If you work in healthcare, it's likely that you’re pretty familiar with healthcare-associated infections (HAIs), such as Central Line-associated Bloodstream Infection (CLABSI), Surgical Site Infection (SSI), Catheter-associated Urinary Tract Infections (CAUTI), and Ventilator-associated Pneumonia (VAP). These are all infections associated with medical devices that are often necessary but can lead to life-threatening complications. 

Preventing HAIs 

Prior to the COVID-19 pandemic, the CDC reported that mandatory healthcare reporting of HAI’s showed improvements in the rates of various HAIs. However, during the first 2 years of the COVID-19 pandemic, many hospitals reported increases in HAIs. This was likely a result of several rounds of enormous ‘surges’ in patient volume, sicker patients who required longer stays and periods of intubation, central lines and urinary catheters, staffing and supply shortages as well as alterations in infection prevention practices.  

As we move into the next stage of the pandemic, with less invasive management options and shorter hospitalizations, many clinicians are looking to circle back to the basics of infection prevention. As the CDC and CloroxPro resources show, infection prevention is a ‘team sport’ that involves engagement from everyone in a healthcare facility. From surface decontamination by Environmental Services (as well as by non-EVS staff) in the form of decontaminating used equipment and high-touch surfaces in workspaces, to monitoring adherence to disinfection protocols by Infection Prevention, to liaising with clinical staff to determine the necessity of “tubes and drains,” all staff have a vital role to play in keeping patients safe. 

A Team Effort

The team dynamic that was so critical during the early days of the COVID-19 pandemic (the “all-hands-on-deck”/“everyone has a crucial role” mentality), once again is a huge part of keeping HAIs at bay. As a hospitalist, I love this aspect of working in health care settings, (whether I’m at the hospital, or skilled nursing facility, or clinic), where the people you work with can set the tone for the day and will routinely save you from yourself! This is why I try to do team rounding on Intensive Care Unit (ICU) patients, so that, hopefully, a team member will ask “is the central line still necessary?” while another clinician might say “can we possibly discontinue the urinary catheter?” to help guide patients safely through their hospital course without picking up any HAIs along the way.

For HAIs where surface contamination is a major source of spread (such as C. diff), thorough handwashing as well as attention to surfaces is key. In terms of decontamination of surfaces and devices, CloroxPro has many resources to help steer healthcare facilities as they try to say “see you later” to HAIs. 

Unlike the pandemic, HAIs are not “unprecedented,” and we know exactly what we need to do to minimize their presence in the healthcare environment. After navigating the uncertainty and fear of the early pandemic, I personally feel a bit of relief when I think about returning (with my healthcare teammates) to the basics of HAI prevention.

In the era of COVID-19, worker shortages seem to be wide-spread. In no industry is this more apparent than in healthcare. According to the U.S. Bureau of Labor Statistics, healthcare employment remains below pre-pandemic levels, with the number of workers down by 1.1%, or 176,000, compared to February 2020.1 This comes at a time when healthcare services are needed more than ever. In March 2022, the American Hospital Association (AHA) wrote a letter to the House Energy and Commerce Committee describing the staffing shortages hospitals were experiencing as a national emergency. They also projected the overall shortage of nurses to reach 1.1 million by the end of the 2022.2 This does not include all of the other critical healthcare roles experiencing shortages; from infection preventionists (IPs) to environmental cleaning service (EVS) professionals. In fact, all parts of the healthcare continuum are feeling the squeeze.

One main safety concern related to the staffing shortages is the potential impact to healthcare associated infections (HAIs). Over the past several years, the healthcare industry has experienced unprecedented challenges, including higher than usual hospitalizations which, combined with the shortages in healthcare personnel and resources, likely resulted in decreased surveillance activities and reporting via the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN).3 According to the CDC’s 2020 National and State HAI Progress Report, each day, approximately 1 in 31 U.S. patients contracts at least one HAI, highlighting the need for improvements in infection prevention practices in U.S. healthcare facilities.4 This recommendation illustrates the juxtaposition that IPs are faced with today – what are the opportunities for improvement that do not add to an already stretched staff in terms of time or resources?

When it comes to EVS impact, I believe there are two main areas of opportunity: training and cleaning efficiency.

