IPM in a Medical Treatment Facility

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IPM in a Medical Treatment Facility

• John D. Nelson, BCE
• Entomologist
• Tripler Army Medical Center

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References

• AR 40-5, Preventive Medicine
• TB MED 561, Occupational and Environmental Health
  Pest Surveillance
• AR 200-5, Environmental Quality, Pest Mgmt.
• DODI 4150.7, Pest Mgmt. Program.
• TIM No. 20 - Pest Mgmt. Operations in a Medical
  Treatment Facility
• TIM No. 29 - IPM Mgmt. In and Around Buildings

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Outline

• TAMC Pest Mgmt. Program Summary
• Urban IPM in a Hospital Environment (MTF)
• MTF Pests
• Pest Mgmt. Process
• IPM Program Elements
• Case Study Crazy Ants
• Opportunities / Iniaitives

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Tripler Army Medical CenterPest Mgmt.
Administration

• Pest Mgmt. services non-standardized in MTFs
  across DA, DoD
• Tenant of USAG-HI (installation)
• USAG-HI Entomologist maintains PMP for entire
  installation TAMC has autonomous program
• Pest Mgmt. activities transferred from DPW to
  TAMC in 1998
• TAMC Entomologist administers the PMP, serves as
  COR for pest control service contracts
• Responsible for pest control activities in CAC
  500 bldgs.
• Subcontractors carry out pest mgmt. actions
  within TAMC (funded by logistics division)
• MOA between Logistics Div. and Dept. Prev. Med.
• Funding 20K LOG, 5K Dept. PV, 20K EPR funds

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TAMC Pest Mgmt. Personnel

• Entomologist
• Dept. of Prev. Med., Env. Health Section.
• Pest Mgmt. Coordinator
• Medical Entomologist
• Currently one-man-show
• 91S
• GS-9 Technician
• Contractors

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Facility
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Installation Description
2,159,509 sq. ft.
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Hospital SettingImportant Issues

• Little to no threshold tolerance
• Nosocomial infectious agents (mechanical
  transmission)
• Sensitive environments pests may affect
  sterility of supplies and equipment
• Immunocompromised individuals
• Infants/children
• Anxiety pests may interfere with patient
  comfort or recovery
• High liability potential if pests implicated in
  compromising quality of patient care

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Hospital Environments

• Sensitive environments
• Surgical suites
• Sterile facilities
• ICUs
• Patient wards/rooms
• Waiting areas
• Food handling / service establishments
• Food areas
• Nonfood areas
• Admin, Maintenance, Utility areas
• Lounges / Break-rooms
• Waiting rooms
• Locker rooms
• Offices

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MTF Demographics

• Generals / senior officers
• Surgeons
• Other physicians
• Nurses
• Senior / junior enlisted
• Civilians
• Patients (AD Beneficiaries)
• Contractors

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Agricultural vs. Urban IPM

• Field Environment
• Monitoring
• Multiple strategies
• Economic thresholds
• Some insects tolerated
• Minimal human interaction

• Human Environment
• Monitoring
• Multiple strategies
• Aesthetic thresholds
• Very few insects tolerated
• Constant human interaction

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Urban environment

• Manmade environment
• Conditions suitable/comfortable for humans
  pests
• Consistent world wide
• Specific assemblage of pests

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Urban IPM Components

• Inspection
• Education - clients and technicians
• Analyzing pest problem
• Taking short term corrective actions
• Implement long-term, preventive action
• Sanitation / Exclusion
• Monitoring, documenting, and evaluating results
• Follow-up
• Measurement of customer satisfaction critical

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Essential Program Elements(keys for success)

• IPM treatment strategies - variety
• Knowledgeable coordinator
• Pest id
• Treatment recommendations
• Reevaluation
• Long-term solutions
• Comprehensive plan
• Decision models
• Paper trail/record keeping
• Public relations
• Contractor relations

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Pests

• Ants
• Roaches
• Rodents
• Birds
• Termites
• Arachnids
• Ectoparasites
• Flies
• Wasps / Bees

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Pest Management Process
Complaint
Inspection/Consultation
Sanitation/Education
Structural modification
Treatment
Monitoring
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1) Complaint

• Avenues
• Telephone
• Email
• Website Sharepoint (internal)
• Direct Hey you
• PMC Inspection routine and random
• Priority assignment
• FY 06 Avg. response time 48 hrs.

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Pest Complaint Percentagesn275 FY 06
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2) Inspection / Consultation

• Talk to POC
• History of problem
• Pest species
• Source of problem
• Food / water
• Other concerns or issues
• DD Form 1532-1 (or equivalent)

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3) Education

• Food / water sources
• Important species
• Control methods used
• Concerns warranted?
• Attainable expectations?
• Listen communicate
• Training opportunity / Empowerment

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Pests in Paradise Primer
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4) Structural Modification Sanitation

• Elements
• Door / windows
• Cracks / crevices
• Water
• Landscape
• Plants
• Water containers
• Garbage / recycle cans
• Harborage

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Pest Requirements
FOOD
WATER
SHELTER
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5) Treatment

