Dilution Accuracy

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Emerging Trends In HealthCare Pat Vanko -
JohnsonDiversey
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Session Objective

• CDC Update
• Disinfects
• Special Care Areas
• New Actives
• Green Products
• Questions

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To Clean or Not to Clean
University of Arizona.
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Cross Contamination

• CDC
• - Hard surfaces generally not directly
  associated with transmission of infections to
  staff or patients
• - Hand contact with the surface
• - Cleaning/disinfecting of surfaces is
  fundamental in prevention of healthcare
  associated infections

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Degrees of Clean

• Environmental Cleaning
• Sanitizing
• Disinfecting
• Sterilizing

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Environmental Cleaning

• Basic Level of Clean
• Cant kill if you dont clean
• Removes many of microbes that are growing on or
  in soil
• Does not control any one microbe
• Recommend a general purpose cleaner

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Importance of Cleaning

• Makes good business sense dividends returned
  for investment in sanitation
• - Furnishings last longer when properly cleaned
• - Healthy environment
• - Productive work area
• - Safety
• - Fire Prevention
• - Public relations
• - Improved customer relations
• - Disinfectant (removal of gross soils required)

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Disinfecting

• Patient contact surfaces, surgical clinical
  surfaces, restrooms and nursing stations
• Contains an active ingredient
• One-Step (Cleans Disinfects)
• Kills microbes
• Tested using AOAC Use Dilution Test

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Sanitizing

• Used in foodservice areas
• Clean first, rinse
• Reduce bacteria to a safe level
• WASH
• RINSE
• SANITIZE
• AIR DRY

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Sterilizing

• Highest level of clean
• All organic inorganic microorganisms and spores
  destroyed
• Required for surgical instrumentation
• Requires heat or extended contact with strong
  chemicals to control/kill microbes and spores
• Not required for housekeeping procedures

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Selection of Disinfectants

• Based on needs within facility
• Judgment guided by label
• Medical devices regulated under FDA EPA
• AOAC Use Dilution Test
• Hospital Grade Disinfectants
• Shelf life of use-dilutions

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Types of Disinfectants

• Quaternary Ammonium Compounds
• Phenolic Compounds
• Alcohols
• Bleach
• Iodophors

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Quaternary Ammonium Compounds

• Advantages
• Broad spectrum of kill
• Excellent cleaner
• Low cost
• Low acute toxicity in use dilution
• Hospital Grade Disinfectant dependent upon
  formula efficacy package
• Technology readily available

• Disadvantages
• Does not Kill Tb
• Effectiveness limited by presence of organic
  substances
• Absorbed by cotton
• Some quats limited by anionic cleaners

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Phenolics

• Advantages
• Effective against broad spectrum of
  microorganisms
• Kills Tb
• Low toxicity in use dilution

• Disadvantages
• Poor cleaner compatible with anionic detergents
• Cannot be used in neonatal area
• Inactivated by hard water organic matter if not
  formulated properly
• Residual film can accumulate on floors
• Accurate dilution critical for germicidal
  activity
• Skin depigmentation possible

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Bleach

• Advantages
• Inexpensive and readily available
• Effective against a broad spectrum of
  micro-organisms

• Disadvantages
• Inactivated by organic matter e.g. blood
• Strong odor
• Mixing of chlorine ammonia based cleaning
  agents will emit highly toxic gas
• Concentrations at gt1100 are corrosive to metals
• Shelf life in diluted form is limited
• Sensitive to heat light

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Alcohol

• Advantages
• Broad spectrum of kill
• Readily available
• Dual use antiseptic disinfectant
• Effective disinfectant for clinical tables,
  counters medical equipment

• Disadvantages
• Evaporates quickly possible insufficient
  contact time
• Can damage rubber plastic
• Volatile flammable

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Iodophors

• Advantages
• Broad spectrum of kill
• Time-sustained antimicrobial activity
• Easily combined with detergents or other
  surfactants

• Disadvantages
• Fair to poor cleaners
• Inactivated by presence of organic substances
• Stains porous substrates
• Can be irritating to eyes and throat
• Potentially corrosive to metals

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Selecting the Right Disinfectant

• Type of Soil
• Some soils demand an acid type product (rust,
  lime scale, hard water deposits)
• Some soils demand an alkaline product (grease,
  oil, protein, smoke)
• Amount of soil
• Surface to be Cleaned
• Cleaner should be strong enough to remove soils
• Pre-test in inconspicuous area
• Pre-cleaning may be necessary
• Method of Application
• Review label
• Spray, mop bucket, equipment (automatic
  equipment)
• Poured (Bowl Cleaners)
• Proper Dilution Rate
• Measuring device
• Dispensing equipment

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Understanding Disinfectants

• Different types of disinfectants
• - high-level
• - intermediate-level
• - low-level
• Decision must be made to match disinfectant and
  procedure to the task and to the microorganism

