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Utilization and impact of a pulsed-xenon ultraviolet room disinfection system and multidisciplinary care team on Clostridium difficile in a long-term acute care facility

Open AccessPublished:September 09, 2015DOI:https://doi.org/10.1016/j.ajic.2015.07.029
      Health care–associated transmission of Clostridium difficile has been well documented in long-term acute care facilities. This article reports on 2 interventions aimed at reducing the transmission risk: multidisciplinary care teams and no-touch pulsed-xenon disinfection. C difficile transmission rates were tracked over a 39-month period while these 2 interventions were implemented. After a baseline period of 1 year, multidisciplinary teams were implemented for an additional 1-year period with a focus on reducing C difficile infection. During this time, transmission rates dropped 17% (P = .91). In the following 15-month period, the multidisciplinary teams continued, and pulsed-xenon disinfection was added as an adjunct to manual cleaning of patient rooms and common areas. During this time, transmission rates dropped 57% (P = .02). These results indicate that the combined use of multidisciplinary teams and pulsed-xenon disinfection can have a significant impact on C difficile transmission rates in long-term care facilities.

      Key Words

      It has been repeatedly demonstrated in the literature that the health care environment suffers from widespread contamination and extended survival of multidrug-resistant organisms.
      • Kramer A.
      • Schwebke I.
      • Kampf G.
      How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.
      A number of studies have linked this environmental contamination to an increased risk of health care–associated infections (HAIs).
      • Carling P.C.
      • Huang S.S.
      Improving healthcare environmental cleaning and disinfection: current and evolving issues.
      • Otter J.A.
      • Yezli S.
      • Salkeld J.A.
      • French G.L.
      Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings.
      For example, a positive culture for Clostridium difficile from a prior room occupant has been found to put the subsequent patient at 2.35 times greater risk of acquiring the same infection.
      • Shaughnessy M.K.
      • Micielli R.L.
      • DePestel D.D.
      • Arndt J.
      • Strachan C.L.
      • Welch K.B.
      • et al.
      Evaluation of hospital room assignment and acquisition of Clostridium difficile infection.
      Because there is no direct contact between the 2 patients, this prior room occupancy risk can is attributable to environmental acquisition.
      • Huang S.S.
      • Datta R.
      • Platt R.
      Risk of acquiring antibiotic-resistant bacteria from prior room occupants.
      Interventions to address HAIs in long-term acute care (LTAC) facilities have posed unique challenges for infection prevention, specifically in the area of enhanced environmental hygiene. Long-term care patients have more compromised immune function than traditional acute care patients and are more likely to be colonized with organisms such as C difficile.
      • Munoz-Price L.S.
      Long-term acute care hospitals.
      Many hospitalized patients are transferred to and from LTAC facilities, increasing the likelihood of acquiring C difficile infection in the process.
      • Guerrero D.M.
      • Nerandzic M.M.
      • Jury L.A.
      • Chang S.
      • Jump R.L.
      • Donskey C.J.
      Clostridium difficile infection in a Department of Veterans Affairs long-term care facility.
      • Ricciardi R.
      • Nelson J.
      • Griffith J.L.
      • Concannon T.W.
      Do admissions and discharges to long-term care facilities influence hospital burden of Clostridium difficile infection?.
      Infected patients and asymptomatic carriers can shed pathogens onto environmental surfaces.
      • Riggs M.M.
      • Sethi A.K.
      • Zabarsky T.F.
      • Eckstein E.C.
      • Jump R.L.
      • Donskey C.J.
      Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents.
      If these surfaces are not properly disinfected, infection can be spread by direct contact or cross-contamination by health care workers. This is especially relevant with C difficile infection, which is the leading cause of health care–associated diarrhea.
      • Kim J.H.
      • Toy D.
      • Muder R.R.
      Clostridium difficile infection in a long-term care facility: hospital-associated illness compared with long-term care-associated illness.
      This issue can be compounded in LTAC facilities, where the average length of stay is close to a month, and the communal design of the facilities enhances the interaction among patients.
      As a result of the well-described link between environmental contamination and HAI acquisition, health care facilities are now exploring new methods of interrupting transmission. Many of these methods are based on the multidisciplinary approaches recommended in infection prevention best practice guidelines. An additional consideration has been enhancing the effectiveness of environmental disinfection. No-touch disinfection technologies have been developed as an adjunct to manual cleaning practices. The goal of these devices is to complete disinfection of surfaces that may have been missed by environmental cleaning staff. Such technologies use hydrogen peroxide vapor, pulsed-xenon ultraviolet light (PX-UV), or mercury ultraviolet light (UV). There are several outcome studies demonstrating reduced infection rates after the implementation of PX-UV, but this evidence has been isolated to acute care facilities.
      • Levin J.
      • Riley L.S.
      • Parrish C.
      • English D.
      • Ahn S.
      The effect of portable pulsed xenon ultraviolet light after terminal cleaning on hospital-associated Clostridium difficile infection in a community hospital.
      • Simmons S.
      • Morgan M.
      • Hopkins T.
      • Helsabeck K.
      • Stachowiak J.
      • Stibich M.
      Impact of a multi-hospital intervention utilising screening, hand hygiene education and pulsed xenon ultraviolet (PX-UV) on the rate of hospital associated methicillin resistant Staphylococcus aureus infection.
      • Haas J.P.
      • Menz J.
      • Dusza S.
      • Montecalvo M.A.
      Implementation and impact of ultraviolet environmental disinfection in an acute care setting.
      To our knowledge, no research exists to date that describes the use of no-touch disinfection in the LTAC setting.
      The purpose of this study is to address the effectiveness of 2 hospital-associated (HA) C difficile prevention methods implemented over a 3-year period. First, the use of a multidisciplinary prevention team of health care workers dedicated to C difficile prevention was assessed. Subsequently, PX-UV was implemented as an enhanced disinfection measure.

