Disinfecting rooms goes higher tech, lower touch

Room disinfection once meant a mop, a bucket and a rag. Not that those aren't good things, they still are the necessary basics, but they can only accomplish so much in a very real battle against life-threatening hospital-acquired infections (HAIs). More sophisticated approaches have become necessary, particularly since antibiotic resistance continues its relentless advance. Nonreimbursed events add a financial incentive to target pathogens more aggressively. These factors, and more like them, have contributed to the evolution of room disinfection.

Healthcare Purchasing News solicited opinions from experts in the field of room disinfection concerning trends spawned by the advent of HAIs, antibiotic resistance and nonreimbursement.

Gunner Lyslo, Founder and CEO, Surfacide, Naperville, IL, talked about the limitations of terminal cleaning, leading to advances that can assist. "Data indicates that more than 50% of environmental surfaces are not cleaned during terminal cleaning. Further, the Affordable Care Act is now reducing reimbursements or applying penalties for institutions that don't meet specific H AI metrics. As a result, the trend toward non-touch disinfection systems is gaining significant momentum as an additive modality to the cleaning process."

"Manual cleaning and disinfection is a critical step to limiting the spread of pathogens, but oftentimes there is a disconnect when it comes to compliance," added Rosie D. Lyles, MD, Head of Clinical Affairs, Clorox Professional Products Company, Pleasanton, CA. "Even the best protocols and products are ineffective if they are not used properly. That is why many facilities are interested in emerging automated technologies, such as hydrogen peroxide vapor and ultraviolet C (UVC) devices, as a way to inactivate pathogens that may be missed during standard manual cleaning, as well as for surfaces that are difficult to clean manually, such as walls, light fixtures, windows, and floors."

Antibiotic resistance is a factor, according to Tim Smith, Executive Vice President and General Manager, American Green Technology (AGT) Clarksdale, MS. "There is a heightened awareness of antibioticresistant pathogens. Infection preventionists are looking for products to assist in their efforts to combat not only known pathogens but new strains that are being discovered."

"As infection prevention plans continue to expand, many hospitals are relying on innovative technology like TRU-D to ensure patient safety, reduce HAIs and guarantee the highest reimbursement rates," said Chuck Dunn, president of TRU-D SmartUVC, LLC.

Healthcare-associated infections like methicillin-resistant Staphylococcus aureus, a bacterium that can cause life-threatening bloodstream infections, pneumonia and surgical site infections, are putting more than patient lives at risk every single day, according to Dunn. They're also poised to take big bites out of hospital budgets across the country - to the tune of millions - as new payment penalties and reporting requirements are being implemented by the government and a majority of private health insurance companies. As a result, many hospital leaders are looking for tools, such as TRU-D SmartUVC, that promote patient safety and ensure high reimbursement payments - keeping both their patient population and their operating budgets as healthy as possible.

Expert advice

With the number of room-disinfection options that have been and are being developed, some good advice on what to look for in such products is in order. Purchasers need to know the capabilities of different products designed for room disinfection offer before deciding which is more appropriate for their facility. Knowing which questions to ask can elicit the information needed.

"Key considerations for purchasers selecting either a manual disinfectant or automated disinfection system include kill claims for the most common healthcare pathogens, fast kill times, safety and ease of use," said Lyles, Clorox Professional Products. "The easier a product is to use, the more likely it is that staff will use it correctly. Purchasers should ask vendors about other factors, such as training and support offered by the manufacturer, as well as costs, i to determine the best product solutions for their facility."