EVS Training

Training is essential for not only worker efficiency, but also overall job satisfaction, as well as retention. In fact, offering employees an opportunity for learning and growth is one of the key metrics of job satisfaction.5 With increased staff turnover and limited time to train new employees, having a best-in-class education and training program in place to help ensure cleaning professionals get the knowledge and skills needed to clean and disinfect effectively, efficiently, and safely is critical. To help address this need, CloroxPro launched a new online learning program in 2022. The course is available on-demand and covers:

Additionally, the Association for the Healthcare Environment (AHE) offers online courses with topics ranging from EVS Leadership: A Seat at the Table to Essentials of Infection Prevention of Environmental Hygiene.

Cleaning Efficiency

In the fight against HAIs, the efficiency and efficacy of ready-to-use disinfectants has been long established. This added benefit is even more important when resources are constrained. Lower priced dilutable disinfectants may be initially attractive, but research has shown6 that initial cost savings is often outweighed by the hidden costs when it comes to cross-contamination, quality control issues, overall efficacy, and low compliance. For example, most dilutable products have varying contact times and pathogen kill claims depending on the dilution. This opens the door for the use of an incorrect dilution and could potentially lead to the spread of HAI-causing pathogens in a facility. This is something we all need to be aware of because we know that:

  1. Disinfectants are one of the most viable protections against multi-drug resistant organisms (MDROs)
  2. Disinfectants could play an increasingly important role in managing bacterial infections in the future if the current trend of antibiotic resistance continues.7

Another way employers can improve cleaning efficiency is by leveraging emerging technologies, such as electrostatic sprayers, in combination with traditional application methods, like disinfecting wipes. Electrostatic sprayers can improve cleaning efficiency by allowing EVS workers to use less time to cover more spaces. In fact, electrostatic spraying has been shown to be 4x faster than manual disinfection.8

Though staffing shortages are not unique to healthcare, they do create an increased concern around patient safety, including HAI prevention. Proper training and the use of efficient strategies, like ready-to-use disinfectants and electrostatic sprayers can be critical in terms of overall HAI prevention and removing the environment as a source of infection. As you evaluate your own team’s needs especially for new hires, be sure to consider where and when ready-to-use products might offer time savings and increased compliance opportunities and do not forget to leverage on-demand training tools to help bridge the gap between teams.

References

1. Economic News Release: Employment Situation Summary [Internet]. U.S. Bureau of Labor Statistics. 2022. Cited September 1, 2022. Available From: https://www.bls.gov/news.release/empsit.nr0.htm
2. AHA Letter Re: Challenges Facing America’s Health Care Workforce as the U.S. Enters Third Year of COVID-19 Pandemic [Internet]. American Hospital Association. 2022. Cited September 1, 2022. Available From: https://www.aha.org/lettercomment/2022-03-01-aha-provides-information-congress-re-challenges-facing-americas-health
3. Wu, Hsiu, et al. Hospital capacities and shortages of healthcare resources among US hospitals during the coronavirus disease 2019 (COVID-19) pandemic, National Healthcare Safety Network (NHSN), March 27–July 14, 2020. Infection Control & Hospital Epidemiology 2021, 1-4; Available From: https://pubmed.ncbi.nlm.nih.gov/34167599/
4. Current HAI Progress Report: 2020 National and State Healthcare-Associated Infections Progress Report [Internet]. Centers for Disease Control and Prevention. 2021 [Cited September 1, 2022]. Available From: https://www.cdc.gov/hai/data/portal/progress-report.html
5. Bersin J. New Research Shows “Heavy Learners” More Confident, Successful, and Happy at Work [Internet]. LinkedIn. 2018; Available from: https://www.linkedin.com/pulse/want-happy-work-spend-time-learning-josh-bersin/
6. Wiemken, T. L. et al. The Value of Ready-to-Use Disinfectant Wipes: Compliance, Employee Time, and Costs. Am. J. Infect. Control 2014, 42, 329–330.
7. 2022 Special Report: COVID-19 U.S. Impact on Antimicrobial Resistance. Centers for Disease Control and Prevention. 2022 [Cited September 1, 2022]. Available From: https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf
8. Cadnum JL, Jencson AL, Livingston SH, Li D, Redmond SN, Pearlmutter B, et al. Evaluation of an Electrostatic Spray Disinfectant Technology for Rapid Decontamination of Portable Equipment and Large Open Areas in the Era of SARS-CoV-2. Am J Infect Control [Internet]. 2020; Available from: https://doi.org/10.1016/j.ajic.2020.06.002

Infection preventionists “raced” to Indianapolis, Indiana to attend the Association for Professionals in Infection Control and Epidemiology (APIC) Annual Conference which was held in-person for the first time since 2019. The conference was abuzz as 2,800 infection preventionists (IPs) celebrated being able to see each other’s masked faces in person once again. For many attendees, the conference was the first time out of their bubble since the COVID-19 pandemic began. An additional 1,500 attendees were able to join and participate virtually. The conference featured stellar keynote speakers, an impressive exhibitor hall, and many knowledgeable session presenters. One of these was Clorox Healthcare’s own infection preventionist, Doe Kley, who shared cleaning and disinfection essentials for long-term care settings.

