Fighting MRSA in the Hospital Environment A new Approach

1. Fighting MRSA in the Hospital EnvironmentA new Approach MRSA Conference July 30, 2007 Philip C. Carling, M.D. Caritas Carney Hospital and Boston Medical Center pcarling@cchcs.org

2. Is Disinfection Cleaning Important?

3. CDC Monitor (i.e., supervise and inspect) cleaning performance to ensure consistent cleaning and disinfection of surfaces in close proximity to the patient and likely to be touched by the patient and health care Professionals (e.g. bedrails, carts, bedside commodes, doorknobs, faucet handles). Category 1B. Management of MDROs in Healthcare Settings – October 2006 V.B.8.b.

4. IHI “Hospitals should use immediate feedback mechanisms to assess cleaning and reinforce proper technique” 5 Million Lives Campaign – Guide to Significantly Reducing MRSA Infections December 2006

5. How Important is the Environment in the Transmission of MRSA?

6. Surface Contamination of Near-patient Environment23 Studies

7. How Important is the Environment in the Transmission of MRSA? • MRSA Survives on Dry Surfaces for 90 to 236 days. • Until we had PGFE fingerprinting there was no way to study this this issue. • Reports over the past two years have now shown: A. More extensive environmental Contamination of the near patient environment than older studies and B. Patients contract strains from prior room occupants

8. How Well Do Environmental Disinfectants Work ?

9. How Well Does Environmental Disinfecting Work ? • Phenolic Compounds • Quartinary Amonium Compounds • Chloride Disinfectants • Formaldehyde Kill a wide range of microbial pathogens Work Rapidly Work effectively in clinical settings ALL

10. How Well Does Environmental Cleaning Work ?

11. Cleaning House: A New Metric in the Objective Evaluation of Environmental Cleaning

12. GOAL OF THE PROJECT To develop a surrogate marking system to evaluate the effectiveness of environmental cleaning/disinfection of the near-patient environment

13. The Targeting Solution A mixture of several glues, soaps and a targeting dye which: Dries rapidly Environmentally stable Readily wetted by spray disinfectants Easily removed with light abrasion Inconspicuous

14. Targeting Patient Rooms Objects were chosen by considering sites A. A patient was most likely to contaminate and B. A care givers may touch with their hands Up to 14 objects marked in each room after terminal cleaning Objects were evaluated after one to two patients had cycled through the room to see if targets had been removed by discharge cleaning activities

15. Environmental Cleaning Evaluation in Three hospitals - A confidential evaluation without Environmental Services awareness was implemented - About 50 patient rooms / Hospital - Up to 14 objects marked when the room was empty - Evaluated after patient had cycled through the room and it had been terminally cleaned

16. Preliminary Results – Three Hospitals Clinical Infectious Diseases – February 2006

17. Goals of the Multi-institutional Terminal Room Cleaning Project To determine if: • The targeting methodology is appropriately user friendly; • The thoroughness of cleaning at other institutions is similar or different from what we had found to date; • Cleaning can be improved using focused educational interventions and feedback to the ES staff using limited resources (time).

18. Health Care Environmental Hygiene Study Group – Acute Hospitals MA = 6 RI = 5

19. RESULTS

20. The Program Phase I Covert Baseline Environmental Cleaning Evaluation (The same as Previously described)

21. Baseline Environmental Evaluation of 20 Acute Care Hospitals Mean = 48.3 % Hospitals % of Objects Cleaned

22. PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS %

23. The Program Phase I – Covert Baseline Environmental Evaluation Phase II A. Educational Interventions – ES Staff B. Feedback to the ES – Staff

24. The Program Phase I – Covert Baseline Environmental Evaluation Phase II A. Educational Interventions – ES Staff B. Feedback to the ES – Staff (frequently repeated)

25. Hospitals Environmental Hygiene Study Group20 Hospital Results % of Objects Cleaned = Mean =/- 95% CI

26. Health Care Environmental Hygiene Study Group – Massachusetts Hospitals • Caritas Carney Hospital – 2003 • Quincy Medical Center – 2004 • Rehabilitation Hospital of the Cape and Islands – 2004 • Braintree Hospital - 2004 • Boston Medical Center – 2004 • MWMC Natick Campus – 2005 • Somerville Hospital – 2005 • Brigham and Women's Hospital – 2006 • Lahey Clinic – 2007 • Shriner’s Burns Institute – 2007 • Whidden Hospital – 2007 • Mount Auburn Hospital - 2007