Smith, AGT, offered advice on what to look for in a UVC system. "The effectiveness of a UVC system is the UVC dosage it can deliver to neutralize even the heartiest of pathogens. A purchaser of any system should ask how many joules of UVC energy per meter squared is delivered. Pathogens have genomic analysis | gg reports that will identify the UVC dose required for neutralization. This is known as a dimerization or D90 rating. Many products cannot provide a defined dosage but will have a calculation based on the size of the space and the time the unit is in use. "

"Data show that there is a direct correlation between total delivered energy (total UVC) and log reduction of bacteria and spore. When one considers room size and shadowproducing objects in the room, delivering necessary energy values to all surfaces using one emitter is not possible. So, therein lies questions: How does the non-touch disinfection system overcome shadows? And, given the large distance from an energy emitter to a surface, how does the non-touch disinfection system overcome distance, ie, the Inverse Square Law: as distance increases, energy delivered is reduced to a V* at each increment? The solution is to incorporate multiple energy emitters into the room, thereby eliminating shadows and greatly reducing distance."

Asking for a product demonstration and explanation of the room-disinfection system's capabilities is good advice from Steve Baiocchi, Chief Operating Officer, Steriliz, LLC, Rochester, NY. "First ask for a demonstration of the system," said Baiocchi. "During the demo, ask the vendor to show what the delivered dose of UVC is at any position in iis the room. The only way to show this requires measuring with a calibrated industry standard meter. If a system doesn't measure the dose each and every time, then the system is substandard, based upon available technology, and there can be no assurance that the dose of UVC required to eradicate the target pathogen has been delivered. Next, ask to see the recorded job data. Does it have user, location, treatment time, final delivered doses, etc? This information is the foundation for reports that are necessary to manage your HAI-reduction program better. Data and reports are key to a successful HAI-reduction program."

Getting specific

UV-C technology

Vendors talked more specifically about how their room-disinfection products work to kill pathogens. Popular UVC products are one effective mode.

Lyles, Clorox Professional Products, talked about their partnership with Ultraviolet Devices, Inc (UVDI). "Clorox Healthcare recently announced a new venture with UVDI to combine the power of manual surface disinfection with UVC technology for optimum prevention. As a result, the Clorox Healthcare Optimum-UV System offers a more comprehensive decontamination approach by inactivating dangerous pathogens, including Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA). The Clorox Healthcare Optimum-UV System produces UVC at a wavelength of 254 nm, which inactivates microorganisms' DNA, rendering them harmless."

An important advantage is a safety feature, explained Lyles. "The Clorox Healthcare OptimumUV System includes four infrared motion sensors that detect the presence of anyone in the room and stop operation of the system for enhanced safety."

Scientific evidence should always be asked for if vendors don't offer it first. Lyles cited relevant findings. "Researchers from the University of North Carolina (UNC) recently investigated the efficacy of the Clorox Healthcare Optimum-UV System to inactivate key pathogens in patient rooms in UNC's Clinical Translational Research Center. Results showed that the unit achieved a total 3.56log10 reduction for MRSA in 5 minutes and a total 2.78-log10 reduction for C difficile spores in 10 minutes, confirming earlier findings that UVC devices can effectively disinfect patient rooms.1

Probably no one needs to be reminded that the subject of cost should be approached as well. Lyles compared cost of their product to competitors'. "Unlike competitors, whose machines contain up to 20 smaller lamps and cost as much as $100,000, the Clorox Healthcare Optimum-UV System uses just four 62-inch maximum output UVC lamps, for greater intensity than bulbs used in other UV systems, to provide 360-degree room coverage. That is partly why it costs less than one-third of competitors' devices."

Smith also highlighted cost-effectiveness plus the convenience of their technology. "AGT's Health Risk Management System (HRMS) is an inexpensive alternative to many of the UVC options on the market. The HRMS can be used right at the source of infection, where the space is occupied, unlike many other UVC products that require a terminal clean. The HRMS is a patented UVC system that disinfects air while unobtrusively doubling as a light fixture. The HRMS provides a constant measured dose of UVC energy at 198 J/M2, which is capable of neutralizing an average of 99.8 percent of known infection-causing pathogens."

Here's how it works: "Using differential pressure, air is drawn into the system at 50 cubic feet per minute" said Smith. "Passing through a MERV 6 filter to remove larger particulates, the air then flows through a set of safety baffles and into a radiation chamber, where pathogens are subjected to high-intensity UVC radiation. The purified air is then exhausted back into the room through a vent at a 30° angle."

