4. Flowers are dangerous?
4
Two papers looked at Pseudomonas
Contaminated flower vases
The Lancet, 1973;302:568-569. A. L. Rosenzweig
Flower vases in hospitals as reservoirs of
pathogens
The Lancet 1973;302:1279-1281. D. Taplin, PM. Mertz
Protecting chrysanthemums from hospital
infection
The Lancet 1974;303:267-268. W. Howard
Hughes
5. Postulates
NW England Communicable Disease Task Force (a zillion years ago)
5
Contamination of the environment by human
pathogens can be shown to occur
We can show that these microbes are able to
persist in the environment
A significant route to the patient can be
demonstrated
A useful level of decontamination of the
environment can be achieved
7. Patient Environment
7
Door knobs, bed rails, curtains, instrument dials,
computer keyboards likely to be contaminated by
hands which onward transmit
MRSA on the door handles of 19% of rooms housing
MRSA & 7% of door handles of non-MRSA rooms
Oie S, Hosokawa I, Kamiya A. J Hosp Infect.
2002;51(2):140-3.
42% of nurses contaminated their gloves with MRSA
while performing activities with no direct patient
contact but involving touching objects in rooms of
MRSA patients
Boyce JM, Potter-Bynoe G et al ICHE 1997;18(9):622-7.
8. Protect the patient from
themselves
French, Otter et al, J. Hosp Infect, 20048
Examined the extent of environmental
contamination surrounding patients known to
be MRSA-positive
74% of sites positive
Moment 2 of the 5 moments for hand hygiene
Dealing with an invasive device after touching the
patient or their environment can increase risk
9. Transmission MDR Organisms
Nseir S, Blazejewski C, Lubret F et al. Clinical Microbiology and Infection 17(2) pp1201-
8 (2010)
Prospective cohort study in ICU: successive
occupiers of a room at risk from organisms
from previous occupants
Pseudomonas aeruginosa (OR 2.3, p<0.02)
Acinetobacter baumanii (OR 4.2, p<0.001)
‘Quality’ audits showed that 56% of rooms
were not cleaned correctly
Failure in room door knobs (45%), monitor
screens (27%) and bedside tables (16%)
9
10. Missing information
What did the quality audits consist of?
Methodology, what was looked at, etc
No attempt to look at the results of the
cleaning audits to see if transmissions
occurred when cleaning was poor
No description of any divisions in cleaning
duties
Cleanliness of clinical equipment not mentioned
10
11. Dancer SJ, White LF, et al BMC Med. 2009;7:28.
Evidence for cleaning as a control
mechanism for MRSA?
One extra cleaner into two wards (Mon-Fri);
each ward receiving extra detergent-based
cleaning for six months in a prospective cross-
over design
Ten hand-touch sites on both wards screened
weekly
Patients monitored for MRSA infection
Patient and environmental MRSA isolates were
characterised using DNA finger-printing
11
12. What did they find?
Extra cleaner responsible for
33% reduction in colony counts on hand-touch sites
27% reduction in new MRSA infections
despite busier wards and more MRSA patient-days
They expected 13 infections during enhanced
cleaning periods but 4 occurred
Molecular studies demonstrated identical strains
from hand-touch sites and patients
Some of which were months apart
Dancer SJ et al BMC Med. 2009;7:28.
12
13. Was the extra cleaning cost
effective?
Costing exercise
Cleaner earned £12,320 a year and the
consumables were £1,100
One MRSA surgical site infection estimated at
£9,000
Reduction by 5-9 cases
The hospital saved £45,000-£81,000 without the
additional costs of cleaner/consumables
Annual nett saving for two wards was between
£31,600 - £67,600
Dancer SJ et al BMC Med. 2009;7:28.
13
14. Who is really caring for your
environment of care?