This year APIC celebrated its 50th Anniversary. Founded in 1972, APIC was organized to bring professionals together, create opportunities to collaborate and network, provide education, and to drive guidance for best practices in infection prevention and control. This year’s APIC conference delivered and will continue to drive forward the important work of creating a safer world well into the future.

New Attendees from Clorox Healthcare

In attendance at this year’s APIC conference for the first time were two Research and Development (R&D) Scientists from Clorox Healthcare; Fanny Frausto Arellano, Ph.D. and Camile Dematos Gomes. Fanny is a lab chemist focused on formulation development for cleaning and disinfection products and Camile is heavily involved in product and process development with expertise in disinfecting wipes. For a new and fresh perspective of the APIC conference, I asked these two R&D scientists to share a bit about their experiences, including their thoughts and insights.

Question: As a first-time APIC Conference attendee, what was your overall impression?

Answer:

Camile: The conference was comprised of some of the brightest and most passionate minds in the field of infection prevention. Everyone I spoke with was knowledgeable and experienced but still came with the desire and eagerness to learn more. It was encouraging to see how we, as an industry, are working together to provide solutions to achieve the same goal of creating a healthier, safer lives for all.

Fanny: The conference was great and provided me an opportunity to better understand the wants, needs, and challenges facing the IP community. The conference shared the latest research and industry information with conference goers.

Question: As an R&D scientist, did you have any big “aha” moments?

Answer:

Camile: The process of how IPs and facilities select cleaning and disinfection products stood out to me. I came to recognize that evaluating products for potential use in a hospital or clinic is extensive and complicated. A better understanding of how IPs look at products, the metrics used to evaluate them, and why this is important, has helped me realize opportunities for future R&D work to support equipment and device compatibility.

Fanny: I learned that even with a big push from IPs, it may still take facilities a long time to fully implement a new cleaning and disinfection product. I heard from IPs the need for products that are easy to use, surface compatible, and affordable. While these attributes are ideal, it’s important for IPs to understand the consideration and possible tradeoffs involved. For example, it may be possible to have better surface compatibility, but this may lengthen contact times.

Question: What were some major themes you noticed throughout APIC 2022?

Answer:

Camile:

Fanny:

Question: What is one big takeaway about Infection Prevention that we can all remember?

Answer:

Camile: We must strive to make the right thing to do the easy thing to do.

Fanny: Wash your hands, disinfect surfaces, and don’t touch your face!

Summary

Infection preventionists have the difficult job of juggling many responsibilities and areas of expertise. The APIC conference demonstrated the incredible efforts of IPs and gave our scientists a glimpse into the challenges they as well as opportunities for the future. Congratulations to the APIC organization on a successful event this year and thanks to you, IPs, for the incredible work that you do. As a proud platinum plus sponsor of APIC, we at Clorox Healthcare look forward to continuing to support and help move the needle towards better healthcare outcomes and a safer future.

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.

Figure 3. Core Components of a Cleaning and Disinfection Program

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:

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.

Figure 4. Common High-Touch Surfaces in LTC Settings

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

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

Authors

Matthew Carlisle BS, William A. Rutala PhD, Jennifer L. Cadnum BS, Brigid M. Wilson PhD, Abhishek Deshpande MD, PhD, and Curtis J. Donskey MD

Download the full article here.

Overview

Dr. Curtis Donskey and his research group at the Louis Stokes Cleveland VA Medical Center conducted a randomized trial evaluating an UV-C decontamination device compared with Clorox Healthcare® Spore10 Defense™ Cleaner Disinfectant applied using the Clorox® Total 360® electrostatic sprayer as a finishing step. Standardized cultures were taken from high-touch surfaces and the floor after completion of manual cleaning and disinfection by environmental services personnel. Pathogens examined included: C. difficile, vancomycin-resistant Enterococcus (VRE), and methicillin-resistant Staphylococcus aureus (MRSA).

