Beyond surface cleaning
Carolyn Hicks, an Environmental Services employee at Levindale Hebrew Geriatric Center
Resident rooms at the Jewish Home and Care Center in Milwaukee are larger than those typically found in skilled nursing facilities, giving germs more places to hide and making terminal cleanings more arduous.
This spring, administrator Elaine Dyer increased the arsenal she's using to attack the kind of superbugs and contagious diseases that threaten lives and cost long-term care facilities billions of dollars annually.
The Jewish Home was the first long-term care center in the United States to buy a pulsed xenon UV disinfection robot, a mobile unit that can stop more than 20 pathogens from replicating and spreading. The robot has cut down on time Dyer's employees spend disinfecting a room between one resident's final departure and another's arrival.
“Now, in about 18 minutes, I can turn that room around safely,” says Dyer, RN, BSN. “We still have to do the manual cleaning first, but this is an extra touch.”
Terminal cleaning presents an opportunity for deep cleaning and sanitizing that is nearly impossible in an occupied room. Turnover efforts ultimately affect other residents' health, as well as a facility's reputation and bottom line.
A recent Clorox Professional Products survey found that 71% of U.S. adults with a friend or loved one in long-term care cite cleanliness as a top factor in selecting a facility. One in five worried about infection because a facility didn't smell clean.
Steven Schweon, RN, board-certified infection specialist, consults with facilities on preventing healthcare associated infections or responding to citations. He says “inadequate” terminal room cleaning puts the next resident at risk of acquiring the same pathogens a previous patient may have been battling.
“Some of the pathogens can remain stable in the environment for weeks or months,” he says.
As vice president of clinical affairs for PDI, J. Hudson Garrett assumes every room is infected. Most facilities can't afford to culture seemingly healthy residents regularly, and that means many illnesses go undiagnosed. Even when cultures are used, more than half of all MRSA-colonized patients remain unrecognized, according to the Centers for Disease Control and Prevention.
“If we don't do a good job of cleaning the room, there's a 50 percent chance that the next patient that comes in there will get an HAI,” says Garrett.
Many facilities are discovering the power of layering turnover techniques, and incorporating new products and technologies to improve outcomes. For example, Clorox Professionals this year partnered with UVDI to market a portable UV lamp that supplements their extensive manual surface disinfection line.
“The partnership is an example of how a bundling of environmental surface solutions can provide healthcare facilities with a more comprehensive approach to help reduce the threat of HAIs among residents, staff and visitors,” says Dane Dickson, Clorox's research and development director.
Clean, eliminate, kill
Every turnover effort should begin with manual cleaning, but experts say not everyone knows the difference between cleaning, sanitizing and disinfecting.
Cleaning with soap and water “does not necessarily kill germs, but it does lower their numbers,” Dickson explains. “Sanitizing lowers the number of germs on surfaces … (and) disinfecting uses chemicals to kill germs on surfaces or objects to further lower the risk of spreading infections.”
Though Dickson says bleach is still the broad-spectrum “product of choice,” Clorox has expanded its professional offerings to help LTC providers become a little greener. Healthcare Hydrogen Peroxide Cleaner Disinfectants are EPA-registered to kill most bacteria and viruses in 30 seconds (without volatile organic compounds — VOCs -— or harsh fumes).
Ecolab recommends hospital-grade Oasis 14 or A456-II products for routine cleaning but suggests ready-to-use Virasept disinfectant cleaner at turnover because it also kills C. diff.
Whatever products a facility uses, PDI's Garrett recommends turnover begin within an hour of a resident's departure and focus on the nooks and crannies often missed when the room is someone's living environment. Get as much portable equipment, furniture and bedding as possible out of the room. Then follow written procedures to ensure every item is cleaned, he advises.
“They should start with the high-touch surfaces and work their way out,” says Garrett. PDI's bleach-and ammonia-free Sani-Cloth AF3 has a three-minute efficacy against 44 microorganisms.
Knowing who will use the product is critical, says Schweon. Should housekeeping or nursing staff wipe down an IV pole or mounted BP cuff? One CDC hospital evaluation found 20% of glucometer storage areas were contaminated. That could be because cleaning teams weren't using the right cleaners. Seventy percent ethanol solutions are not effective against viral blood borne pathogens and 10% bleach solutions could lead to device degradation.
Talking to vendor representatives about what solutions to use — and when — can help head off infections.
“I think they embrace that challenge of some of the more difficult items,” says Steven Hietpas, business development manager for Maytag Commercial Laundry. He says microprocessors on today's washing machines are made to accommodate detergents activated at specific temperatures: use the wrong temperature and you might kill the active ingredients in an “ozone” cleaner instead of the infectious agent you're targeting.
Ecolab's Aquanomic Program includes solid, low-temperature laundry products that pair with the company's SMART wash process to deliver utility savings and hygienically clean results. Their Advacare 120 Sanitizer Sour is recommended for facilities that must abide by EPA-registered laundry sanitizer requirements. But chemical pros know even the most advanced products are undermined by cross-contamination.
