Aggressive Use of Portable Pulsed Xenon UV Light (PPX-UV) Disinfection Results in Significant Reduction in Environmentally Important Healthcare Associated Infections
Daniel English, MHCIMA ; Linda Riley, MEd, RN, CIC ; Joanne Levin, MD; Christine Parrish, MSN, RN, CIC; John Donarumo; Eric Blondin Cooley Dickinson Hospital, 30 Locust Street, Northampton, Massachusetts Context:
An Environmental Services (EVS) department, working in collaboration with the Infection Prevention department, implemented portable pulsed xenon ultraviolet light (PPX-UV) as an additional step after regular hospital terminal discharge cleaning protocol for patient rooms. The Environmental Services team used Microsystems, a process improvement approach involving front line staff in process decision making, to develop the work process. The team was coached in this process by the Quality department.
Chart 1. Hospital Acquired Clostridium difficile Infections 2009- Q3 2012
Your room was disinfected with UV light.
Problem:
Due to the volume and complexity of surfaces and equipment needing to be cleaned in patient rooms and time constraints on Environmental Services workers related to patient flow issues, it is difficult to assure that all microbial contamination has been eliminated through the manual cleaning process. Patients are at an increased risk of Clostridium difficile infection (CDI) infection if the patient previously in the room was colonized or infected with C. difficile.* In addition, patients with CDI are at increased risk for death and colectomy. Specifically, there was concern that despite meeting SHEA recommendations for prevention of C. difficile transmission (chlorine based products for C. difficile room/equipment disinfection, contact precautions from symptom onset until patient discharge, and use of soap and water for hand hygiene), our hospital continued to have ongoing transmission of C. difficile (See chart 1). In addition, we continued to note cases of hospital associated MRSA and VRE despite “best practice” policies and an active surveillance program for MRSA.
Aim:
To determine the effectiveness of PPX-UV light disinfection on decreasing the transmission of environmentally important hospital pathogens: C. difficile, MRSA and VRE. To maximize the use of PPX-UV light by engaging staff to meet the goal of providing UV light disinfection or “flashing” every patient discharge room, all emergency department rooms once daily, and all operating rooms nightly, without significantly increasing room turnover times.
The Implementation Process:
The Environmental Services department annual quality and safety goal was to reduce hospital acquired C. difficile infection (CDI) rates. Department leadership brought the challenge to the EVS Microsystems team, a group of front line staff empowered and supported to drive the initiative. In the previous two years, the team had accomplished the following: • Educated EVS staff about C. difficile, symptoms of infection, the difference between vegetative and spore states, the consequences of CDI infections, and their role in preventing the transmission of this organism. • Assessed cleaning/disinfectant product efficacy and educated on the importance of dwell time. • Developed a process for daily and terminal patient room cleaning. • Developed a communication process that reduced room turnover from 65 to 48 minutes. • Implemented bleach disinfection in all bathrooms. • Implemented the use of microfiber cloths and mops. • Partnered with Infection Prevention to assess innovative technologies for environmental disinfection and selected the Xenex Portable Pulsed Xenon Ultraviolet Light (PPX-UV) for trial. Two PPX-UV machines were leased for use beginning in January 2011. No other infection prevention or environmental services interventions were made during 2011 in order to determine the effectiveness of the PPX-UV. There was no active antibiotic stewardship process in place. A third machine was leased in January 2012. Environmental Services staff: • Were trained to use PPX-UV. They were also educated about the science behind the device so they could give expert replies to patient or staff questions. • Established the ambitious goal of “flashing” every patient room after discharge cleaning, as well as daily flashing of the emergency department and operating rooms, and other areas (nursery, kitchen, wound clinic, etc.) periodically and as requested. • Developed the following process: Cleaned the bathroom, ran the UV light in the bathroom with the door closed for a 5-minute cycle while cleaning the patient room, then ran two 5-minute cycles with the room empty/door closed. In the case of two-bed rooms where one patient was discharged and there remained an occupant, only the bathroom was flashed. • Developed a system to transfer the PPX-UV to another staff member by communicating via pagers. • Provided recommendations for design changes that were incorporated by the manufacturer that improved ease of use. • Designed table tent cards to inform patients that their room was “flashed” by ultraviolet light prior to arrival. The cards incorporate a photograph of the Environmental Services worker assigned to that unit next to the PPX-UV, increasing a sense of ownership and pride.
