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 hes 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

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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 didnt
  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 OHS 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

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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

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Two into one? Not necessarily a good idea
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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

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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)

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Feedback from staff during trial

• This product is easier to mix and doesnt sting
  my eyes
• I dont want to go back to using the other
  stuff
• Much better as its 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

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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
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Trial by outbreak
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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

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Summary

• The introduction of a combined detergent-disinfect
  ant 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

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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

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Two into one will go