The importance of daily surface disinfection in reducing the spread of HAIs

by Ruth M. Carrico, PhD, RN, CIC

Healthcare-associated infections (HAIs) are the fourth leading cause of death in the United States, resulting in the death of more people annually than AIDS, breast cancer and auto accidents combined ¹ According to research, the cost of one infection for a hospital is $18,000, which is not likely to be reimbursed by Medicare or some other payers, and the related increase in length of stay for a patient is seven to 12 days.² In total, the Centers for Disease Control and Prevention (CDC) estimate that 1.7 million HAIs occur each year and contribute to the death of 99,000.³ Further, for U.S. hospitals, infections result in annual direct costs that may exceed $45 billion.⁴

Clostridium difficile infections, also known as C. difficile, C. diff or CDI, have increased in frequency, recently surpassing methicillin-resistant Staphylococcus aureus (MRSA) infections as the most prevalent HAI in hospitals.⁵ C. difficile causes a wide variety of symptoms, from diarrhea to more serious life threatening intestinal disease. A 2008 study conducted by the Association for Professionals in Infection Control and Epidemiology (APIC) found that C. difficile infection rates were 6.5 to 20 times higher than previous estimates.⁶ CDI is not a nationally reportable disease, and the true incidence of infection is not known. Using information provided by the APIC prevalence study, the costs associated with care and additional days in the hospital have been estimated to range from $17.6million to $51.5 million.

One of the primary challenges with C. difficile involves the dramatic changes in CDI epidemiology. Not only has there been an overall increase in the incidence of CDI, but outbreaks have increased in severity as well. These more severe and recurrent infections were first identified in Quebec, Canada in late 2002 and have since been identified in most states in the U.S. This new strain of C. difficile is commonly known as NAP1/B1/027 and may be referred to as the “toxigenic” strain of C. difficile. Recognizing the severity and threat to patients, hospitals and other healthcare facilities have been taking steps to stop the spread of C. difficile, but more needs to be done. When healthcare facilities identify where and when infections are likely to occur and take concrete steps to prevent them, the rates of HAIs drop, some more than 70 percent.⁷

Strategies to Fight the Spread of C. difficile and Other HAIs

Transmission of C. difficile occurs from person to person, most commonly via three important processes:

• Contact with a healthcare worker with contaminated hands;
• Contact with a patient with CDI;
• Contact with the contaminated environment.

It is important that hospitals and other healthcare institutions adopt a comprehensive C. difficile prevention program. The 2010 Clinical Practice Guidelines for C. difficile Infection in Adults, provided by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) outline specific control measures that include hand hygiene, surveillance, use of contact precautions and private rooms, and environmental cleaning and disinfection.⁸

Hand Hygiene

Hand hygiene is considered to be one of the cornerstones of an effective infection prevention program. The ability to maintain clean hands is of special importance to a C. difficile prevention program, and some of the mainstay hand hygiene activities may need additional attention and staff education. It is no surprise that hand washing is associated with a reduction in the incidence of infection, but low compliance with hand hygiene best practices continues to plague infection prevention programs.

Alcohol-based hand hygiene products have been viewed as a breakthrough for increasing compliance, but they may have limited effectiveness when hands are contaminated with the C. difficile spore. Mechanically washing with soap and water is much more effective in physically removing the organism from the hands. This does not mean that alcohol-based hand rubs should be removed from patient care areas where CDI has been identified. Instead, vigorous monitoring of hand hygiene practices and heightened attention toward increasing hand hygiene rates should be among the first responses.

Healthcare staff need to understand that C. difficile organisms may be difficult to remove, even with the physical actions of hand washing, so a critical element in a hand hygiene program also includes appropriate use of gloves as a barrier to hand contamination. Ensure gloves are readily available and in sizes appropriate for the users. Teach staff how to remove and discard gloves in ways that minimize hand contamination during removal. Stress the need to perform hand hygiene after glove removal. Enable healthcare personnel to perform hand hygiene appropriate for the situation. Continue to provide alcohol-based hand rubs for routine hand hygiene performance but ensure that soap and water hand wash facilities are readily available for the cleansing of hands when they are visibly soiled and when hands may be contaminated with C. difficile. Engage healthcare staff in hand hygiene product selection, as healthcare staff may be more likely to use a product they like and choose themselves. Remember to include families and visitors in hand hygiene education.

Surveillance

Hospitals and healthcare facilities should also perform surveillance to quickly identify cases of C. difficile infection. Standardized case definitions should be used and surveillance should be conducted for healthcare facility-associated CDI as a means of detecting outbreaks and monitoring patient safety.⁹

Contact Precautions

Once patients with CDI have been identified, they should immediately be placed on “contact precautions.” Healthcare personnel must utilize protective equipment, including gowns and gloves, as a means of preventing transmission. Patients with CDI should be placed in private rooms. If single rooms are not available, cohorting can be done with other CDI patients but each patient should have their own dedicated commode. Contact precautions should continue until diarrhea resolves but may be continued in outbreak situations or when ongoing transmission is present.

