Introduction to CDC

1
Introduction to CDCs Guidelines for
Environmental Infection Control in Health-Care
Facilities

• Lynne Sehulster, PhD, M(ASCP)
• Division of Healthcare Quality Promotion
• Centers for Disease Control and Prevention
• Atlanta, GA 30333
• Hosted by Paul Webber paul_at_webbertraining.com
• Sponsored by 3M Canada
• www.3m.ca

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Objectives of Todays Presentation

• After the completion of this session, the
  participant will
• Be familiar with the overall content of the EIC
  guidelines
• See how the guidance is applied to an airborne
  disease outbreak and
• Be familiar with performance measures and
  standards on environment of care

3
Target Audiences for the EIC Guidelines

• Hospital epidemiologists
• Infection control practitioners
• Laboratorians
• Facility managers and engineers
• Housekeeping and laundry staff
• Administration

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Where Can I Find the EIC Guidelines?

• Part II Recommendations
• MMWR 2003 52 (RR-10) 1-44
• Errata MMWR 2003 52 (42) 1025-6
• Full text version
• http//www.cdc.gov/ncidod/hip/enviro/
• guide.htm
• Print version
• ASHE will print in the near future

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CDC Contributors to These Guidelines

• Division of Healthcare Quality Promotion
• Lynne Sehulster, PhD Matthew Arduino, DrPH Joe
  Carpenter, PE Rodney Donlan, PhD
• Division of Bacterial and Mycotic Diseases
• David Ashford, DVM, DSc, MPH Richard Besser, MD
  Barry Fields, PhD Michael McNeil, MBBS, MPH
  Cynthia Whitney, MD Stephanie Wong, DVM, MPH
• Division of Parasitic Diseases
• Dennis Juranek, DVM
• Division of Oral Health
• Jennifer Cleveland, DDS, MPH
• HICPAC Sponsor
• Raymond Chinn, MD, Sharp Memorial Hospital, San
  Diego

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U.S. Organizations Whose Standards are
Incorporated into These Guidelines

• American Institute of Architects (AIA)
• American Society of Heating, Refrigeration, and
  Air-conditioning Engineers (ASHRAE)
• Association for the Advancement of Medical
  Instrumentation (AAMI)

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U.S. Federal Regulatory Agencies

• Environmental Protection Agency (EPA)
• Department of Labor, Occupational Safety and
  Health Administration (OSHA)
• Food and Drug Administration (FDA)
• Department of Agriculture (USDA)
• Department of Justice (DoJ)

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Air Section
9
Air Section Subtopics

• Airborne microorganisms
• HVAC components and function
• Construction
• Special care settings
• Airborne infection isolation (AII)
• Protective environment
• Operating rooms
• Other aerosol hazards (infectious)

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Ventilation Specifications
Specifications Airborne Infection Isolation (AII) Protective Environment (PE)
Air pressure Negative Positive
Room air changes gt 6 ACH for existing areas gt 12 ACH for new construction or renovation gt 12 ACH
Sealed Yes Yes
Filtration on supply air 90 (dust-spot testing) 99.97 (HEPA)
Recirculation No Yes
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Ventilation Specifications
Specifications Critical Care Room Operating Room
Air pressure Positive, negative, or neutral Positive
Room air changes gt 6 ACH gt 15 ACH
Sealed No Yes
Supply air filtration gt 90 (dust-spot testing) 90 (dust-spot testing)
Recirculation Yes Yes
12
Ventilation Specifications
Specifications Isolation Anteroom
Air pressure Positive or negative
Room air changes gt 10 ACH
Sealed Yes
Supply air filtration gt 90 (dust-spot testing)
Recirculation No
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Construction Issues

• Multidisciplinary team
• Risk assessment prior to project start
• External construction keep dust out!
• Internal construction contain the dust!
• Barriers
• Surveillance and air sampling

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External Construction

• Keep the facility air pressure positive to the
  outside
• Ensure that roughing filters are changed
  frequently
• Seal and caulk windows, especially in PE
• Keep doors closed as much as possible
• Wet dust surfaces
• Protect immunocompromised patients from dust
  during transfers

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Internal Construction

• Dust containment, removal and moisture control
• Educate construction workers and staff
• Prepare the site
• Notify staff, visitors, patients re precautions
• Relocate patients and move staff as needed
• Monitor for adherence to infection control
• HVAC system maintenance water system
• Daily clean-up and removal of debris

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Particle Sampling

• Simple to perform, immediate results
• Verify HVAC system performance
• Filtration efficiency
• Rank order from dirty to clean
• Verify infection control measures during
  construction
• Construction barrier and dust containment

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Aspergillosis Outbreak
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Impact of Aspergillosis, 1996

• 10,190 hospitalizations average length of stay
  17.3 days
• 1970 deaths mortality rate 19.3
• Economic burden in health care 633.1 million
• Conditions associated with secondary diagnosis of
  aspergillosis
• pneumonia, other respiratory infections, cancer
  or leukemia, HIV infection

Dasbach EJ, Davies GM, Teutsch SM. Clin Infect
Dis 2000 31 1524-1528
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Impact of Aspergillosis, 1996

• When there is a secondary diagnosis of
  aspergillosis in cancer or leukemia patients
• 26 more hospital days
• 115,262 in additional costs
• 4 times the mortality rate compared to similar
  patients without aspergillosis

Dasbach EJ, Davies GM, Teutsch SM. Clin Infect
Dis 2000 31 1524-1528.
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Healthcare-Associated Outbreaks of IPA

