‘mundane’ aspects of environment infection control are just as important in 2020 as they were each year prior. It’s critical that healthcare team members, including nurses, doctors, technicians and EVS staff responsible for cleaning equipment, or the environment, use products that are EPA-registered to be effective against these HAIs.
Seeing C. diff Differently – What Has Changed in Prevention?
CDI is the most common cause of HAIs in the U.S., with specific guidelines for infection prevention given its prevalence from national societies (Infectious Diseases Society of America and the Society of Healthcare Epidemiology of America) and from the CDC. There are several key steps to preventing CDI as a HAI:
- Antibiotic use is the primary driver for development of CDI, therefore it is imperative to follow antibiotic stewardship principles to minimize risk of development of CDI.
- Implement contact precautions for those with confirmed or suspected infections, to avoid unintended spread to others.
- Consider use of innovative engineering for improving adherence to isolation precautions with solutions such as the "Red Box."
- Maintain appropriate personal protective equipment with gowns, gloves and hand washing (especially in outbreak settings) to prevent spread of spores.
- Confirm with appropriate testing strategies. This is key as colonization exists with this organism, so non-infectious etiologies should be considered, do not test if laxatives have been used in the last 48 hours, do not send solid stool for testing and remember that repeat testing for cure is not necessary.
- If non-disposable equipment is used, dedicating equipment to the patient room should be done if possible. If there is an inadequate equipment supply, cleaning before and after each patient use should be done. For CDI, even if using a 2-in-1 product, cleaning should occur prior to disinfecting and should be completed with a compatible sporicidal disinfectant (EPA List K agents; such as Clorox Healthcare® Bleach Germicidal Wipes) should be utilized.
- Terminal room cleaning for patient rooms in which C. diff was present is also critical to prevent ongoing spread of infection as the spores can survive for months within the hospital room and many standard disinfectants are ineffective, therefore effective disinfection is critically important, especially during outbreak situations. Methods may include cleaners, such as Clorox Healthcare® Bleach Germicidal Disinfectants or Clorox Healthcare® Fuzion® Cleaner Disinfectant.
Despite all the efforts on COVID-19, as frontline healthcare teams, we must all pitch in to continue the fight against HAIs. Our patients are depending on us.
Kelly Cawcutt, MD, MS, FACP is a paid consultant for Clorox Healthcare.
In part one of this 3-part blog series, we learned about SARS-CoV-2, the virus responsible for COVID-19 infection. We reviewed how infections occur using the Chain of Infection framework, including ways in which the chain can be broken to stop transmission. A special emphasis was placed on the role of environmental surfaces in transmission. In part two, we focused on preventing the transmission of COVID-19 within the hospital, looking at both what hospitals are doing and what patients can do. Next, we shared ways to prevent transmission to household contacts within the home environment. In this final part, we will review disinfectant safety and understanding the label.
The COVID-19 pandemic has brought to light the need for safe use of cleaners and disinfectants. Calls to Poison Control Centers regarding exposures to cleaners and disinfectants have increased since the beginning of 2020. In fact, the CDC published a Morbidity and Mortality Weekly Report (or MMWR) on this very topic in June of this year. They conducted a survey and found knowledge gaps in the safe use of household cleaners and disinfectants. Approximately one-third of the respondents reported engaging in non-recommended high-risk practices with the intent to prevent the spread of COVID-19 virus. Some of these unsafe practices include washing produce with bleach, applying these household cleaner-disinfectants to bare skin, and intentionally inhaling or ingesting these products.
It’s important to be knowledgeable about cleaning and disinfectant products being used. The product label provides a wealth of information so be sure to read it. A very important piece of information to look for is the registration number from the Environmental Protection Agency (EPA). All disinfectants in the US are required to be registered with the EPA. Failure of a disinfectant product to be registered with the EPA is not only against federal law, without it, the safety and efficacy of unregistered products cannot be guaranteed.
Other important information that can be found on the product label are the chemicals or active ingredients, the germs they kill ("kill claims"), precautions, and directions for use (DFUs). Keep in mind that SARS-CoV-2 is a new pathogen so it may not yet be listed on the label. However, if the product has the emerging viral pathogen claim and is listed on EPA’s List N, then the product is approved for use against the COVID-19 virus.