Dumigan DG, Boyce JM et al AJIC 38:387-92 (2010)
Procedures for cleaning patient care
environments, but often confusion about the
division of labour when it comes to cleaning
responsibilities
Systems to monitor cleaning effectiveness are
frequently suboptimal
Implemented ATP monitoring and reported
improvement
looked at ‘housekeeping’ items only
14
15. Time spent cleaning doesn’t
indicate thoroughness
Rupp ME, Adler A et al, ICHE 34(1) 100-2 (2013)
15
16. Assessing cleanliness?
Luick BS, Thompson PA et al AJIC (2013)
Compared ATP, UV and visual methods with
micro cultures used as the ‘Gold’ standard
Fluorescent marker and an adenosine
triphosphate bioluminescence assay system
demonstrated better than subjective visual
inspection
If visual checks are solely used, there is a greater
chance that contaminated surfaces will be passes
as ‘clean’
16
17. Audit of Equipment
Anderson RE, Young V et al, JHI 78(3) 2011
Many items of clinical equipment in patient
care do not receive appropriate cleaning
attention
Average ATP score indicated that surfaces
cleaned by professional cleaning staff were 64%
lower than those by other staff (P=0.019)
Nurses don't clean very well – of 27 items
cleaned by clinical staff, 89% failed the
benchmark
17
18. Failure of terminal cleaning
Carling PC et al. ICHE 29:1-7 (2008)
18
Ultraviolet marker was used to test whether
items felt to be high touch in patient isolation
rooms would be cleaned
Overall, 49% of objects/surfaces were not
cleaned (range 35-81%)
Wide variation in cleaning particular items
Poor were toilet handles, bedpan cleaners,
light switches and door handles – under 30%
20. Lack of compliance with cleaning
Alfa M, Duek C et al. BMC Infectious Diseases 8:64 (2008)
20
Marker applied to toilets and commodes
Inspected daily and microbiologically sampled for
C. difficile
UVM marker found in half of toilet samples and
75% of commode samples
Commodes not cleaned at all on 72% of days
sampled
Toxigenic C. difficile recovered from 33.3% of
toilet samples and 62.5% of commode
samples
21. Do Nurses Clean?
Survey of >1000 UK Nurses and
Healthcare assistants
Calkin, S. Nursing Times 108 (36) p2 (2012)
>50% felt that their organisation’s cleaning
services were ‘inadequate’
37% stated that a bed would not be closed if it
had not been cleaned properly
75% stated that they had not adequate
training
21
22. In the preceding12 months
Calkin, S. Nursing Times 108 (36) p2 (2012)
0
10
20
30
40
50
60
70
80
90
Roon (non-inf) Room (Infected) Toilets Bathrooms
% Undertaking cleaning
22
23. ‘The root of evils which have to be dealt with
is the division of responsibility and
reluctance to assume it’
F. Nightingale
23
25. Cleaning by nursing staff
Havill N, Havill H et al, AJIC 39: 602-4
(2011)25
ATP and aerobic cultures to assess the
cleanliness of portable medical equipment
disinfected by nurses between each patient
use
Equipment was not disinfected as per protocol
26. Using wipes for cleaning
26
Common use but label claims may be
misleading
Mode of action, technique, absorbtion etc etc
No evidence for use against biofilms
Sattar SA, Maillard JY. AJIC 2013;41(5 Suppl):S97-
104.
Repeatedly using a wipe transfers organisms
and C. difficile spores from contaminated to
clean areas in significant numbers
Siani H, Cooper C et al. AJIC 2011;39(3):212–218
Cadnum J, Hurless K et al, ICHE 2013; 34(4) 441-2
27. Biofilms in the environment
Viable MRSA grown from biofilm clinical
surfaces from an ICU despite terminal
cleaning
current cleaning practices may not be adequate
to control biofilm development
The presence of organisms being protected within
these biofilms may be the mechanism by which
they persist within the hospital environment
Vickery K, Deva A et al J Hosp Infect. 2012;80(1):52-5.
27
29. Who is responsible?
Ptak and Tostenson (2009) Outpaientsurgery.net
29
When assigning cleaning duties to different
staff members, avoided using general
categories
Nurses in charge of "equipment" and
housekeeping in charge of "furnishings" can
cause confusion
Created a simple pictorial cleaning manual
Each page displays photo of an item, who is
responsible for cleaning, instructions on how to
clean and frequency
Staff involved in drafting and agreeing
responsibilities
30. ‘Low Risk’ items
Creamer E., Humphreys, H; JHI (2008) 69 pp 8-23
30
“While designated a low-risk item, it is clearly
evident that the hospital bed poses a potential
risk of infection to patients if not adequately
decontaminated”
Regular, e.g. weekly, decontamination is
advised
Ideally decontaminate a bed by thermal
disinfection between patients
If endemic with MRSA and VRE at least try to
ensure that the critical components, e.g.