Environmental Cleaning and Disinfection

Effective use of cleaning and disinfection is another important addition to the prevention armamentarium. The role of the environment in infection transmission has never been more appreciated. Microorganisms are demonstrating a hardiness that allows them to survive on environmental surfaces for extended periods of time. C. difficile spores can survive on surfaces for several months. Because of the resilience of these spores, it is important to routinely clean and disinfect surfaces to reduce the risk of transmission. Daily environmental attention is a must if CDI transmission is to be prevented.

Healthcare facilities may elect to change from the routine hospital germicide to one that has a demonstrated effect against C. difficile spores. Switching to a cleaning agent such as a sodium hypochlorite (bleach) solution is an important consideration, especially during an outbreak or to address increasing CDI rates. The use of a product that is registered by the U.S. Environmental Protection Agency (EPA) and has proven efficacy claims is crucial. Product selection should involve an assessment of the organisms encountered within the facility and their impact on patients.

Selecting appropriate disinfectants and ensuring that staff are properly trained to use them may make a difference in the well-being of the patients. If making a germicide switch, it is important to recognize that staff education and systems support are critical for a successful implementation. When planning for such an event, effort must be devoted toward the development of a complete set of policies and procedures that identify individual and departmental responsibilities in the process. Specific activities, including the order of cleaning and disinfection, must be clearly outlined and tested. Products must be used that support these activities and engage everyone in the process. Maintenance of a hygienic environment is everyone’s responsibility so prevention plans should consider ways to make that happen. For example, germicidal wipes may be included as an adjunct to the cleaning and disinfection process. If so, the products should be evaluated to ensure that they are of sufficient size and efficacy for the tasks.

Each of these steps may seem like they are easy to implement, but ensuring consistent application of improvements and the rapid addressing of practice deviations take time and attention. Recognizing that everyone has a stake in improving activities and ideas for successful and sustainable implementation should come from those involved in the process. Attention to hand hygiene, rapid identification of patients with CDI, quick response and isolation, and meticulous attention to the environment are essential steps in a CDI prevention program.  Success depends upon involvement and commitment by everyone.

References

1. www.cdc.gov/ncidod/dhqp/healthDis.html Accessed October 16 2007
   1. www.cdc.gov/hiv/topics/surveillance/basic.htm#ddaids Accessed October 16 2007
   2. www.cancer.org/downloads/STT/CAFF2005BrF.pdf Accessed October 16 2007
   3. www.car-accidents.com/pages/fatal-accident-statistics.html Accessed October 16 2007
2. Perencevich EN, Pittet D. Preventing catheter-related bloodstream infections: thinking outside the checklist. JAMA. 2009;301(12):1285-1287.
3. http://www.cdc.gov/ncidod/dhqp/hai.html
4. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf. Accessed on August 26
5. http://www.eurekalert.org/pub_releases/2010-03/sfhe-rfc031510.php
6. http://www.cloroxprofessional.com/cdiff/index.html
7. http://www.hhs.gov/news/press/2010pres/06/20100608d.html
8. Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH; Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control Hospital Epidemiology. 2010 May; 31(5):431-55.
9. Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH; Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control Hospital Epidemiology. 2010 May; 31(5):431-55.

Ruth M. Carrico, PhD, RN, CIC is an Assistant Professor with the University of Louisville School of Public Health and Information Sciences and Associate Faculty with the Center for Health Hazards Preparedness. With more than 30 years in healthcare, Dr. Carrico has focused her practice toward issues dealing with infection prevention in the healthcare and public health sectors and is board certified in infection control. She has received training specific for healthcare epidemiology and public health at the Centers for Disease Control and Prevention (CDC) in conjunction with the Rollins School of Public Health at Emory University in Atlanta and the Society for Healthcare Epidemiology of America (SHEA).  In 2010, Dr. Carrico was deemed a SHEA Fellow.

Dr. Carrico has authored or co-authored numerous peer reviewed manuscripts as well as abstracts, posters, e-learning modules, two book chapters, and six books.  Dr. Carrico served as the editor for the Association for Professionals in Infection Control and Epidemiology Inc. (APIC) 2005 and 2009 Text of Infection Control and Epidemiology, the primary textbook for infection preventionists in the United States, Canada, and Asia. She currently serves as a reviewer for the American Journal of Infection Control (AJIC), Infection Control and Hospital Epidemiology (ICHE), and Critical Care Medicine and has served on the APIC national Board of Directors. During 2008-2010, Dr. Carrico served on the National Biosurveillance Subcommittee (NBS) Advisory Committee to the Director, Centers for Disease Control and Prevention.