• Physical, biological, and or chemical control
• Pesticides, baits (must be labeled for hospital
  use)
• No preventive treatments allowed by regs
• Coordinator or Contractor as PCO?
• Common Sense Rule
• Work order generation
• On-call priority designations

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Control Options

• Sanitation
• Education
• Monitoring
• Exclusion
• Trapping
• Baiting
• Pesticide application

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Problem Areas

• Lockers
• Break rooms
• Plumbing
• Restaurants
• Office goodies
• Patient waiting rooms

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6) Monitoring

• Pesticides should only be applied with supportive
  monitoring data
• Population estimation
• Decision levels
• Baseline information
• Conducted regularly (fixed traps, customer
  survey, or pest log)

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Pest Control Contract Problems

• No direct control
• Control options
• Quality of work
• Liability of environmental regulations
• No vested interest in organization
• Difficult to terminate
• More difficult to rehire new company

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Contract Relations

• Recruiting quality companies
• Communication
• Quality Control
• Professionalism
• Client satisfaction
• Efficacy
• Timeliness
• Safety
• Compliance with laws / regs

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Pest Ants of HI

• big-headed
• crazy
• glaber
• pharaoh
• long-legged
• carpenter
• ghost
• argentine

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Ant Requirements

• Food
• protein
• fat
• sugar
• Water
• Shelter (harborage) - sometimes
• carpenter ants
• glaber ants

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Ant Food Preferences Colony Structure
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Ant IPM - Baiting

• Low toxicity
• Feeding preference
• Pre-baiting
• Closest to source
• NO insecticide use
• Bait acceptance
• Re-inspection / refresh baits

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Ant IPM - Bait Types

• Stations - various
• Gels various
• Liquids - sugar/boric acid
• Custom mixtures

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Ant IPM
Start
Ant Aesthetic Threshold A/D Ants per day
() A/D 10 (Complaint) (-) A/D (Satisfaction)
()
Pest Complaint
(-)
Inspection / identification
()
(-)
Education/Sanitation/ Environmental modification
()
Group A
Group B
(-)
Interior/exterior Baiting
1-month follow-up inspection
Seek and destroy colonies (outside)
()
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Ant IPM

• Group A Species
• Glaber Ants
• Long-legged
• Argentine
• Carpenter
• Big-headed

• Group B Species
• Crazy
• Pharaoh
• Ghost

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Pathogens Associated with Pharaoh Ants in
Hospitals

• Pseudomonas aeroginosa
• Staphlococcus spp.
• Steptococcus pyogenes
• Salmonella spp.
• Clostridium spp.
• Many others...

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Crazy Ant Case Study
Paratrechina longicornis (Latr.)
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Crazy Ant Complaints

• Several urgent complaints from A-wing, 2nd floor
• Party Friday - Department of Surgery
• Refreshments left out over the weekend covered
  with ants
• Ants now in exam rooms and doc offices
• Origin perimeter of hospital

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Crazy Ants Contract PCO Managed

• Boric acid sugar-based gel bait
• Perimeter treatment
• Cyfluthrin (Tempo WP)
• Cypermethrin (Demon WP)
• Re-infestation- one month
• Re-treatment with same strategy
• Infestation continuing and spreading to other
  areas

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Crazy Ant Biology

• Large colonies
• Multiple queens colonies split readily
• Shifting food preferences difficult to bait
• Very mobile invades quickly
• Associated with nectar producing plants
• Tends aphids/scale insects

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Crazy Ants Coordinator Managed

• Reevaluation of infestation
• Boric acid Hydromethylnon baits inside
• Rapid control - no re-infestations
• Continual sporadic infestations
• Perimeter treatments
• Exclusion
• Educate staff

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Crazy Ants Perimeter Program

• Vegetation management
• Monthly monitoring
• Exclusion
• Perimeter treatments
• Borate baits (Terro II)
• Hydromethylnon baits (Amdro, Maxforce granules)
• Bifenthrin (Talstar granules)
• Follow-up treatments as necessary

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Crazy Ant Complaints
PCO
Coordinator
Perimeter Program
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Crazy Ant ControlKeys to Successful Management

• Manage exterior populations
• Exclusion
• Vegetation Management
• Eliminate nectar producers
• Control aphids/scale insects
• Bait aggressively be flexible
• Granular pesticide
• Client Education

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Underlying Issues - People

• Perimeter vegetation
• Personal sanitation food / shelter / water
• Trash management

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Underlying Issues - Contractors

• Do
• Apply treatments
• Treat a single point (in time)
• Dont Do
• Prevention
• Sanitation
• Education
• Solve long-term problems

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Crazy Ants Coordinator Managed

• Rapid feedback and reevaluation/re-treatment
• Rapid control inside - no re-infestations
• Continual sporadic infestations
• Definitive ID of pest and source
• Precise application of appropriate treatment
• Historical perspective
• Centralized solution for entire facility not
  just a given point
• Long-term solutions

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Initiatives / Opportunities

• GPS geo-referencing Bar-coding
• Research projects
• Pesticide resistance studies
• Bait preference studies
• Establish self-help pest management program
• Waste water / Sewer line treatments
• Enforce designated staff eating areas
• Steam-clean or cold store carts, tray racks, and
  other portable items

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Aloha!