For your safety, we use UV light
Quarter Q1 2009 Q2 2009 Q3 2009 Q4 2009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 C-diff Pt. Days
11 8944
5 9498
10 9035
8 9156
11 9023
7 8774
6 8633
6 8472
1 8546
5 8206
1 8379
6 8592
1 8344
5 8613
2 8166
59% reduction in CDI from 2009-2010 (rate 0.89 or 64 infections) to 2011-2012 YTD (rate 0.36 or 21 infections) Chart 2. Deaths and Colectomies Attributed to CDI
Measurement of Improvement: • • • • •
About Cooley Dickinson
Chart 3. Hospital Acquired MRSA 2009-Q3 2012
Cooley Dickinson, a 140-bed acute care hospital, is ranked in the top 5% of U.S. hospitals in patient safety by HealthGrades®, the leading provider of information to help consumers make an informed decision about a physician or hospital. It is the only hospital in the Springfield area to achieve the HealthGrades Patient Safety Excellence Award™ for four consecutive years (2009-2012). Learn more at www.cooley-dickinson.org. Visit www.youtube.com/user/Cooley-Dickinson to watch how UV light is used at our hospital. Below, a staff member shows one of the hospital’s Xenex© UV light machines. Above, representatives from Cooley Dickinson’s Environmental Services team.
Contact the Authors Q1 2009 Q2 2009 Q3 2009 Q4 2009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 CDH Acquired 0 2 6 5 7 5 4 3 3 3 0 3 1 3 1 Pt. Days 8944 9498 9035 9156 9023 8774 8633 8472 8546 8206 8379 8592 8344 8613 8166 Quarter
47% reduction in MRSA from 2009-2010 (rate 0.45 or 32 cases) to 2011-2012 YTD (rate 0.24 or 14 cases) Chart 4. Hospital Acquired VRE
2009-Q3 2012
Results:
Room Cleaning Time: Increased 12 minutes after implementation of PPX-UV. Time spent cleaning the room: 2010 average 25 minutes, 2012 January to September average 37 minutes. Overall room turnover time (time from patient discharge until room available for next admission) did not increase and averages 48 minutes.
Lessons Learned:
Using PPX-UV in patient care areas after routine discharge cleaning decreased HAIs related to environmental contamination in our hospitalized population. Effective use of this technology depends on environmental services staff engagement in this initiative. Involving front line staff from the beginning of an initiative, establishing clear goals for performance, and incorporating staff feedback and experience into the work redesign process all contributed to the success of this intervention and improved patient outcomes.
Message for Others:
*Shaughnessy MK, Micielli RL, DePestel DD, Ardnt J, Strachen CL, Welch KB, Chenoweth CE. Evaluation of Hospital Room Assignment and Acquisition of Clostridium difficile Infection. Infect Control Hosp Epidemiol. 2011; 32(3):201-20.
CDH studies show that with these steps we have dramatically decreased the spread of these infections. CDH is one of the few hospitals in the country using this technology.
86% reduction in CDI Mortality 2009-2012: 14 deaths, 2011-2012: 2 deaths
Room cleaning time. Hospital associated C. difficile infection (HA-CDI) rate/1,000 patient days. Number of deaths and colectomies related to HA-CDI. Hospital associated MRSA infections and colonizations found on screening. Hospital associated VRE infections.
To achieve the best possible results, the users need to be engaged in the implementation process, motivated by feedback on patient outcomes and recognized for their efforts and accomplishments.
We have strict cleaning protocols and use the UV light as an added step to prevent the spread of infections such as C.diff and MRSA.
If you have questions about how we prevent infections and keep patients safe, call ext. 2135.
Strategy for Change:
All Environmental Services staff were engaged and mobilized to implement maximum UV light usage by: • Daily huddles that included: 1. Feedback on the number of rooms disinfected with the device. 2. The use of stories about real patients and what happened to them as a result of CDI. 3. Ongoing feedback from the Infection Preventionist on the decrease in hospital acquired infection rates, as well as lives saved and colectomies prevented. 4. Solicitation of their feedback on the machine and the work processes they were developing to implement its use and then incorporating their recommendations in the machine design and Environmental Services workflow. • Communicating this innovative and unique initiative to the hospital and our community in news releases, radio interviews, television commercials, trade publications, and signage. • Recognition of their accomplishments by hospital leaders. • Next step: Department leadership feedback requested a method of digitally recording the PPX-UV users’ initials to check compliance with the process. Xenex upgraded the software in October 2012, making this possible. Moving forward, staff performance will be measured so that further reward and recognition or guidance can be implemented.
Your housekeeping team disinfected your room and bathroom with UV light, which has been shown to kill 99.9 percent of disease-causing germs.
Quarter Q1 2009 Q2 2009 Q3 2009 Q4 2009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 VRE Pt. Days
0 8944
5 9498
1 9035
3 9156
6 9023
1 8774
0 8633
2 8472
2 8546
0 8206
0 8379
1 8592
0 8344
0 8613
0 8166
80% reduction in VRE from 2009-2010 (rate 0.25 or 18 infections) to 2011-2012 YTD (rate 0.05 or 3 infections with none in 2012)
Disclaimer: There is no financial relationship between Cooley Dickinson Hospital and Xenex, Inc., other than the machine rental.
[email protected], (413) 582-2323
[email protected], (413) 582-2135