The precautionary text informs the user of potential hazards when using (or misusing the product). Signal words used in the precautionary text include CAUTION, WARNING, or DANGER and informs the user of physical or chemical hazards such as flammability and corrosiveness. This label section also advises on first aid instructions and if the product should be kept out of reach of children.
The DFUs focus on what task (e.g., disinfect, sanitize, deodorize, etc) the product is intended to perform and how to correctly use the product. This includes surfaces that the product can safely be used on as well as those the product should not be used on. The DFUs provide the contact time or how long the surface must remain wet with the disinfectant in order to be fully efficacious. It also addresses whether it’s safe or not to mix the product with other products or chemicals. For example, toxic fumes can result when bleach is mixed with ammonia or vinegar. Adherence to the DFUs is key. If product DFUs state to apply the product directly to the surface followed by wiping once the contact time has been met, then applying the product to the cloth first may impede efficacy.
Some key safety measures to consider include:
- Ensure the room being cleaned and disinfected has adequate ventilation
- Don’t mix bleach with other chemicals including vinegar and ammonia
- When diluting bleach, always add bleach to the water and not vice versa
- Don’t use cleaners and disinfectants on your bare skin
- Don’t ingest or inhale disinfectants
- Wear appropriate personal protective equipment such as gloves and eye protection according to manufacturer’s written instructions for use
- Wash hands after cleaning and disinfecting tasks or contact with any cleaners-disinfectants
- Store disinfecting products according to manufacturer’s instructions for use and keep them out of reach of children
In this 3-part blog series, we addressed the safe transition from hospital to home during a pandemic as it can be a very scary experience. And we learned that with basic infection control measures we can protect both ourselves and our loved ones. The COVID-19 pandemic has shown a glaring light on the need to faithfully adhere to these basic practices. Frequent hand hygiene, respiratory etiquette, and routine cleaning and disinfection go a long way in preventing transmission of pathogens, including SARS-CoV-2, the cause of COVID-19.
Be sure to educate yourself on proper cleaning and disinfection and understand what is in the bottle and how to safely use it. Always follow the instructions for use. Be sure you allow surfaces to remain wet long enough to kill the targeted pathogens. This means adhering to the contact time on the label for the product you are using.
To learn more, visit the CloroxPro Resource Center which includes valuable educational resources such as videos, pathogen education sheets, CE webinars and more.
1. Coronaviruses. Retrieved from https://www.niaid.nih.gov/diseases-conditions/coronaviruses
2. Coronavirus Disease 2019: Frequently Asked Questions. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/faq.html
3. Disease 2019: How it Spreads. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/prepare/transmission.html.
4. New coronavirus stable for hours on surfaces. Retrieved from https://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces.
5. COVID-19, FAQ, Spread. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/faq.html#:~:text=At%20this%20time%2C%20CDC%20has,Coronavirus%20Spreads%20for%20more%20information.
6. Coronavirus Disease 2019: Symptoms. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
7. Are You at Higher Risk for Severe Illness? Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhigh-risk%2Fhigh-risk-complications.html
8. Severe Outcomes Among Patients with COVID-19 – United States, February 12-March 16, 2020. Retrieved from https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm
9. COVID-19 Cases in U.S. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
10. CDC Media Telebriefing: Update on COVID-19, March 9, 2020. Retrieved from https://www.cdc.gov/media/index.htmlhttps://emergency.cdc.gov/coca/calls/2020/callinfo_013120.asp
In part one of this blog series, we described COVID-19 disease and used the chain of infection to demonstrate how this and other infections occur. In part two of this series, we will address how the spread of COVID-19 can be prevented within the hospital, as well as how to prevent its spread to loved ones within the home.
Preventing Transmission in the Hospital
Measures the healthcare team is taking to prevent transmission of COVID-19 to patients and others within the hospital walls include:
- Screening everyone who enters the building for signs and symptoms consistent with COVID-19, including temperature checks or exposure to persons infected with SARS-CoV-2
- Having separate areas for evaluating patients suspected of having COVID-19 infection
- Restricting visitors
- Implementing isolation precautions as indicated
- Use of personal protective equipment such as masks or respirators, face shields, gloves, and gowns
- Performing frequent hand hygiene
- Ensuring spatial separation of at least six feet including in nurses stations and waiting rooms
- Use of barriers such as plexiglass to eliminate exposures
- Postponing elective surgeries and procedures
For additional recommendations, see CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.