      Methods

      Baseline infection prevention and surveillance

      This evaluation was conducted at an urban LTAC hospital in the Southeastern United States. Most patient rooms contain a single bed with a connected private bathroom. Per Centers for Disease Control and Prevention guidelines, facility policy required contact precautions and hand hygiene with soap and water when caring for patients with C difficile. After discharge, rooms and bathrooms are terminally cleaned with a sodium hypochlorite solution. C difficile infection rates were determined using the National Healthcare Safety Network's infection surveillance reporting criteria. Institutional review board exemption was not sought because the research used existing data. During the 12-month preintervention period, no new infection prevention policies or protocols were implemented.

      Multidisciplinary team intervention

      A multidisciplinary C difficile prevention team was formed in March 2011 and was comprised of staff members from pharmacy, nursing, respiratory therapy, rehabilitation, dietary, laboratory, environmental services, building maintenance, and infectious disease. Before the formation of the prevention team, efforts to control the spread of C difficile infection included increasing the visibility of isolation signage using large and brightly colored signs, daily round to assess compliance with isolation practices, re-education for staff on the need for hand hygiene with soap and water when caring for C difficile patients, and implementation of disposable patient care equipment in isolation rooms (blood pressure cuffs, stethoscopes, and thermometers).
      The multidisciplinary team reviewed available best practice guidelines for prevention of C difficile and implemented several new processes in June 2011. An initial measure recommended by the group was the installation of additional sinks on the nursing units in an effort to increase compliance with soap and water hand hygiene. Hand hygiene rates were monitored by hospital staff throughout the study period, and compliance rates did not change over time. Equipment disinfection was reinforced with staff, and sodium hypochlorite wipes were made available in room housing patients with C difficile infection. Additional disposable equipment was added for isolation rooms, including lift slings, wash basins and bedside commode liners. The team identified the potential for cross-contamination of mobile work stations and multiuse medication vials during the medication administration process. This was combatted by eliminating the mobile work stations and installing a permanent work station within each patient room. A checklist for terminal cleaning was also implemented, which emphasized steps to reduce cross-contamination during the disinfection process. Finally, clinical staff were re-educated on the signs of C difficile infection to ensure that patients were identified and isolated in a timely manner.

      PX-UV device

      The PX-UV device (Xenex 426i; Xenex Disinfection Services, San Antonio, TX) uses a high-voltage discharge capacitor connected to a xenon flash lamp to release high-intensity, polychromatic pulses of UV light that cover the entire germicidal spectrum (210-280 nm). This novel technology differs from other sources of UV disinfection, which use low-pressure mercury lamps to produce monochromatic UV light.
      • Chemaly R.F.
      • Simmons S.
      • Dale C.
      • Ghantoji S.S.
      • Rodriguez M.
      • Gubb J.
      • et al.
      The role of the healthcare environment in the spread of multidrug-resistant organisms: update on current best practices for containment.
      The implementation of these devices has been previously described.
      • Jinadatha C.
      • Quezada R.
      • Huber T.W.
      • Williams J.B.
      • Zeber J.E.
      • Copeland L.A.
      Evaluation of a pulsed-xenon ultraviolet room disinfection device for impact on contamination levels of methicillin-resistant Staphylococcus aureus.
      The devices are designed to deliver UV light to surfaces throughout the room, with a specific focus on high-touch surfaces. Multiple disinfection positions are used to assure that surfaces are not shadowed from the light. Information about each disinfection cycle is logged by the device and uploaded to an online portal. These data are used to assure that housekeeping staff are placing the robot in the appropriate number of positions for the area they are disinfecting and to track the overall usage within the health care facility.

      PX-UV adjunct

      One PX-UV device was deployed between July 2012 and September 2014, in addition to the performance improvement programs already implemented by the multidisciplinary team. The PX-UV device was used specifically as an adjunct to standard manual cleaning of patient areas. The usage goal across the LTAC facility included all patient rooms after discharge and communal living areas on a weekly basis, such as dining rooms, rehabilitation areas, and lounges. Device usage was tracked using an on-board data log. On average, the PX-UV device was used to disinfect 85 discharge rooms and communal living areas per month. Disinfection was primarily done in the communal living areas because of the low discharge volume at the facility.

