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Re: Environmental hygiene and disinfection as part of Standard Precautions model

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  • #68745
    Mitchell, Brett (TIPCU)
    Participant

    Author:
    Mitchell, Brett (TIPCU)

    Position:

    Organisation:

    State:

    Thanks John
    Yes a long overdue debate on a complicated issue.

    I would make a few points:
    – I think the term environmental disinfection is misleading and prefer environmental hygiene
    – Evidence for the role of the environment in both HAI transmission and reduction is improving and I suspect more will shortly be coming. Although I am initially in favour of a concept to include environmental hygiene as part of SP, we must be confident of the evidence base. If we don’t we will end up on the same situation we have had with other IC issues.
    – The NHMRC guidelines may ‘hedge their bets’, but in fact it is a major step forward when talking about issues such as the frequency of cleaning based on risk and frequently touched objects (Section B5.1). It is now for other to prove/disprove these recommendations through research. No other guideline has gone as far as this before (in relation to this specific issue of frequency). Terminology used in other guidelines (including the CDC) such has as ‘frequent’ or ‘regular’ are meaningless when trying to argue the point for increased levels of cleaning for example.
    – routine management of the environment is included in SP in the NHMRC guidelines, but I think you are talking about more than that.

    If we go down the route of significantly increasing the profile and importance of environ hygiene then we need to consider/be prepared for
    – evidence to support it
    – cleaning frequencies
    – cleaning products – choice
    – who cleans what
    – recommendations for staffing
    – recommendation for evaluating cleanliness

    Many aspects of the above are progressing quickly. Thanks John for raising this important issue. Personally, I agree that the role of the environment is critical in HAI prevention and reduction.

    Brett Mitchell
    Tasmania Infection Prevention & Control Unit
    DHHS

    —–Original Message—–

    Dear All,

    In NSW there is current debate about the role of environmental disinfection. My view is that we should mandate the routine cleaning AND DISINFECTION of near patient touch sites, bathrooms and toilets. This requirement forms part of the CDC 2007 Isolation guideline Standard Precautions model which is arguably the basis for IPC practice around the world.

    The NHMRC IC Guideline hedges its bets with a uninterpretable requirement (below) under use of disinfectants to determine whether there is uncertainty about the nature of soiling on the surface!! This is a nonsense. We know from many sampling studies that the near patient surfaces are frequently contaminated with MROs etc and also that unadequate management of env hygiene leads to increased risk of MRO acquisituion in patients managed later in the same room (see attached recent review for a summary of the evidence).

    Over to you all! This is an issue, along with fomite management (clean between is not good enough!) that I think is overdue for local debate! Should we start to talk in detail about “Environmental Hygiene” (rather than Env Cleaning) as a companion standard to Hand Hygiene under Standard Precautions?

    Kind regards
    john
    John Ferguson
    Infectious Diseases Physician and Microbiologist,
    Hunter New England Health, John Hunter Hospital, Newcastle
    Conjoint Associate Professor, University of Newcastle
    Tel 61 2 49214444, Fax 61 2 49214440, Mobile 0428 885573

    CDC 2007 Excerpt (p60 under Fundamental elements needed to prevent transmission of infectious agents in healthcare settings):

    “Cleaning and disinfecting non-critical surfaces in patient-care areas are part of Standard Precautions. In general, these procedures do not need to be changed for patients on Transmission-Based Precautions. The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces, especially those closest to the patient, that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient) 11, 72, 73, 835. The frequency or intensity of cleaning may need to change based on the patient’s level of hygiene and the degree of environmental contamination and for certain for infectious agents whose reservoir is the intestinal tract 54. This may be especially true in LTCFs and pediatric facilities where patients with stool and urine incontinence are encountered more frequently. Also, increased frequency of cleaning may be needed in a Protective Environment to minimize dust accumulation 11. Special recommendations for cleaning and disinfecting environmental surfaces in dialysis centers have been published 18. In all healthcare settings, administrative, staffing and scheduling activities should prioritize the proper cleaning and disinfection of surfaces that could be implicated in transmission. During a suspected or proven outbreak where an environmental reservoir is suspected, routine cleaning procedures should be reviewed, and the need for additional trained cleaning staff should be assessed. Adherence should be monitored and reinforced to promote consistent and correct cleaning is performed.”

