When Two Into One Does Go

1. When Two Into One Does Go The introduction of a novel approach to environmental cleaning and disinfection Joanna Harris Manager, Infection Management and Control Service

2. Balancing and addressing risks FOR improved outcomes • July 2008 • 450 bed hospital providing range of acute services. The largest in our group of 9 hospitals. • In-house hotel service department • Endemic methicillin resistant S. aureus (MRSA) and vancomycin resistant Enterococcus (VRE) • Norovirus • Inconsistency in environmental and equipment cleaning and disinfection practices

3. 2008 practices • Routine environmental cleaning • Hotel service staff responsibility • Neutral detergent solution for all areas • Routine equipment cleaning • Clinical staff responsibility • Neutral detergent solution or alcohol wipe • Routine discharge clean • Neutral detergent solution for bed and other equipment • Nurses’ responsibility

4. But he’s infectious! • Routine environmental cleaning • Same as non-MRO patient if patient has MRSA • Neutral detergent followed by sodium hypochlorite (NaOCl) solution if patient has VRE • Routine equipment cleaning • Neutral detergent followed by alcohol wipe for VRE

5. “Terminal” Clean • Following discharge of patients with any multi-resistant organism (MRO), C. difficile or gastroenteritis • Curtains changed • Neutral detergent for entire area for MRSA • Neutral detergent followed by NaOCl solution for patients with VRE, C. difficile or gastro-enteritis • Nurses do equipment including bed • Hotel services do the rest including walls

6. Outbreak • Outbreaks – Norovirus or VRE • Neutral detergent followed by NaOCl for all areas of affected ward • Toilets and bathrooms twice a day using neutral detergent followed by NaOCl solution

7. Problems and confusion • Outbreak management required use of NaOCl across wide areas. • Staff reported nosebleeds, headaches and sore eyes • Some staff refused to handle the product • Others made the solution up “weaker so it didn’t smell so bad” • “I use half a sachet rather than all of it” • Policy of different processes according to MRO created confidentiality issues and confusion • Terminal cleans for VRE patients taking up to two hours • VRE was seen as a significant risk (over and above MRSA) with resultant disproportionate anxiety occurring • MRSA not seen as a concern • Improvement needed as a priority

8. Clostridium difficile

9. Four stages of leading change (Golden 2006) Golden B, 2006. Change: Transforming Healthcare Organizations. Healthcare Quarterly 10 (special issue); 10-19

10. Determine desired end state • Assurance of a safe environment for patients, staff and the organisation as a whole • Chlorine-releasing environmental disinfection • Workplace Health and Safety • Effective outbreak management • Reduction in healthcare associated infections and multi-resistant organisms, especially VRE • Improved patient privacy • Cost effective solution

11. Assess readiness for change • Initial concerns raised with hotel services manager following observations of current practice and listening to hotel service and nursing staff and managers’ comments • Formal risk assessment documented • Use of outbreak reports and existing surveillance mechanisms • Interrogation of incident reporting system (IIMS)

12. Broaden organisational support and re-design • Presentation of risk assessment and action plan to OH&S committee • consider change to a different disinfectant agent • Needed sporicidal and non-enveloped virucidal properties • Had to be TGA approved • development of new hotel service role ‘Discharge Support Assistant’. Job description specifically allocates bed cleaning to hotel service responsibility.

13. Reinforce and sustain change • Substantial education programme provided by the product distributer to support its introduction into one site and then across entire District • Troubleshooting promptly to avoid stakeholder disengagement • Feedback to hotel service and ward based staff on outbreak management

14. Chosen product • Blind trial involving 100 hotel service staff testing 5 different products • Two products led the field when measured according to smell and ease of use by hotel service staff • The potential for productivity savings led to the decision to run a 3 month trial for one of these products

15. Chosen product • Combined detergent and chlorine-releasing disinfectant • TGA listed as a hospital grade disinfectant • Synergistic effect of detergent to produce a slightly acid one-step cleaning and disinfection solution. • Sodium dichloro-isocyanurate (NaDCC) more stable and less irritant than NaOCL solutions • Provides required sporicidal action • Presented in tablet form. No inhalational risk. Less likelihood of incorrect dilution

16. Two into one? Not necessarily a good idea

17. 3 month trial • New product to be used routinely • All toilets including public toilets • All patient shower rooms • All rooms accommodating patients with any MRO, C. difficile, and possible viral gastroenteritis • Facility-wide education programme • Safe work practice developed and communicated • Hotel service communication book • Standing item on hotel service team meeting agenda and infection control committee meetings • Incident reporting system to be used

18. Summary of 3 month trial • Reduction in cleaning time • Number of ‘cleans’ 840 per month. Reduction in time needed = 532 hours per month • Improved patient flow by reducing the time isolation rooms remained empty • Reduction in work health and safety concerns reported by hotel service staff • 2 minor splash incidents reported • One more significant incident caused by under-dilution of the product (4 tablets per litre rather than the required 1 tablet per litre)

19. Feedback from staff during trial “ This product is easier to mix and doesn’t sting my eyes” “I don’t want to go back to using the other stuff” “Much better as it’s easy to use and we can get round quicker” “If we have to use bleach, this is better than the other one” “We should be using this everywhere in the hospital”

20. How does environmental hygiene look in 2012? • Routine cleaning • Neutral detergent solution routinely for majority of areas • Use of combined detergent-disinfectant for all high risk areas • ICU • haematology ward • renal ward • ED • ALL toilets and bathrooms • Rooms accommodating people with any MRO, C. difficile, gastro-enteritis and • outbreak environments • Combined detergent-disinfectant product to all areas • including toilets and bathrooms twice a day

21. What has been achieved? • “Terminal clean” time reduced to approx. 35 minutes per isolation room including bed • Simplified regime; • Combined product for all toilets, bathrooms and high risk areas at all times • Consistent regime required for all MRO patients’ environment • Consistent regime required in outbreak situations • Reduction in staff health concerns and IIMS reports compared to previous regime

22. Norovirus outbreaks

23. Trial by outbreak

24. A word about Clostridium difficile • There has been only one outbreak of C. difficile identified since 2009 despite burden of disease being present across District • Small 100 year old rehab. unit with only 6 hours per day hotel service provision • Outbreak controlled with increased hotel service provision using combined detergent disinfectant product • Product also used for equipment decontamination

25. Summary • The introduction of a combined detergent-disinfectant into a network of 9 hospitals was successfully achieved during 2009-10 • The product has enabled significant efficiencies in hotel service and nursing time by reducing “terminal clean” duration by 50% • Norovirus outbreak management and control of C. difficile has been maintained

26. Conclusion • A risk management approach was used to identify high risk areas that warranted routine environmental cleaning and disinfection • Introduction of a novel combined detergent-chlorine disinfectant product has enabled efficient resource utilisation halving room-readiness times • Workplace health and safety concerns have been minimised

27. Two into one will go