      Statistical analysis

      HA C difficile infection rates for each intervention were compared with infection rates of the directly previous intervention period. Because of the nonparametric nature of our data, comparisons were made using a 2-sample Wilcoxon rank-sum test in Stata software version 12.1 (StataCorp, College Station, TX). The analysis was sufficiently powered to detect differences between the intervention groups.

      Results

      During the 12-month preintervention period, the HA C difficile infection rate was 23.3 per 10,000 patient days. On the addition of the multidisciplinary team, the HA C difficile infection rate dropped 17.3% to 19.3 per 10,000 patient days (P = .91). PX-UV was then implemented in July 2012 while the multidisciplinary team approach continued (Fig 1). Over a 15-month period, infection rates dropped 56.9% compared with the baseline year to 8.3 per 10,000 patient days (P = .02) (Table 1). Based on these outcomes, it is predicted that the facility was able to prevent 29 HA C difficile infections and generate over 210 additional patient bed days within the 15-month intervention. At $13,500 in hospital care costs per case, this could have potentially resulted in net savings of approximately $300,000.
      • Carrico R.
      • Ghantoji S.S.
      • Sail K.
      • Lairson D.R.
      • DuPont H.L.
      • Garey K.W.
      Economic healthcare costs of Clostridium difficile infection: a systematic review.
      • Scott II, R.D.
      The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention.
      • Lucado J.
      • Gould C.
      • Elixhauser A.
      Clostridium difficile infections (CDI) in hospital stays, 2009: statistical brief #124.
      • McGlone S.M.
      • Bailey R.R.
      • Zimmer S.M.
      • Popovich M.J.
      • Tian Y.
      • Ufberg P.
      • et al.
      The economic burden of Clostridium difficile.
      • Stone P.W.
      Economic burden of healthcare-associated infections: an American perspective.
      • Zimlichman E.
      • Henderson D.
      • Tamir O.
      • Franz C.
      • Song P.
      • Yamin C.K.
      • et al.
      Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system.
      Figure thumbnail gr1
      Fig 1HA-CDI rates expressed per 10,000 patient days by month (July 2010-September 2014). The PX-UV arm was added to a continuing multidisciplinary team approach. HA-CDI, Hospital-acquired Clostridium difficile infection; PX-UV, pulsed-xenon ultraviolet light disinfection.
      Table 1Hospital-acquired Clostridium difficile infection rates by intervention period
      Intervention PhaseIntervention periodInfection rate per 10,000 patient days (no. of cases)SD% reduction from previous periodP value
      No interventionJuly 2010- June 201123.3 (30)19.64NANS
      C difficile teamJuly 2011-June 201219.3 (23)14.0617.3.91
      PX-UV + C difficile teamJuly 2012-September 20148.3 (22)8.8856.9.02
      NA, not applicable; PX-UV, pulsed-xenon ultraviolet light disinfection.

      Discussion

      HA C difficile rates during the use of PX-UV in conjunction with the multidisciplinary team were lower than those rates during the multidisciplinary team intervention alone. Based on the available data, it is not possible to determine whether this impact is solely from the addition of PX-UV or from a synergistic effect of the 2 interventions.
      The use of PX-UV in the LTAC setting is very different from the applications that have previously been reported in acute care settings. Patients are discharged much less frequently from LTAC facilities; therefore, there is less daily demand for PX-UV for terminal cleaning purposes. Rather, PX-UV was used in high-traffic ancillary and communal living areas. These areas provide an environment where health care workers and patients regularly intermingle, and there are frequent opportunities for environmental contamination and transmission. These data show the potential of enhanced disinfection for impacting the rates of C difficile in LTAC facilities and other facilities with different operational patterns than acute care hospitals.
      These findings further support the previous research implicating the environment as a factor in the transmission of C difficile. Colonized and infected C difficile patients will shed large numbers of bacteria into the environment, and these bacteria can persist for months. Because of extended length of stay, lower immune function of patients, and the communal nature of long-term care, it is reasonable to expect that the exposure risk to C difficile from the environment is substantial in this care setting. While these results demonstrate that no-touch disinfection could be successfully implemented a single LTAC, more studies are needed to demonstrate that this type of program can be replicated in other LTACs. It may be useful for future research to perform environmental sampling of the patient rooms and communal areas of LTAC facilities to validate the assumption that the communal areas serve as an important reservoir in this care setting.
      This study is inherently limited by the quasi-experimental design. The nonrandomized design limits the ability to attribute the reduction in HA C difficile solely to the implementation of the PX-UV device. However, these results are corroborated by previous quasi-experimental studies showing reductions in infections after the implementation of PX-UV. This research adds to the body of evidence describing the effectiveness of PX-UV devices and demonstrates that this technology can be successfully implemented in the long-term care setting.

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