    NHMRC excerpt:
    Recommendation
    11 Routine cleaning of surfaces

    Grade

    Clean frequently touched surfaces with detergent solution at least daily, and when visibly soiled and after every known contamination.
    Clean general surfaces and fittings when visibly soiled and immediately after spillage.

    GPP

    Use of disinfectants
    In acute-care settings where there is uncertainty about the nature of soiling on the surface (e.g. blood or body fluid contamination versus routine dust or dirt) or the presence of MROs (including C. difficile) or other infectious agents requiring transmission-based precautions (e.g. pulmonary tuberculosis) is known or suspected, surfaces should be physically cleaned with a detergent solution, followed or combined with a TGA-registered disinfectant with label claims specifying its effectiveness against specific infectious organisms.

    Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of AICA.

    Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

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    Want to Get Healthy?

    The Tasmania Government’s Get Healthy Information and Coaching Service provides free information and coaching support to Tasmanian adults who would like to learn healthier eating habits, be more active or achieve and maintain a healthy weight. Call 1300 806 258 between 8am and 8pm, Monday to Friday or visit http://www.gethealthy.tas.gov.au for more information.

    CONFIDENTIALITY NOTICE AND DISCLAIMER

    The information in this transmission may be confidential and/or protected by legal professional privilege, and is intended only for the person or persons to whom it is addressed. If you are not such a person, you are warned that any disclosure, copying or dissemination of the information is unauthorised. If you have received the transmission in error, please immediately contact this office by telephone, fax or email, to inform us of the error and to enable arrangements to be made for the destruction of the transmission, or its return at our cost. No liability is accepted for any unauthorised use of the information contained in this transmission. If the transmission contains advice, the advice is based on instructions in relation to, and is provided to the addressee in connection with, the matter mentioned above. Responsibility is not accepted for reliance upon it by any other person or for any other purpose.

    Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of AICA.

    Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

    Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au

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    #68746
    Thomson, Rachel EA
    Participant

    Author:
    Thomson, Rachel EA

    Position:

    Organisation:

    State:

    Hi all,

    The issue of environmental hygiene is clearly on the national radar at
    present. I would suggest that the NHMRC IC guidelines have indeed
    helped to open debate in relation to management of the environment. I
    would dare to suggest that the document, especially section B5.1 has
    potentially raised more questions than it answers. Not a bad thing, but
    creating fertile ground for ongoing discussion and research. As a
    Manager in an acute care hospital the recommendations spelt out in the
    guidelines are, at a practical level, difficult at best and impossible
    at worst. For example the simple recommendation to clean AHR dispensers
    “daily and between patient use” is difficult to interpret and I
    personally wonder about the risk represented by such static items.

    I would like to commend the TICA who under Brett’s stewardship have
    embarked on raising this very issue at the upcoming TICA conference. I
    would suggest that this area is a topic that not only could be, but
    should be firmly placed on the National Agenda and would see a place for
    the AICA and the Commission to engage coal face clinicians and to
    support a research agenda in this critical (and often under rated)
    domain.

    Kind regards

    Rachel

    Rachel Thomson

    Nurse Unit Manager

    Infection Prevention & Control Unit

    Royal Hobart Hospital

    E: rachel.thomson@dhhs.tas.gov.au

    ________________________________

    Behalf Of Mitchell, Brett (TIPCU)
    Precautions model

    Thanks John
    Yes a long overdue debate on a complicated issue.