“Elimination of cross-contamination sources throughout a long-term care facility is very important for minimizing the spread of disease,” says Leah Larson, director of long-term care marketing for Ecolab's Institutional business. “The laundry room and housekeeping staffs need to be aware of and follow correct procedures throughout the linen flow process from the very beginning of the collect phase and ending with the storage and use phases. Practices include use of proper personal protective equipment [PPE] … designated clean and soiled linen carts and storage areas, and decontamination of hard surfaces throughout the laundry room.”
Technology moves in
For items that can't be laundered, Medical Facilities of America opted for Vancare ESS carts in its 40 nursing and rehabilitation facilities in Virginia and North Carolina. The cart uses technology developed for cruise lines — a handheld gun sprays electro-statically charged chemicals that are drawn under and in-between surfaces — in a long-term care-friendly delivery system.
“Before, we were using good products, but the application and the user variability weren't giving good results,” says MFA's Clinical Education Specialist Lajuana Jordan, RN, MSN. “We wanted something that would keep it as simple as possible for our environmental services folks while being highly effective.”
MFA staff use the cart once a week in all resident rooms, increasing this to three times a week in isolation rooms. They roll it in again for terminal cleanings. Instead of trashing or laundering items such as privacy curtains or pillows, those without stains can be treated by the spray — making turnover quicker and requiring less of the laundry department.
Before instituting the roughly $7,000 carts system-wide, Jordan wanted proof they worked. Her team swabbed two C. diff-infected rooms treated with Virex 256 or Ultra Clorox and isolated 325 organisms (including acinetobacter, MRSA, VRE and pseudomonas). Thirty days after beginning the ESS protocol, the same sampling methods turned up just 10 organisms — all of them common environmental players such as staphylococcus coagulase or bacillus.
Jordan credits the carts with completely knocking out pervasive norovirus and flu infections that forced a 180-bed building to shut down admissions twice last year.
The ESS system requires non-toxic chemicals that are more costly than bleach. Gary Krupa, president of HAI Solutions, designed the cart for Vancare. He says its cost of use pales in comparison to what's required to treat HAIs. They're also marketable — to residents, families and hospitals that refer patients.
“The regulatory and payment stars have aligned” to force some operators to seek out these next-generation solvents and technologies, Garrett notes.
At the Centers for Living and Rehabilitation in Vermont, administrators followed the lead of an affiliated hospital and began using Sanosil's Halo fogger to sanitize rooms. Each machine cost about $5,000 when Southwest Vermont Medical Center purchased them about two years ago.
Halo's “fog” combines hydrogen peroxide and silver in a way that allows free radicals to attack microorganisms. Once it's done its job, the mixture breaks down into water and oxygen.
European import Novaerus has built its reputation on its ability to reduce upper respiratory infections. The machines use airflow to pull microorganisms across a charged plasma field and destroy their cellular structure.
“Once the product is installed, that technology is working constantly to reduce airborne pathogens,” says Chief Marketing Officer Brendan Sullivan.
Since being introduced in Florida in early 2013, they've been ordered by some 100 nursing homes in 20 states, according to Sullivan. The focus on airborne pathogens had grown in recent years, especially given an MIT study published in March that found some particles could travel much farther through the air than previously thought.
Dangerous organisms that live for long periods untouched by typical daily cleaning may be aerosolized again by vacuuming, wiping or other cleaning and room-arranging activities. Novaerus says routine use of its products (an average of 35 to 40 mounted units for a 120-bed SNF at $69 a month each) will keep zapping the germs. Sullivan said a mobile unit could conceivably be used only at terminal cleanings, but no long-term care provider currently is using it that way.
In Milwaukee, Dyer turned to Xenex after reading about its successful rollout in hospitals. Advanced clinical interventions now standard in skilled nursing also make patients more susceptible to nosocomial infections. That fact helped Dyer make her case to her facility's foundation, which funded the purchase of a $70,000 refurbished demo. She estimates a 15% reduction in C. diff cases over six months will pay for the robot.
Xenex spokeswoman Melinda Hart says a new robot runs $134,000 over three years, or leases for $5,000 a month. Dyer sees the robot as an investment that can help attract hospital referrals. She shares it with a connected assisted living facility.
The robot destroys pathogens by emitting pulses of the inert gas xenon at high frequencies capable of shattering DNA. Similar systems depend on mercury bulbs. With Xenex, staff can program blueprints that tell staff how to move the robot to hit often-overlooked areas. Hart says two to three positions — and turning items like phones between each five-minute blast — provide full disinfection.
Although expensive, neither mercury nor xenon-based UV should lose its efficacy. A study headed by clinical infectious diseases specialist Chetan Jinadatha, M.D., at the Central Texas Veterans Healthcare System, found that several multi-drug resistant organisms did not mutate in response to repeated UV exposures. That means they are “unlikely” to generate UV resistance, something that can no longer be said about many traditional cleaners.