mattresses and pillows, are processed in a
thermal disinfection unit
33. Pillow Talk
33
Long recognised as a potential risk
Acinetobacter in feather pillows
Weernink A., Severin WPJ et al; JHI (1995) 29 (189-
99)
34. Pillows as a Risk Area
Lange V. AJIC (2014) 42 S34-35
34
Exterior surface of 100 pillows swabbed
Previously cleaned with a quaternary ammonium
compound
38% contaminated
MRSA, VRE, Coliforms, inc E. coli and K. pneumoniae
Concluded
Reusable hospital pillows may serve as reservoirs for
nosocomial pathogens
Clear and rigorous guidelines should be established for
decontamination of patient beds and pillows
Outbreak investigations should include assessment of
pillows and mattresses
Made a temporary switch to disposable pillows
Currently reviewing other options such as a barrier pillow
cover with and without antimicrobials
35. Control of CA-MRSA in a Burn
Centre
Shik N., Ford S. et al AJIC (2014) 34(5) E100-10235
PVL-producing MRSA
Pustules or boils
2 outbreaks in a Burns Unit
During the outbreak investigation it was noted
that pillows used in the hospital were not fluid-
proof, and when cut open, many were visibly
contaminated with body fluids
36. Examination of Pillow Cores
Mottar R., Roth M et al AJIC (2006) 34(5) E107-108
36
Burn Centre
When inspecting pillows used on the burn unit,
nurses discovered patient pillows varied in weight
and detected stains on some pillow covers
Presence of small manufactured openings for
air exchange within the pillow core
Potential for wound drainage contamination and
transfer of microorganisms
37. Examination of Pillow Cores
Mottar R., Roth M et al AJIC (2006) 34(5) E107-108
37
Patient pillows and a control (unused) sent for
testing
Pillow seams and pillow label tags were found to be a
mechanism for pillow contamination allowing for
drainage wicking from outside the pillow to the pillow
core
Multiple pathogens found growing within pillow
cores of all patient pillows
correlation to organisms from colonised and infected
patients
Acinetobacter cultured from a patient with colonisation of
the face
No growth within the pillow core of the control pillow
38. CPE contamination
Lippmann N., Lubbert C et al Lancet ID (2014)
38
Large outbreak of KPC in Germany
Environmental reservoir sought
Positioning pillows for ARDS internally
contaminated and remained so for 6 months
Ward pillows and mattresses not externally
positive
Attributed to frequent steam cleaning of pillows and
mattresses
Concluded that the search for environmental
contamination should leave no stone unturned
40. Pillow is a Vector
Tucker A., Dewhurst, M. Abstract, IPS Conference
201240
Study looking at 100 standard and 100 barrier
pillows (Sleepangel™, a class 1 medical
device)
Pneumapur™ nanofilter membrane
In use for 3 months and sent for analysis
External contamination of both types
Internal contamination of standard pillows, all
barrier pillows contamination free
60% of standard pillows failed mechanically at 3
months, no barrier pillows failed
Whole Trust replacement programme
Significant MRSA and CDI reduction
41. Southport and Ormskirk NHST
41
Same story – pillows as a potential vector
They don’t just get used under heads..
Respiratory ward – a problem area (Abx,
relvolving door)
Prior to intervention; 0.52 CDI/month
Post intervention; 0.12 CDI/month
No other differences (virtually all other wards
increased)
Although antibiotic prescribing targets were raised the ward
was already meeting new standards
Very popular with staff
Plus: Easy to clean, robust and comfortable for
patients; Less numerically required
Concern: Disappearing act..
42. Research is still needed….
42
Does daily disinfection of high-touch surfaces
and increased attention to portable equipment
add significant benefit to terminal room
cleaning?
What is the optimal frequency of disinfection?
Is it beneficial to include all rooms on high-risk
wards or the whole organisation in interventions?
Interesting that we seem to need evidence
+++ when implementing ‘technical’
interventions, yet none when we change
‘convenience’ items
43. Final Points
43
Time to accept the obvious
Nurses do have to clean
They don’t do it well; this will increase risks to
patients
What they do clean must be cleanable
We must convince nursing colleagues that this
is a critical task and train them to undertake
this important duty
Gaps in our IPC Strategies may be under our
noses (literally)