Key Findings

Methods

After completion of manual cleaning and disinfection by the environmental services (EVS) personnel at the Cleveland VA Medical Center, 40 non-Clostridioides difficile infection (CDI) hospital rooms were randomized to either UV-C or Clorox Healthcare® Spore10 Defense™ Cleaner Disinfectant applied using the Clorox® Total 360® electrostatic system. Research personnel operated both the UV-C device and the Total 360® system. EVS personnel were not made aware of the study.

The UV-C device was operated for 5 minutes on each side of the bed and in the bathroom. The Clorox Healthcare® Spore10 Defense™ Cleaner Disinfectant applied using the Clorox® Total 360® electrostatic system was sprayed on all room and bathroom high-touch surfaces and the entire surface area of the floor. Surfaces were allowed to air dry. Enough disinfectant was applied to remain visibly wet for 2 minutes or longer. In alignment with manufacturers, instructions for use (IFU), the patient rooms were unoccupied during use.

Before and after use of the UV-C or Clorox Healthcare® Spore10 Defense™ Cleaner Disinfectant applied using the Clorox® Total 360® electrostatic system, standardized cultures were collected from high-touch surfaces (bedrail, bedside table, call button, telephone, toilet seat, and bathroom handrail) and from areas on the patient room floor and bathroom floor. Pathogens examined included C. difficile, vancomycin-resistant Enterococcus (VRE), and methicillin-resistant Staphylococcus aureus (MRSA).

Conclusions

This study demonstrated that high-touch surfaces and floors in patient rooms were frequently contaminated with healthcare-associated pathogens after manual cleaning and disinfection. Clorox Healthcare® Spore10 Defense™ Cleaner Disinfectant applied using the Clorox® Total 360® electrostatic sprayer provided an effective and efficient option as an adjunct finishing step compared to manual cleaning and disinfection and required less overall time until the room was ready to be occupied by another patient than the UV-C device.

Download a pdf version of this study here.

References

Carlisle, M., Rutala, W., Cadnum, J., Wilson, B., Deshpande, A., & Donskey, C. (2022). A randomized trial of ultraviolet-C (UV-C) light versus sodium hypochlorite delivered by an electrostatic sprayer for adjunctive decontamination of hospital rooms. Infection Control & Hospital Epidemiology, 1-4. doi:10.1017/ice.2022.132

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.

Adapted from CDC's Healthcare Environmental Infection Prevention: Reduce Risk from Surfaces

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:

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

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

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

The past two years of battling against the COVID-19 pandemic has weighed heavily on healthcare workers and infection preventionists. While our attention has focused so much on COVID-19, there is a continued need to find a sustainable approach that allows infection preventionists and healthcare facilities to address healthcare-associated infections (HAIs).

According to the Centers for Disease Control and Prevention (CDC) on any given day, one in thirty-one hospitalized people will have at least one HAI. This number is likely underrepresented, as some HAIs are not reportable or identified properly. Coupled with the ever-changing threat of antimicrobial resistance (AMR), it is critical that healthcare facilities target their infection prevention measures to address all relevant pathogens.

During the first few months of the pandemic, we were trying to put out the fire that was COVID-19. Guidance changed in waves and we were trying our best to simply stay afloat. Slowly, we started to notice trends – patients hospitalized with COVID-19 were often given or required antibiotics and/or had prolonged hospital stays. From central-line associated bloodstream infections to drug-resistant urinary tract infections, it became apparent that hospitalized COVID-19 patients faced a real risk of HAIs and multi-drug resistant organisms (MDROs).

In my experience, HAI prevention has always been a hurdle and the COVID-19 pandemic only exacerbated this issue. From ensuring proper protocols are followed to making sure personal protective equipment (PPE) is worn, to ensuring proper and effective cleaning and disinfection. While the focus for COVID-19 has moved to a more holistic approach that still incorporates daily cleaning and disinfecting, the over-correction we saw with COVID-19 prevention initially trickled into healthcare. While we now know that COVID-19 is primarily spread through shared air, cleaning and disinfection remains important as part of the holistic prevention strategy.