For disinfectants effective against the SARS-CoV-2 virus, see the Environmental Protection Agency’s (EPA) List N. This list includes disinfectants used in healthcare settings as well as disinfectants used at home. It’s important to note that while SARS-CoV-2 can cause severe illness in some, the virus is very easy to kill on surfaces with appropriate disinfection.
Hierarchy of Pathogen Kill
For patients admitted for a health issue other than COVID-19, there are things that they can do to protect themselves from getting COVID-19 while in the hospital. First and foremost, patients must be their own advocate. This means speaking up when something doesn’t look or seem quite right. This includes reminding healthcare workers and visitors to perform hand hygiene before touching you. Along these same lines, patients should be sure to perform hand hygiene before they eat or before taking oral medications, after they use the restroom, and upon returning to their room from a test or procedure or even a walk in the halls. It’s also important to ensure your room and bathroom are cleaned every day you are in the hospital. Focal points for cleaning should include surfaces that are frequently touched such as the over-bed table, bed rails, call light, and tv remote to name a few. Additionally, patients should ensure that the healthcare team has disinfected any medical equipment that will come into contact with them. Lastly, during the pandemic, patients should wear a mask as tolerated while in the hospital to help prevent inadvertent exposure to COVID-19.
Similarly, there are things that essential workers can do to prevent bringing COVID-19 home from work with them and infecting their family members. The COVID-19 pandemic has certainly made us take a closer look at how we can safely transition from work to home each day to protect not only ourselves but our loved ones. Please see my blog post from March 2020 titled “From Outside In: 6 Tips for Minimizing the Risk of Bringing COVID-19 Home After Your Shift”.
Preventing Transmission in the Home
There are measures that patients infected with COVID-19 can do to prevent infecting their loved ones when it’s time to be discharged from the hospital. Adherence to the 6 basic measures that we all should be doing will go a long way in preventing the spread of COVID-19:
- Stay home if feeling unwell
- Practice social distancing
- Wear a mask and cover coughs/sneezes
- Avoid touching the face
- Perform frequent hand hygiene
- Perform frequent cleaning and disinfection of environmental surfaces
To clean surfaces in the home that may be contaminated with the SARS-CoV-2 virus be sure to use an EPA-registered household disinfectant. Most of these will be effective as this is not a difficult virus to kill (see Hierarchy of Kill image above). For a complete list of appropriate household disinfectants for COVID-19, visit the Clorox Coronavirus Resource page to view a list of approved products and tips on how to safely and effectively disinfect surfaces in the home. Additionally, diluted jug bleach can be used to disinfect surfaces.
1:10 Jug Bleach Dilution
In addition to frequent cleaning and disinfection of frequently touched surfaces in the home, only one person in the household should take care of the person who is ill. And this person should not be someone in the high-risk group for COVID-related complications. In addition to the 6 basic measures mentioned earlier, the ill person should:
- Stay home and stay away from other people,
- Follow the care instructions from their healthcare provider and be sure to get plenty of rest and stay hydrated, and most importantly,
- Monitor their symptoms and seek immediate medical attention by calling 911 in the event of difficulty breathing or you otherwise think it’s an emergency.
Everyone in the household, especially the ill person, should practice respiratory etiquette which includes covering coughs and sneezes, properly discarding used tissues, and performing frequent hand hygiene. Also, avoid sharing personal items with others in the home including dishes, towels, and bedding.
The COVID-19 infected person should remain separated from others in the household, including pets, by staying in a designated room. This person should also have a separate bathroom, if possible. If the bathroom must be shared, then after each use, the frequently touched surfaces should be cleaned and disinfected.
The bathroom and the “sick room” are not the only rooms in the house that should be cleaned frequently. All frequently-touched surfaces in the home should be cleaned and disinfected daily at a minimum according to the Centers for Diseases Control & Prevention (CDC), but it certainly doesn’t hurt to disinfect more frequently.
If sleeping in the same room is necessary, put a curtain up to act as a divider. And if you must share a bed, sleep head-to-toe. Weather permitting, open doors and windows and use fans to help circulate fresh air. The ill person should not prepare food and should eat separately from the rest of the family.
Read part 3 of the blog series as we end with the safe and proper use of disinfectants.