Fighting MRSA in the Hospital Environment

A new Approach

MRSA Conference

July 30, 2007

Philip C. Carling, M.D.

Caritas Carney Hospital and Boston Medical Center

pcarling@cchcs.org

Is Disinfection Cleaning Important?

CDC Monitor (i.e., supervise and inspect)

cleaning performance to ensure consistent cleaning and disinfection of surfaces in close proximity to the patient and likely to be touched by the patient and health care Professionals (e.g. bedrails, carts, bedside commodes, doorknobs, faucet handles). Category 1B.

Management of MDROs in Healthcare Settings – October 2006 V.B.8.b.

IHI“Hospitals should use immediate

feedback mechanisms to assess cleaning and reinforce proper technique”

5 Million Lives Campaign – Guide to Significantly Reducing MRSA Infections

December 2006

How Important is the Environment in the Transmission

of MRSA?

Surface Contamination of Near-patient Environment

23 Studies

0

20

40

60

80

100

C. DIFFICILE VRE MRSA

% C

ON

TAM

INA

TED

How Important is the Environment in the Transmission of MRSA?

• MRSA Survives on Dry Surfaces for 90 to 236 days.

• Until we had PGFE fingerprinting there was no way to study this this issue.

• Reports over the past two years have now shown:A. More extensive environmental Contamination

of the near patient environment than older studies and

B. Patients contract strains from prior room occupants

How Well Do Environmental Disinfectants Work ?

How Well Does Environmental Disinfecting Work ?

• Phenolic Compounds

• Quartinary Amonium Compounds

• Chloride Disinfectants

• Formaldehyde

Kill a wide range of microbial

pathogens

Work Rapidly

Work effectively in clinical

settings

ALL

How Well Does Environmental Cleaning Work ?

Cleaning House: A New Metric in the Objective Evaluation of

Environmental Cleaning

GOAL OF THE PROJECT

To develop a surrogate marking system to evaluate the effectiveness of environmental cleaning/disinfection of the near-patient environment

The Targeting Solution

A mixture of several glues, soaps and a targeting dye which:

Dries rapidly

Environmentally stable

Readily wetted by spray disinfectants

Easily removed with light abrasion

Inconspicuous

Targeting Patient Rooms

Objects were chosen by considering sites

A. A patient was most likely to contaminate and B. A care givers may touch with their hands

Up to 14 objects marked in each room after terminal cleaning

Objects were evaluated after one to two patients had cycled through the room to see if targets had been removed by discharge cleaning activities

Environmental Cleaning Evaluation in Three hospitals

- A confidential evaluation without Environmental Services awareness was implemented- About 50 patient rooms / Hospital- Up to 14 objects marked when the room

was empty- Evaluated after patient had cycled through the room and it had been terminally cleaned

Preliminary Results – Three Hospitals

45 42

56

8682

92

0

20

40

60

80

100

% O

BJEC

TSCL

EANE

D

HOSPITAL A HOSPITAL CHOSPITAL B

Clinical Infectious Diseases – February 2006

Goals of the Multi-institutional Terminal Room Cleaning Project

To determine if:• The targeting methodology is appropriately

user friendly;• The thoroughness of cleaning at other

institutions is similar or different from what we had found to date;

• Cleaning can be improved using focused educational interventions and feedback to the ES staff using limited resources (time).

Health Care Environmental Hygiene Study Group – Acute Hospitals

MA = 6

RI = 5

RESULTS

The Program

Phase I

Covert Baseline Environmental Cleaning Evaluation

(The same as Previously described)

0

2

4

6

8

1-5% 11-15%

21-25%

31-35%

41-45%

51-55%

61-65%

71-75%

81-85%

91-95%

Baseline Environmental Evaluation of 20 Acute Care Hospitals

% of Objects Cleaned

Hos

pita

ls Mean = 48.3 %

PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS

0

20

40

60

80

100

%

The Program

Phase I – Covert Baseline Environmental Evaluation

Phase II

A. Educational Interventions – ES Staff

B. Feedback to the ES – Staff

The Program

Phase I – Covert Baseline Environmental Evaluation

Phase II

A. Educational Interventions – ES Staff

B. Feedback to the ES – Staff

(frequently repeated)

Hospitals Environmental Hygiene Study Group20 Hospital Results

30

50

70

90

PRE INTERVENTION FOLLOWING EDUCATION FOLLOWING FEEDBACK

% o

f O

bjec

ts C

lean

ed

= Mean =/- 95% CI

Health Care Environmental Hygiene Study Group – Massachusetts Hospitals

• Caritas Carney Hospital – 2003• Quincy Medical Center – 2004• Rehabilitation Hospital of the

Cape and Islands – 2004• Braintree Hospital - 2004• Boston Medical Center – 2004• MWMC Natick Campus – 2005• Somerville Hospital – 2005• Brigham and Women's Hospital – 2006• Lahey Clinic – 2007• Shriner’s Burns Institute – 2007• Whidden Hospital – 2007• Mount Auburn Hospital - 2007