However, the amount of attention put on enhanced cleaning in the early days of the pandemic can send the wrong message about the importance of this prevention strategy across the board. There are many times we absolutely need to perform enhanced cleaning and disinfection — consider C. diff or a hardier organism, like a highly resistant C. auris. Both require us to ensure the products being used are effective and we’re properly following contact time directions. Just because COVID-19 may not require enhanced cleaning and disinfection, which is a good thing, doesn’t mean that other organisms are going to let up also. As a result, now more than ever, we are working to re-align healthcare and infection prevention efforts to include a sustainable approach that allows us to focus on COVID-19 in addition to the daily threat of HAIs.

Too often the daily cleaning and disinfection is forgotten in the hectic world of healthcare. Running a million miles a minute, it can seem like there is no time for the cleaning of a bed-side table or knobs of medical equipment. These though, are the times and situations we must continue to be vigilant. In fact, each year in the United States, there are 2.8 million antibiotic resistant infections and as a result, 35,000 people die – we can’t afford to forget about MDROs, even if we’re in the midst of a pandemic. For example, healthcare continuously struggles to contain HAIs. In fact, much of the progress we’ve been working towards with HAIs has plateaued and slowed during the COVID-19 pandemic. While we’ve made some gains in reducing C. diff, we still struggle to bring these preventable infections to zero. C. diff, in particular, is preventable by both proper antibiotic use and proper infection prevention efforts including cleaning and disinfecting and use of PPE. Cleaning and disinfection, both routine and in high-risk situations, is one of the most basic forms of infection prevention we can undertake.

It’s not so simple though to reiterate the importance of doing the cleaning and disinfection, but also consider several factors – like correct product selection for the organism. C. diff is a prime example of why we work to ensure there are enhanced cleaning and disinfection protocols. We want to ensure staff have easy access to a sporicidal or bleach-based product but are also aware of how to properly use the product and follow contact times appropriately. It can be helpful to incorporate reminders of proper use or effective products on isolation signage. Such efforts reduce the risk of exposure to seasonal organisms like influenza and norovirus, but also MDROs and those we often see in hospitalized patients causing infections.

Unfortunately, I have seen HAIs that occurred as a result of poor cleaning and disinfection, which led to further antibiotic use, longer hospital stays, and a transition to an MDRO, underscoring the importance of this basic infection prevention effort. As the world tries to normalize post-pandemic, the role of cleaning and disinfection has increased in importance. Our ability to maintain continued efforts and follow protocols will make the difference between infections in patients and staff alike, but also the future of antimicrobial resistance. Now is the time to build up the infection prevention toolbox with everything from appropriate products for the task at hand to education resources to the most effective cleaning and disinfecting protocols — all things you can find on cloroxhealthcare.com

The Covid-19 pandemic has raised awareness of the critical role of Environmental Services (EVS) in preventing the spread of germs that can cause illness within healthcare environments as well as the need for targeted training and education in the EVS field. EVS professionals play a pivotal role in both maintaining a clean and sanitary environment for the patient but also in reducing potential patient harm. Regardless of the type of pathogen, routine cleaning and disinfection with an EPA-registered, broad-spectrum disinfectant remain a mainstay in any infection prevention and control program in healthcare facilities. Those that use disinfectants, such as EVS Technicians, must be thoroughly knowledgeable about any disinfectants that are used in the facility including core items such as contact time, proper use of Personal Protective Equipment (PPE), first aid, and product disposal instructions. It can be quite difficult to find comprehensive training programs designed to enhance cleaning operations and improve operational efficiencies. In addition, EVS departments often face difficulties in staff retention, which creates a continuous need for on-demand training and education.

This is why I’d like to share information about CloroxPro’s new HealthyClean™ Certificate Program — Trained Specialist Course, which is designed to meet the unique needs of both frontline cleaning personnel as well as managers and supervisors. Because this certificate program is accredited by the ANSI National Accreditation Board (ANAB), it has been subjected to the industry’s most stringent reviews, vetted by top experts, and is a globally recognized certificate standard for quality program development and training comprehension. This high bar for approval is the testimony of the program’s contents, design, and ability to assess program participants.

In addition to the specific cleaning for health content incorporated into the program, the required elements to meet many standards from the United States Occupational Safety and Health Administration (OSHA) for both frontline personnel and supervisory personnel are also included. OSHA-specific topics include bloodborne pathogens, waste disposal, and handling sharps appropriately. The use of the CloroxPro™ HealthyClean™ Certificate Program can not only assist EVS leaders with meeting compliance requirements but also help protect EVS technicians from the inherent risks of infection found in healthcare facilities.

