Decontamination is the process to remove pathogenic microorganisms from objects for the purposes of safe handling and use. The CDC states that cleaning (i.e., removing visible material from surfaces) is a first step in the decontamination process so that organic or inorganic material does not interfere with decontamination. As outlined in this section, the use of sporicidal agents to manually clean healthcare environments is a form of both cleaning and decontamination. Use of touchless automated methods are solely for the purpose of environmental decontamination. Recommendations applicable to environmental cleaning and decontamination include: • Terminal room cleaning (cleaning after a patient is discharged or transferred from a room) with a sporicidal agent should be considered in conjunction with other measures to prevent CDI during endemic high rates or outbreaks, or if there is evidence of repeated cases of CDI in the same room. • Daily cleaning with a sporicidal agent should be considered in conjunction with other measures to prevent CDI during outbreaks or in hyperendemic (sustained high rates) settings, or if there is evidence of repeated cases of CDI in the same room. • Measures of cleaning effectiveness should be incorporated to ensure quality of environmental cleaning. • Disposable patient equipment should be used when possible and reusable equipment should bethoroughly cleaned and disinfected, preferably with a sporicidal disinfectant that is equipment compatible. The CDC guidelines for environmental cleaning and decontamination for C. difficile include the creation of daily and terminal cleaning protocols and checklists for patient-care areas and equipment. Other guidelines recommend frequent education for environmental service personnel in the primary language of the cleaning team and the use of various techniques to help improve cleaning and decontamination practice as outlined by the CDC (e.g., observation, fluorescent markers, and bioluminescence). Safety practices for laundry, bedding, and other environmental services are included in the CDC’s “Guidelines for Environmental Infection Control in Health Care Facilities.” Guidelines for specific facility types, including hospitals, nursing homes, long-term acute care facilities, and outpatient facilities, are available from the CDC and other healthcare agencies. Environmental cleaning as a safety practice The healthcare environment is recognized as a primary source of C. difficile transmission. C. difficile is spread through the feces of infected and colonized patients. Patients with contaminated hands may spread C. difficile by touching surfaces in the healthcare environment. Some evidence suggests C. difficile may be dispersed to surfaces near the patient through droplets in the air.
Transmission can occur when other patients, healthcare staff, or visitors touch contaminated surfaces and orally ingest C. difficile (e.g., while eating). Those who take antimicrobials, are advanced in age, or have compromised immune systems are at high risk of getting CDI from exposure to the pathogen. Others may become asymptomatic carriers of C. difficile . Both symptomatic and asymptomatic carriers have the potential to contaminate the environment. In one hospital, C. difficile was recovered from 59% of samples in rooms of asymptomatic carriers and 75% of samples of rooms with patients with CDI.69 Patients may continue to contaminate the environment after treatment. The most contaminated areas, or “high-touch surfaces,” include the bed rails, bed surface, supply cart, over-bed table, and intravenous pumps. In one study, CHWs’ hands were just as likely to be contaminated with C. difficile after touching high- touch surfaces as they were by touching a CDI patient. C. difficile produces spores that are especially robust and may remain viable in the environment for over 4 days. Eliminating C. difficile in the healthcare environment requires specialized practices. Evidence shows that C. difficile spores are resistant to alcohol and many hospital disinfectants. In one study, exposure of the bacteria to low levels of certain cleaning agents resulted in higher CDI sporulation capacity (the ability for vegetative cells to forms spores during unfavorable environmental conditions). 70 Among cleaning and decontamination agents for washing surfaces by hand, chlorine-releasing solutions (e.g., bleach), at sufficient concentration and with appropriate exposure time (at least 10 minutes), demonstrate the best evidence for killing C. difficile . 71 Decontamination by hand is challenging and not always effective in reaching all contaminated surfaces in the healthcare environment. Automated touchless methods have been developed and implemented to supplement cleaning by hand and prevent the spread of CDI and other HAIs. The two most commonly studied touchless methods for C. difficile decontamination are hydrogen peroxide decontamination (HPD)—including vaporized, aerosolized, atomized, and dry mist systems— and ultraviolet disinfection (UVD), which includes UV radiation and pulsed xenon UV light systems. In laboratory studies, both methods have shown effectiveness in almost entirely eliminating C. difficile contamination from targeted surfaces. Although subject to some debate, it is generally recommended that surfaces be precleaned by hand prior to use of UVD or HPD, as organic matter is thought to reduce the efficacy of the UVD and HPD methods. The UVD methods generally take less time than HPD to decontaminate a room. There is increasing incentive for facilities to implement an effective environmental cleaning and decontamination program as facility rankings and CMS reimbursement rates are tied to reported rates of healthcare facility-acquired onset (HO CDI).
BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 4 ON THE NEXT PAGE. Implementation: challenges and facilitators One of the challenges reported across several of the studies on HPD and UVD was being able to use the touchless machines in all intended cases. For example, Levin et al. (2013) reported that the goal was to conduct terminal UVD on all contact precautions rooms but only 56% of discharged contact precautions rooms received the UVD treatment. 72 This discrepancy was due to limited device availability or the presence of a second room occupant. Compliance with cleaning procedures is essential for eliminating active C. difficile from the environment. Research shows that touchless methods require appropriate operation. For example, the UVD machine may require repositioning in order to be most effective. Ways to assist with manual cleaning compliance include cleaning checklists and audit and monitoring. Key findings • The most-recommended cleaning and decontamination agents for manual use are chlorine-based solutions. • The addition of hydrogen peroxide decontamination (HPD) or ultraviolet light decontamination (UVD) to standard cleaning is associated with significant reductions in facility-level CDI rates. • HPD and UVD have drawbacks, including expense and the time it takes to decontaminate a room. However, the process for UVD is shorter than for HPD. • The performance of environmental cleaning services staff is important and can be improved through the use of training, checklists, and audit and feedback. • Future directions include research and development of nontoxic decontamination agents, new technologies, and research on patient outcomes and environmental cleaning in diverse healthcare settings. Testing methods and C. difficile colonization Patients with C. difficile shed C. difficile spores, which contaminate the environment and may infect other patients. Rapid identification of patients with CDI helps expedite contact precautions and isolation of these patients and prevent transmission to other patients. The symptoms of CDI often match those of other causes of diarrhea; therefore, early and rapid diagnosis is important to start the appropriate treatment and improve patient outcomes. Starting treatment and infection protocols sooner may ultimately reduce hospital length of stay, thereby reducing healthcare costs. Rapid diagnosis also ensures that providers modify any existing therapies, such as discontinuing antimicrobial agents, which could worsen a patient’s condition.
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