    I would make a few points:
    – I think the term environmental disinfection is misleading and prefer
    environmental hygiene
    – Evidence for the role of the environment in both HAI transmission and
    reduction is improving and I suspect more will shortly be coming.
    Although I am initially in favour of a concept to include environmental
    hygiene as part of SP, we must be confident of the evidence base. If we
    don’t we will end up on the same situation we have had with other IC
    issues.
    – The NHMRC guidelines may ‘hedge their bets’, but in fact it is a major
    step forward when talking about issues such as the frequency of cleaning
    based on risk and frequently touched objects (Section B5.1). It is now
    for other to prove/disprove these recommendations through research. No
    other guideline has gone as far as this before (in relation to this
    specific issue of frequency). Terminology used in other guidelines
    (including the CDC) such has as ‘frequent’ or ‘regular’ are meaningless
    when trying to argue the point for increased levels of cleaning for
    example.
    – routine management of the environment is included in SP in the NHMRC
    guidelines, but I think you are talking about more than that.

    If we go down the route of significantly increasing the profile and
    importance of environ hygiene then we need to consider/be prepared for
    – evidence to support it
    – cleaning frequencies
    – cleaning products – choice
    – who cleans what
    – recommendations for staffing
    – recommendation for evaluating cleanliness

    Many aspects of the above are progressing quickly. Thanks John for
    raising this important issue. Personally, I agree that the role of the
    environment is critical in HAI prevention and reduction.

    Brett Mitchell
    Tasmania Infection Prevention & Control Unit
    DHHS

    —–Original Message—–
    disinfection as part of Standard Precautions model

    Precautions model

    Dear All,

    In NSW there is current debate about the role of environmental
    disinfection. My view is that we should mandate the routine cleaning AND
    DISINFECTION of near patient touch sites, bathrooms and toilets. This
    requirement forms part of the CDC 2007 Isolation guideline Standard
    Precautions model which is arguably the basis for IPC practice around
    the world.

    The NHMRC IC Guideline hedges its bets with a uninterpretable
    requirement (below) under use of disinfectants to determine whether
    there is uncertainty about the nature of soiling on the surface!! This
    is a nonsense. We know from many sampling studies that the near patient
    surfaces are frequently contaminated with MROs etc and also that
    unadequate management of env hygiene leads to increased risk of MRO
    acquisituion in patients managed later in the same room (see attached
    recent review for a summary of the evidence).

    Over to you all! This is an issue, along with fomite management (clean
    between is not good enough!) that I think is overdue for local debate!
    Should we start to talk in detail about “Environmental Hygiene” (rather
    than Env Cleaning) as a companion standard to Hand Hygiene under
    Standard Precautions?

    Kind regards
    john
    John Ferguson
    Infectious Diseases Physician and Microbiologist,
    Hunter New England Health, John Hunter Hospital, Newcastle
    Conjoint Associate Professor, University of Newcastle
    Tel 61 2 49214444, Fax 61 2 49214440, Mobile 0428 885573

    CDC 2007 Excerpt (p60 under Fundamental elements needed to prevent
    transmission of infectious agents in healthcare settings):

    “Cleaning and disinfecting non-critical surfaces in patient-care areas
    are part of Standard Precautions. In general, these procedures do not
    need to be changed for patients on Transmission-Based Precautions. The
    cleaning and disinfection of all patient-care areas is important for
    frequently touched surfaces, especially those closest to the patient,
    that are most likely to be contaminated (e.g., bedrails, bedside tables,
    commodes, doorknobs, sinks, surfaces and equipment in close proximity to
    the patient) 11, 72, 73, 835. The frequency or intensity of cleaning may
    need to change based on the patient’s level of hygiene and the degree of
    environmental contamination and for certain for infectious agents whose
    reservoir is the intestinal tract 54. This may be especially true in
    LTCFs and pediatric facilities where patients with stool and urine
    incontinence are encountered more frequently. Also, increased frequency
    of cleaning may be needed in a Protective Environment to minimize dust
    accumulation 11. Special recommendations for cleaning and disinfecting
    environmental surfaces in dialysis centers have been published 18. In
    all healthcare settings, administrative, staffing and scheduling
    activities should prioritize the proper cleaning and disinfection of
    surfaces that could be implicated in transmission. During a suspected or
    proven outbreak where an environmental reservoir is suspected, routine
    cleaning procedures should be reviewed, and the need for additional
    trained cleaning staff should be assessed. Adherence should be monitored
    and reinforced to promote consistent and correct cleaning is performed.”