To successfully and reliably mitigate risks associated with the healthcare environment, EVS leaders should prioritize the three P’s: People, Process and Product. First, leaders must have the right people with the correct, role-specific competency to perform the role. Next, the correct processes must be in place that are both highly reliable and closely monitored such as environmental cleaning and disinfection of a patient's room following discharge. Last, EVS frontline professionals must be equipped with the most comprehensive product solutions available to combat environmental pathogens. This comprehensive approach provides the best possible outcomes when it is rigorously followed. This three-tiered approach can assist EVS leaders with identifying risks associated with cleaning and disinfection and healthcare team safety issues such as exposure to bloodborne pathogens.

1) People:

2) Process:

3) Product:

By improving the overall competency of individual frontline cleaning personnel and those who supervise them, EVS leaders can immediately use the CloroxPro™ HealthyClean™ Certificate Program to train and deliver annual training to provide frontline EVS Technicians and supervisors with the essential knowledge and skills to help them improve overall competency. To learn more about CloroxPro™ Healthy Clean™, visit: www.CloroxPro.com/healthyclean.

Updated on 8/18/2022

For more information on monkeypox and to learn how to use CloroxPro and Clorox Healthcare products that have demonstrated effectiveness against viruses similar to the monkeypox virus, please reference our FAQs and monkeypox pathogen education sheet.

Monkeypox: A Global Outbreak

Monkeypox has recently become a trending topic in the news and on social media. The Centers for Disease Control and Prevention (CDC) recently reported more than 13,000 monkeypox cases in the U.S., with cases confirmed in nearly every state.1 As the monkeypox situation worsens and cases continue to grow globally, the World Health Organization has declared monkeypox a public health emergency of international concern.

Monkeypox, historically a rare disease, is an example of an emerging viral pathogen (EVP). While it does not spread as easily as some other respiratory viral pathogens, the sudden appearance of monkeypox in several non-endemic countries suggests that there may have been undetected transmission for some time.2 Close contact with an infected animal, human, or materials contaminated with the virus can lead to spread.3 Though most cases of monkeypox are mild, the illness and symptoms can last 2-4 weeks and include fever, headache, swollen lymph nodes, back pain, muscle aches, and fatigue followed by a rash.4

Combating New Threats

In the case with monkeypox and other new and emerging threats, the CDC provides guidance and recommendations for infection prevention and control. Familiar practices are still effective against monkeypox: isolation of a sick individual, hand hygiene, wearing personal protective equipment (PPE) like gloves and masks, and performing routine cleaning and disinfection of environmental surfaces.

To support environmental surface disinfection, the Environmental Protection Agency (EPA) has activated its EVP Policy for monkeypox. This means that product manufacturers can make off-label claims about a disinfectant’s effectiveness against monkeypox. This same approach was used during the COVID-19 pandemic with SARS-CoV-2. The EPA has also created List Q to address and provide additional cleaning and disinfection guidance emerging viral pathogens.

EPA List Q

The EPA has provided guidance for disinfecting against EVPs in the form of a new web tool know as EPA List Q. Unique from other lists that the EPA has published to address individual pathogens, List Q allows users to search all products eligible for use against any of the three main categories of EVPs based on difficulty to inactivate. The categories are as follows:5

Since emerging pathogens may not be listed on a disinfectant product label, List Q can help determine which set of directions to follow to kill the pathogen of interest.5 You can use EPA List Q in a few ways (see image below).

  1. Search for a product by entering the EPA registration number or name to determine whether the disinfectant product has EVP claims. Since marketed product names can evolve over time, leveraging the EPA registration number is the quickest way to navigate the tool.
  2. Identify an appropriate disinfectant product by first determining the tier the pathogen of interest falls into, and then selecting “Yes” on the corresponding dropdown.
  3. Once results are displayed, refer to the column “Follow directions for the following pathogen(s)” to determine what directions on the product label, including contact time, to follow during use.

As a new tool, EPA List Q is evolving and not be inclusive of all products with EVP claims. Those not included, may still be effective against monkeypox or other emerging pathogens. To determine this, review the product’s master label for specific claims or contact the product manufacturer for recommendations.

As the world continues to change and new threats emerge in the future, our vigilance looking for and continuing to follow outlined guidance will provide the means to help combat the spread of illness causing germs, in an effort to keep our communities safer and well.