• Activities that cause increases in counts of
  airborne Aspergillus spores
• Building demolition, construction, renovation,
  repair
• Bird droppings in air ducts supplying high-risk
  patient care areas
• Contaminated fireproofing material
• Damp wood, sheet rock

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Aspergillosis Outbreak Hospital A

• February, March 1996 September 1996
• 940 bed facility Oncology Center is a 3-story
  building connected to the hospital
• Pressure differentials, HVAC system checked
  monthly
• Construction immediately adjacent to the Oncology
  Center
• A. flavus emerges, previously A. fumigatus

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Investigative Findings 1996

• 21/29 surveillance-identified patients met case
  definition of definite or probable
• Housekeeping procedures inadequate clean wet
• Univariate analysis location near the stairwell
• Large volume samplers detected A. flavus, while
  small volume samples were negative

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Thio CL, Smith D, Merz WG, et al. Infect Control
Hosp Epidemiol 2000 21 18-23
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Investigative Findings 1996

• Pressure differentials
• 25 PE rooms, 3 of which were negative relative to
  the corridor (-0.35 to 3.2 Pa)
• Air pressure in the central stairwell was
  positive relative to the corridor of the unit
• Oncology Center was neutral negative compared
  to the adjacent hospital

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Environmental Control Measures Spring 1996

• Reviewed the function of the HVAC system
• Doors engineered to close automatically kept
  closed at all times
• Wet dusted and cleaned surfaces
• Sealed windows, exterior walls

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Environmental Control Measures Spring 1996

• Closed nearby entrance redirected pedestrian
  traffic
• Construction policy
• Air sampling for fungal spores
• N95 respirators for high-risk patients

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Environmental Control Measures Fall 1996

• Closed the stairwell between the HSCT and
  leukemia units
• Conducted case-control studies
• Additional environmental cultures
• Reviewed housekeeping procedures
• Large volume air sampling
• Supplemental HEPA filtration when structural
  modification not feasible

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Water Section
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Water Section Subtopics

• Waterborne microorganisms
• Facility water systems
• Strategies for controlling Legionella spp.
• Cooling towers
• Hemodialysis and water quality
• Ice machines
• Hydrotherapy
• AERs and dental unit water lines (DUWLs)

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Modes of Transmission of Microorganisms in Water

• Direct contact (hydrotherapy)
• Ingestion of water (drinking water, ice)
• Indirect contact (improperly reprocessed medical
  device)
• Inhalation of aerosols (showers)
• Aspiration of contaminated water

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Updates on Air and Water

• Updated recommendations for air and water
  infection control measures
• Guidelines for Preventing Health-Care-Associated
  Pneumonia, 2003
• Available at http//www.cdc.gov/ncidod/hip/pneu
  monia/ default.htm

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Environmental Services Section
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Environmental Services Section Subtopics

• Principles of cleaning and disinfection
• Cleaning spills of blood/body substance
• Carpeting, cloth furniture
• Flowers and plants
• Pest control
• Special pathogen concerns and cleaning

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Should Environmental Sampling Be Done?

• NO, not routinely
• Environmental sampling may be useful
• To verify the effectiveness of a new cleaning
  and disinfecting process
• To identify environmental reservoirs during
  outbreak situations
• Coordinate sampling with the laboratory

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Environmental Sampling Section
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Environmental Sampling Section Subtopics

• Principles of environmental sampling
• Air sampling
• Water sampling
• Environmental surface sampling

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Laundry and Bedding Section
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Laundry and Bedding Section Subtopics

• Epidemiology
• Collecting and sorting soiled linens
• Laundry processes
• Antimicrobial-impregnated articles
• Pillows, mattresses
• Air-fluidized beds

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Animals in Healthcare Facilities Section
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Animals in Healthcare Facilities Section Subtopics

• Animal-assisted activities, animal-assisted
  therapy, resident animals
• Service animals
• Animals as patients in healthcare facilities
• Research animals in healthcare facilities

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Regulated Medical Waste Section
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Regulated Medical Waste Section Subtopics

• Epidemiology
• Categories of medical waste
• Management of waste
• Treatment of waste
• Discharge of blood, body fluids to the sanitary
  sewer
• CJD issues

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EIC Guidelines Performance Measures

• Document infection control professionals
  involvement in all phases of construction
• Monitor and document airflow for AII and PE,
  especially when occupied
• Monitor water in hemodialysis settings monthly
  for endotoxin and bacteria
• Determine source(s) of NTM
• Identify and respond to water damage

44
JCAHO 2004 Standards for the Management of the
Environment of Care

• Planning and Implementation Activities
• EC 1.10 EC 1.30 safety risks, smoking policy,
  safe environment
• EC 2.10 security risk management
• EC 3.10 hazardous materials and wastes
• EC 4.10 EC 4.20 emergency management

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JCAHO 2004 Standards for the Management of the
Environment of Care

• Planning and Implementation Activities
• EC 5.10 EC 5.50 fire safety and Life Safety
  Code issues
• EC 6.10 EC 6.20 medical equipment
• EC 7.10 EC 7.50 utilities management
• EC 8.10 EC 8.30 environmental management

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JCAHO 2004 Standards for the Management of the
Environment of Care

• Measuring and Improving Activities
• EC 9.10 EC 9.30 monitoring and analyzing
  environmental conditions implementing
  recommendations to improve the environment of care

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JCAHO 2004 Standards for the Management of the
Environment of Care

• Standard
• Performance expectation
• Rationale
• Background, justification
• Elements of Performance
• Steps needed to achieve the standard

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Thank You!

• Protect patients, protect healthcare personnel,
  and promote safety, quality, and value in the
  healthcare delivery system

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