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Levels of Disinfection

• High-level sporicidal chemicals
  (glutaraldehyde, peracetic acid, hydrogen
  peroxide) not appropriate for use on housekeeping
  surfaces, can be highly toxic
• Intermediate-level Inactivates Tb (sodium
  hypochlorite (chlorine), alcohols, some phenolics
  idophors)
• Low-level hospital disinfection w/o Tb claim
• Antiseptics FDA approved, not appropriate for
  use as environmental surface disinfectants

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EMERGING DISEASES

• Tb
• Bloodborne Pathogens
• SARS
• Avian Influenza
• MRSA
• VRE
• C.Diff

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Tuberculocidal Disinfectants

• Do not interrupt or prevent transmission of Tb
• Not acquired from environmental surfaces
• Benchmark
• OSHAs Bloodborne Pathogen

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Bloodborne Pathogens

• No evidence that BBP has been transmitted from
  floor, wall or countertop
• HIV HBV readily inactivated with disinfectants
  including quats
• Products to use
• - Sodium Hypochlorite
• - EPA registered product with Tb claim
• - EPA registered product with both HIV and HBV

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MRSA/VRE

• Antibiotic Resistant Organisms
• - MRSA VRE
• - transmitted patient to patient
• - indirectly hands of healthcare worker
• - hand transfer from environmental surfaces
  patient care equipment
• - VRE can persist on dry surfaces from 7 days to
  4 months
• - VRE recovered from inoculated health workers
  hands (with or without gloves) for up to 60
  minutes
• - Control of MRSA, VRE, VISA
• - Enforce hand washing and use of barrier
  precautions to minimize spread
• - Cleaning of patient/resident rooms medical
  equipment
• - Routine cleaning with either low or
  intermediate disinfectant cleaners
• - No need to increase dilutions of disinfectant
  cleaners
• - Follow label directed use

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Special Pathogens

• Clostridium Difficile
• - Successful measure to control spread has been
  restriction of antimicrobial agents
• - Little evidence especially housekeeping
  surfaces (floors, walls) that environment is
  direct source of infection
• - Direct exposure to contaminated patient-care
  items (rectal thermometers)
• - High-touch surfaces in patients bathrooms
  source of potential infection
• - Most likely mechanism of exposure is
  healthcare workers hands
• - Colonized patients may also service as a
  source for contamination
• - Use of chlorine containing products showed
  reduction on environmental surfaces
• - Recommendations for control - meticulous
  cleaning, followed by disinfection

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Norovirus

• Norwalk Virus Feline Calicivirus Family
• Unable to grow Norwalk in Lab
• Requires surrogate
• EPA announces surrogate - 2004

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Norwalk - Transmission

• Hands (39)
• Mouth (12)
• Air
• Hard Surfaces
• Food
• Water

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Critical Characteristics

• Highly contagious
• Multiple modes of transmission
• Stabile in the environment
• Resistant to routine disinfection methods
• Limited immunity
• Asymptomatic

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Routine Cleaning of Housekeeping Surfaces

• Regular cleaning is required
• Use soap and water or a detergent/disinfectant
• - Nature of surface
• - type and degree of contamination
• Surfaces can be divided into two categories
• - Minimal hand contact floors, walls
• - Frequent hand contact doorknobs, bedrails,
  switches, restroom areas (fixtures, walls around
  the stools)

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What is Bird Flu, Avian Influenza?

• Causative agent (Avian) Influenza A, subtype
  H5N1, a member of the family Orthomyxoviridae.
  www.fao.org/ag/againfo/subjects/en/health/diseases
  -cards/avian.html
• Transmission The virus is excreted from infected
  birds via feces, nasal or ocular discharge which
  then infects new birds via conjunctival, nares or
  the trachea. The virus has been isolated from
  feed, water and soil as a result of cross
  contamination. The virus has been transmitted to
  humans via direct handling of an infected bird or
  in contact with an infected farm. Airborne
  transmission is also a possibility.
  www.fao.org/ag/againfo/subjects/en/health/diseases
  -cards/avian.html
• Stability The virus can survive for extended
  periods in the tissues and feces of infected
  birds. In water, the virus can survive for up to
  4 days at 22 deg C and more than 30 days at 0 deg
  C. www.who.int/csr/don/2004_01_22/en/

Revision 04 April 13, 2006
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Regulatory Recommendations - WHO

• Good hygiene practices during handling of
  poultry products, including hand washing,
  prevention of cross-contamination and thorough
  cooking (70 deg C). www.who.int/csr/don/2004_01_2
  4/en/
• Stringent sanitary measures on the farm,
  including disinfection of contaminated farm
  equipment, transport vehicles, and cages.
  www.who.int/csr/don/2004_01_15/en/
• Quarantining infected farms, destruction of
  infected or potentially exposed flocks and feed.
  www.who.int/csr/don/2004_01_15/en/

Revision 04 April 13, 2006
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Recommendations for Avian Influenza

• Precautions
• Hand hygiene before and after patient contact or
  with items contaminated with respiratory
  secretions
• Use gloves gowns for patient contact
• Use dedication equipment (blood pressure cuffs,
  disposal thermometers, etc.)
• Wear eye protection within 3 ft of patient
• Place patient in airborne isolation room
  (negative air handling) HEPA filters if negative
  air handling unavailable.
• Use fit test respirator NIOSH
• Vaccination of Health-Care Workers with recent
  vaccine