References

1. CDC. Monkeypox in the United States. [Internet]. [Cited 2022 May 23]. Available from https://www.cdc.gov/poxvirus/monkeypox/outbreak/us-outbreaks.html
2. World Health Organization (WHO). USA Today, May 30, 2022. [Internet]. [Cited 2022 Jun 3]. Available from https://www.usatoday.com/story/news/nation/2022/05/30/who-not-concerned-global-monkeypox-pandemic/9992496002/
3. CDC. Monkeypox Transmission. [Internet]. [Cited 2022 Jun 3]. Available from https://www.cdc.gov/poxvirus/monkeypox/transmission.html
4. World Health Organization (WHO). Monkeypox Signs and Symptoms. [Internet]. [Cited 2022 Jun 3]. Available from https://www.who.int/news-room/fact-sheets/detail/monkeypox
5. US EPA. Disinfectants for Emerging Viral Pathogens (EVPs): List Q 2022. [Internet]. [Cited 2022 Jun 6]. Available from https://www.epa.gov/pesticide-registration/disinfectants-emerging-viral-pathogens-evps-list-q

Last month, the Society for Healthcare Epidemiology of America (SHEA) held its first in-person conference in over two years. Over 1,100 attendees from 24 countries participated in-person or online and included members and non-members of all disciplines relating to Infection Prevention Programs, Antibiotic Stewardship Programs, Public Health, Pharmacy, Occupational Health, Clinical Microbiology, Quality Improvement, and Patient Safety.

As with previous years, the SHEA Spring conference consisted of:

  1. Two training courses:
    1. SHEA/CDC Training Course in Healthcare Epidemiology
    2. SHEA Antibiotic Stewardship Training Course
  2. General conference sessions focused on innovative topics in Healthcare Epidemiology and Antibiotic Stewardship
  3. New research abstracts related to healthcare, surveillance, epidemiology, patient safety and infection prevention strategies

Notably, COVID-19 was not a main focus of this year’s conference. Presenters shared research that examined the unintended consequences and lessons learned from the pandemic, but it was unmistakable that our collective focus has shifted to identifying, predicting, and hopefully, preventing the next global pandemic. One of the most fascinating talks was a Plenary Session given by Dr. Ali S. Khan and Dr. Tom Chiller on Climate Change and the Emergence of Novel Pathogens in Healthcare. Former Director of the Office of Public Health and retired Assistant Surgeon General, Dr. Khan highlighted that we are in a bit of a perfect storm scenario with (1) climate change, (2) stress on healthcare infrastructure, and (3) the spread of new pathogens in healthcare settings before they are identified. His best guess was that our next pandemic is likely to be viral in nature with some top candidates being Influenza A and other Coronaviruses.

Similarly, Dr. Chiller, who is currently the Chief of the Mycotic Diseases Branch at the Centers for Disease Control and Prevention (CDC) agreed that we are undoubtedly in the “viral era,” but that fungi is the future and potentially on a path to be the source of the next deadly plague. Dr. Chiller cited that this is because fungi are inherently sensitive to environmental and climate change. He went on to explain that this theory is well supported and illustrated by the emergence of Candida auris. C. auris was first identified in 2009 and by 2018 was labeled an urgent threat by the CDC. As of 2022, it has now been found on every populated continent, including North America and the United States.1 It appears to prefer warm, salty conditions and in many ways behaves more like a bacteria than a yeast because it:

For all the above reasons, a robust cleaning and disinfection protocol is critical when C. auris has been identified at your facility. Currently, the CDC recommends use of a disinfectant that is registered with the Environmental Protection Agency (EPA) and is effective against C. auris. If a product with an EPA claim is not available, the CDC recommends using a disinfectant that is effective against C. difficile (see EPA List K).2 Disinfectants with an EPA claim for C. difficile have been used effectively against C. auris.

Ultimately, Drs. Khan and Chiller made clear that we can no longer separate global health and climate change from our work in public health and infection prevention. The good news is that important research is already underway. One example is CDC’s ONE HEALTH. One Health “is a collaborative, multisectoral, and transdisciplinary approach — working at the local, regional, national and global levels — with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants and their shared environment.” You can learn more at https://www.cdc.gov/onehealth/.

References

1. General Information about Candida auris. Centers for Disease Control and Prevention website. https://www.cdc.gov/fungal/candida-auris/candida-auris-qanda.html Updated 2019. Accessed March 24, 2022.
2. Infection Prevention and Control for Candida auris. Centers for Disease Control and Prevention website. https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html Updated 2021. Accessed March 24, 2022.

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