Maintenance and its cost are minimal. "The HRMS system requires very simple maintenance, with an annual replacement of the UVC lamp and MERV 6 filter at a retail cost of approximately $100 per fixture," said Smith.

Smith offered anecdotal evidence of the product's efficacy. "We installed the HRMS in the Baylor Medical Center at Uptown in Dallas for an on-site test," said Smith, "and it proved not only that the system reduces the number of pathogens that are airborne but it has a significant effect on the level of surface microbe concentrations as well. This validation study was conducted on April 19 of this year by Aerobiology Laboratory Associates, Inc., of Virginia, who conducted all of our clinical lab tests."

Another proponent of UVC is Surfacide. Lyslo described their product. "The Surfacide triple emitter system incorporates the use of three UVC emitters during the same disinfection cycle. As a result, this overcomes the significant challenges to single emitter UV systems: shadows and distance. The use of three emitters during the same disinfection cycle eliminates shadows while being closer in proximity to all surfaces, thereby allowing more UVC energy to be delivered in less time. Less time, with greater efficacy, is critical, given the challenges of bed management and throughput."

Versatility of this system adds to its value, explained Lyslo. "Value of any non-touch disinfection modality should include flexibility. Can the technology be used for more than a single application, ie, can it be used in operating rooms, patient rooms, and hightouch equipment such as mobile carts, work stations on wheels, etc.? Is the technology limited in use for terminal cleaning only, or can it be easily incorporated during a daily clean? Surfacide's triple emitter system can be de-coupled, so a facility can utilize the technology in multiple ways. Surfacide has a unique 'energy scrub' feature that allows the technology to The R-D Rapid direct all energy to a specific location, eg, a mobile cart or corral of mobile carts, as an adjunct to normal cleaning."

Lyslo offered an additional cost advantage of Surfacide. "Total cost of ownership must include labor costs. Single-emitter systems demand one fulltime employee for each non-touch disinfection system, appreciating that often the system must be moved multiple times in the room. Surfacide's triple emitter system demands less labor, given that once the system is turned on in the room, everything is automatic. Once the system is operating, the environmental services associate can be productive elsewhere in the facility while Surfacide is operating."

Many hospitals often times choose to deploy a fleet of TRU-Ds across a healthcare system. The robot, which uses UV-C light to effectively disinfect hospital environments and is a validated weapon against deadly hospital pathogens, is the only portable UV disinfection system that precisely measures reflected UV-C emissions with Sensor360 to automatically calculate the pathogen-lethal UV dose required for proper and consistent disinfection of health care environments. TRU-D's latest innovation, iTRU-D, is the only secure cloud-based infection prevention data tracking tool available with a UV disinfection robot on the market and addresses the recommendation to report MRSA data and MRSA prevention efforts to key leaders on a regular and frequent basis. With iTRU-D, disinfection data is instantaneously uploaded during every room cycle, and hospital staff has easy access and reporting capabilities through a custom portal.

Baiocchi said, "The R-D Rapid Disinfector UV system is the only UV system that measures, records, and reports. The R-D is not a timeor distance-based UV system; it is a dose-based system. The R-D system is set, or pre-programmed, for the C difficile dose. Other doses may be programmed into the system, if desired. The system will not complete a disinfection cycle until each sensor receives the pre-programmed dose of UVC, which could take approximately 13 to 14 minutes, for a single patient room including bathroom, for C difficile. The proprietary UV sensors take the guesswork out of determining where the UV light goes or, just as importantly, where it does not go."

Sam Trapani, President and CEO, Steriliz, related the experience of a customer, in support of the R-D system's efficacy. "In its first year of operation at Rochester General Hospital, a 528-bed, acute-care, teaching hospital located in Upstate NY, the R-D Rapid Disinfector achieved a year over year C difficile reduction of 25.8 percent, representing a savings of more than $1.25 million and approximately 1,000 patient-days. This, along with other hospital results, is published in a report available at http://rapiddisinfector.com/ documents / C.diff_Study_January_2014_Final.pdf and is verifiable by visiting the New York State Department of Health website. Currently, the R-D is being used in a threeyear Institutional Review Board-approved C difficile collaborative reduction initiative that includes four competing hospitals located in Rochester, NY, the New York State Department of Health, and Excellus BlueCross BlueShield in the North-East."