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Breaking the Chain through Effective Cleaning

• Use appropriate cleaner/disinfectant
• Apply liberally
• Give proper contact time
• Shelf life of diluted products
• Disinfect and clean equipment and receptacles
  (sharp, sanitary napkin, and trash containers)
• Keep equipment clean (buckets, trigger spray
  bottles, dispensing equipment)
• Dispose of contaminated cleaning materials
• Clean frequently touched public surfaces
• Keep pests and rodents out of your facility
• Keep kitchen, refrigerators and all food contact
  surfaces cleaned and sanitized

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Directions for use of disinfectant

• Use Product according to label
• Contact times
• Dilute accurately (more is not better)
• Apply liberally
• Surface should be visibly wet for recommended
  contact time
• High soil loads may require precleaning
• Soils provide food source

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New Actives

• Drug Resistant Organisms
• Shorter Contact Times
• Rumblings in industry that microorganisms
  becoming resistant to quats
• One product to do all

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Hydrogen Peroxide

• Advantages
• Can enhance removal of organic matter
  microorganisms
• No disposal issues
• No odor or irritating fumes
• At higher concentrates (116) lower contact
  times

• Disadvantages
• Incompatibility with some metals
• Eye damage
• High concentration required at end use dilution
  (116) for disinfecting

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Peracetic Acid

• Advantages
• Compatible with a wide variety of materials
  instruments
• Sporicidal properties
• Rapid sterilization (30-45 minutes)

• Disadvantages
• More expensive than high level disinfectants
• Not compatible with aluminum

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Silver Ion

• Formulated with Silver Quat
• Provides various contact times 30 seconds to
  ten minutes
• Residual 24 hours
• Ready to use

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Looking Ahead

• Key People in the industry and academia are
  saying the future of cleaners will be in
  non-halogen based oxidizers.
• What are the desired traits in these futuristic
  cleaners?

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Desired Traits

• Non-toxic to humans animals
• Non-allergenic non-sensitizing
• Non-hormone disrupting
• Environmentally sound
• Low Volatile Organic Compounds (VOC)
• Longer shelf life
• Safe to transport
• Safe and easy to store
• Non-corrosive
• Compatible with todays and tomorrows new
  materials (flooring, countertops, plastics,
  equipment, etc)

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On-Going Innovation

• Higher concentrations
• Use more of less
• Products that are safe to the environment
• Green Seal certified products
• Little or no impact on the environment or indoor
  air quality
• Less hazardous to people
• - Products with little to no impact on human
  health
• - Dispensing systems no contact with
  concentrated chemicals
• More synergistic actives
• Improved performance
• Performs multiple cleaning processes in one step

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Whats Next

• Cleaning trends are moving towards minimization
• - Products will be required to perform multiple
  tasks
• - Little or no impact on the environment,
  animals or humans
• - Automated cleaning systems
• - Programmed to clean at specific times
• - Detection of soiled surfaces
• - Self-cleaning surfaces that degrade soils or
  prevent soil from adhering

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Disinfectant Product Labels

• EPA Registration Number
• Label Claims
• Actives
• Product Uses
• Test Method
• Contact Time

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Handwashing

• Is important to prevent spread of disease
• Wash hands frequently with soap and water
• Use alcohol-based handrubs when hands are not
  visibly soiled
• Wash hands for 15-20 seconds
• Wash hands after removing gloves
• Dispose of gloves
• Reusable gloves follow facility guidelines

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Carpeting

• ADVANTAGES
• Noise Reduction
• Humanizing
• Contributes to reduction of falls

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Carpeting

• DISADVANTAGES
• Difficult to keep clean (spills)
• Harder to push equipment (wheelchairs, carts,
  gurneys)
• Increased activity levels increase bacteria counts

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Carpeting

• Despite bacterial growth
• little epidemiologic evidence to show that
  carpets influence healthcare-associated infection
  rates in areas housing immunocompetent patients
• Guideline includes no recommendations against
  the use of carpeting in these areas

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Carpet Maintenance

• Care to prevent dispersal of carpet
  microorganisms into the air
• - maintain equipment
• - use of HEPTA filters in high-risk patient-care
  areas
• - carpet cleaning chemicals
• - powder liquids
• - TOTAL PROGRAM REQUIRED

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Mold Mildew

• Conditions
• Remove source
• Products available
• Construction

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Microfiber

• Blend of microscopic polyester and polyamide
  fibers
• Due to fine filaments the microfiber loosens dirt
  even in the smallest structures (mechanical
  action)
• Capillary force of the micro fiber textile
  absorbs large amounts of loose dirt and/or soiled
  solution

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Microfiber Advantages

• Reduce chemical use and disposal
• Reduce cleaning times for patient rooms or other
  high use areas
• Prevents dirty mop heads from contaminating clean
  solutions
• Cleans removes soils that microorganisms feed
  on
• Clean solution each time tool/microfiber pad is
  used

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Wipes

• Require EPA registration
• Wet Task System
• Shelf life

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QUESTIONS ??