    NHMRC excerpt:
    Recommendation
    11 Routine cleaning of surfaces

    Grade

    Clean frequently touched surfaces with detergent solution at least
    daily, and when visibly soiled and after every known contamination.
    Clean general surfaces and fittings when visibly soiled and immediately
    after spillage.

    GPP

    Use of disinfectants
    In acute-care settings where there is uncertainty about the nature of
    soiling on the surface (e.g. blood or body fluid contamination versus
    routine dust or dirt) or the presence of MROs (including C. difficile)
    or other infectious agents requiring transmission-based precautions
    (e.g. pulmonary tuberculosis) is known or suspected, surfaces should be
    physically cleaned with a detergent solution, followed or combined with
    a TGA-registered disinfectant with label claims specifying its
    effectiveness against specific infectious organisms.

    Messages posted to this list are solely the opinion of the authors, and
    do not represent the opinion of AICA.

    Archive of all messages are available at http://aicalist.org.au/archives
    – registration and login required.

    Replies to this message will be directed back to the list. To create a
    new message send an email to aicalist@aicalist.org.au

    To send a message to the list administrator send an email to
    aicalist-request@aicalist.org.au.

    You can unsubscribe from this list be sending ‘signoff aicalist’
    (without the quotes) to listserv@aicalist.org.au

    Want to Get Healthy?

    The Tasmanian Government’s Get Healthy Information and Coaching Service
    provides free information and coaching support to Tasmanian adults who
    would like to learn healthier eating habits, be more active or achieve
    and maintain a healthy weight. Call 1300 806 258 between 8am and 8pm,
    Monday to Friday or visit http://www.gethealthy.tas.gov.au for more
    information.”

    CONFIDENTIALITY NOTICE AND DISCLAIMER

    The information in this transmission may be confidential and/or
    protected by legal professional privilege, and is intended only for the
    person or persons to whom it is addressed. If you are not such a person,
    you are warned that any disclosure, copying or dissemination of the
    information is unauthorised. If you have received the transmission in
    error, please immediately contact this office by telephone, fax or
    email, to inform us of the error and to enable arrangements to be made
    for the destruction of the transmission, or its return at our cost. No
    liability is accepted for any unauthorised use of the information
    contained in this transmission.

    If the transmission contains advice, the advice is based on instructions
    in relation to, and is provided to the addressee in connection with, the
    matter mentioned above. Responsibility is not accepted for reliance upon
    it by any other person or for any other purpose.

    Messages posted to this list are solely the opinion of the authors, and
    do not represent the opinion of AICA.

    Archive of all messages are available at http://aicalist.org.au/archives
    – registration and login required.

    Replies to this message will be directed back to the list. To create a
    new message send an email to aicalist@aicalist.org.au

    To send a message to the list administrator send an email to
    aicalist-request@aicalist.org.au.

    You can unsubscribe from this list be sending ‘signoff aicalist’
    (without the quotes) to listserv@aicalist.org.au

    Want to Get Healthy?

    The Tasmania Government’s Get Healthy Information and Coaching Service provides free information and coaching support to Tasmanian adults who would like to learn healthier eating habits, be more active or achieve and maintain a healthy weight. Call 1300 806 258 between 8am and 8pm, Monday to Friday or visit http://www.gethealthy.tas.gov.au for more information.

    CONFIDENTIALITY NOTICE AND DISCLAIMER

    The information in this transmission may be confidential and/or protected by legal professional privilege, and is intended only for the person or persons to whom it is addressed. If you are not such a person, you are warned that any disclosure, copying or dissemination of the information is unauthorised. If you have received the transmission in error, please immediately contact this office by telephone, fax or email, to inform us of the error and to enable arrangements to be made for the destruction of the transmission, or its return at our cost. No liability is accepted for any unauthorised use of the information contained in this transmission. If the transmission contains advice, the advice is based on instructions in relation to, and is provided to the addressee in connection with, the matter mentioned above. Responsibility is not accepted for reliance upon it by any other person or for any other purpose.

    Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of AICA.

    Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

    Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au

    To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.

    You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au

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