As for cost, Trapani said, "Obviously, the greater the reduction in HAI cases, the greater the return on investment (ROI). System cost can be recovered relatively quickly by just reducing a few HAI cases per year. ROI is maximized by better understanding when to use UV and how to use UV to better disinfect and reduce more HAIs."

Other factors Trapani advised purchasers to consider include cost of ownership, such as cost of capital equipment up front or amortized over a period of time; costs for employees to operate the system(s); throughput/time to disinfect a room; monthly or annual service agreements; repairs and maintenance costs with replacing bulbs; and down time if a bulb goes out.

The power of cluster ions

Pure cluster ions are behind the success of Xstream 2000 room disinfector. Jim Masterson, CEO, XSTREAM Infection Control, LLC, Fairfax, VA, described how the Xstream 2000 works to disinfect patient rooms, operating rooms and more. "Xstream 2000 is the most powerful, deployable and cost-effective technology available to confront the crisis of HAIs. It fights germs on surfaces, fomites and in the air 24 hours a day, seven days a week, without disrupting the daily functions in a healthcare facility. The Xstream 2000 fourth generation continuously delivers a germicidal mix of pure cluster ions that actively seek out pathogens via electromagnetic charge. Upon contact, the stored energy of these cluster ions are unleashed through the pores of the bacterial cell wall, thereby destroying it from the inside out."

"Xstream 2000 was released early this year from its plant in Baltimore, MD. It is currently being evaluated at top-tier hospitals in Tucson, AZ, and Camden, NJ. Other regional hospitals, long-term care facilities, and dialysis centers will be added in the fourth quarter. The UK National Health Service also is scheduled to evaluate the technology in early 2015."

"Studies by major cleaning companies have stated that an operating room, patient room, or ICU is only 50 percent pathogen-free," noted Masterson. "Dr. Asnish Jha, Harvard School of Public Health professor, testified before a Senate Subcommittee on healthcare issues. When asked if patients are safer now than 15 years ago, he replied, 'the unfortunate answer is no. We have not moved the needle in any demonstrable way overall. No one is getting it right consistently.' Our mission," said Masterson, "is to help the industry increase their standard of care."

Masterson has a very personal interest in eradicating HAIs. "[I] almost died of an HAI after minor surgery." Explaining that he spent an 18 additional days in the hospital and 3 months of home care for recovery, Masterson counted the cost: "The hospital paid approximately $145,000 for the care and stay due to the infection. This is when we decided to develop the next generation. For a cost of $12 per day to destroy bacteria, especially C difficile, Xstream 2000 can really save lives.

Air cleansing

Novaerus airborne infection control technology also battles the most feared and difficult-to-manage pathogens. Bill McCabe, CEO, Novaerus, Chicago, IL, explained how it works: "Novaerus improves the business and quality of care through the application of airborne infection control technology. Our proactive solution is a continuous airmanagement process that works 24 hours a day to cleanse the air and protect against the aerial dissemination of infectious pathogens, including influenza, norovirus, C difficile spores, and MRSA. While our main focus is airborne viruses and bacteria, our antiinfection technology is also effective against allergens, mold and odors. The Novaerus plasma technology is unique, patented and proven. Our innovation is dielectric barrier discharge cold plasma, generated within a closed coil source. The Novaerus units continuously draw in contaminated air, where pathogens encounter the plasma field, and are rendered inert in 0.002 seconds. Cleansed air is then released."

References

1. Rutala WA, Gergen MF, Tande BM, Weber DJ. Room decontamination using an ultraviolet-C device with short ultraviolet exposure time. Infect Control Hosp Epidemiol. 2014;35(8):1070-1071.

by Susan Cantrell, ELS