They wheel the trash-can-sized machine into the OR. It looks a little like R2-D2, only more sinister than the spunky droid from Star Wars. Punch a few buttons, exit the room and soon it bathes the OR in pulsed ultraviolet light, silently killing viruses, bacteria and bacterial spores on every surface the light touches. In 10 minutes, its job is done and the OR is ready for the next case, all surfaces and equipment decontaminated.

The Geisinger Health System owns 10 UV light room disinfection machines. They've named each one. There's Wally and Freda and Roosevelt. They can disinfect an entire room in as little as 5 minutes.

Are these small but mighty superbug-zapping robots, priced at around $80,000 apiece, the newest craze in infection prevention? "What's the cost of an infection?" asks Tamara Almquist, Geisinger's senior director of environmental and surgical cleaning services. "That would be more than the unit itself. If we reduce just one HAI, we show a return on our investment."

A complement to manual cleaning
Besides portable UV disinfection systems, automated room sterilization technologies include hydrogen peroxide vapor sterilization units. Neither is a replacement for manual room cleaning. Automated systems are not meant to be used routinely between cases. Rather, they're meant to complement a surgical facility's cleaning and disinfection program, not to replace it.

After Geisinger's environmental service crew cleans a room using traditional methods (read: elbow grease), they'll sometimes wheel the UV system into the room to finish the job, killing germs on any surfaces they might have missed. "We did not change any of our cleaning processes when we implemented this device," says Ms. Almquist. "It's an extra added step in the cleaning process that ensures the safety of our process."

Depending on the size of the OR, they typically run either 2 10-minute or 2 15-minute cycles. Yes, most surgeons would not tolerate 20-minute turnovers. But these machines aren't for use after every case. Infection prevention authorities recommend their use primarily for terminal cleaning, following standard manual cleaning practices. "It is more time, but it's time well spent," says Ms. Almquist, adding that "we're not using it for between-case cleaning, so we're not holding up the schedule."

Geisinger uses the machines in its 5 hospitals either for selected between-case cleaning and on at least weekly terminal OR cleans. "We work closely with infection control," says Ms. Almquist. "They'll tell us if they know of an area we should use the machine in, such as an isolation room after discharge." A terminal clean in the OR takes place after 11 p.m. "It hits all of the things that don't typically get disinfected all of the time," says Ms. Almquist, before ticking off the oft-neglected high-touch surfaces: door knobs, overhead lamps, OR table controls, light handles, computer keyboards, IV poles, patient warming units, controls on the anesthesia equipment, cautery power controls and the Mayo stands.

SPOT CHECK Cambridge Hospital environmental service team members Cecilia Pineda and Francisco Cruz ready a UV light disinfection unit for use after a routine terminal clean.

The Medical Center of Central Georgia, a 637-bed hospital located in Macon, Ga., has 5 UV disinfection systems: 2 are dedicated to operating rooms while 3 rotate among patient rooms. "We have experienced major savings due to the reduction in overall infections," says Nancy Osborn, RN, manager of the Medical Center of Central Georgia's prevention and control center. Ms. Osborn attributes the reduction in hospital-associated infections in large part to the use of her UV disinfector on rooms that bed patients and a nightly rotation in the surgical suites.

GERM-BUSTERS Portable UV light disinfection devices destroy viruses, bacteria and bacterial spores in a patient or operating room without requiring the use of chemicals.

High-touch surfaces
Lou Ann Bruno-Murtha, DO, medical director of infection prevention and division chief of infectious diseases at Cambridge Health Alliance in Cambridge, Mass., and assistant professor of medicine at Harvard Medical School, recently put UV disinfection systems to the test. Could they curb a rise in surgical site infections in prosthetic joint cases? Dr. Bruno-Murtha looked at all possible culprits of infection, including environmental cleaning in OR. Specifically, she wanted to know if pressure to turn over the rooms was chasing the housekeeping crew out before it was finished cleaning.

She became intrigued with the concept of UV disinfection. "Could the use of an automated system in the OR get the surfaces that are being missed, that are critical to the next patient?" For a 2-week study, she compared the bacterial burden in the OR after a case to the bacterial burden after a quick clean (defined as cleaning the table and visibly soiled areas) and after UV disinfection. Dr. Bruno-Murtha was not surprised to find that adding UV to the standard cleaning process reduced bacterial contamination significantly. She found that ultraviolet light room disinfection system reduced surface contamination in the OR by 81% and air contamination by 46%.

"If researchers are able to demonstrate that if you do this, you'll decrease your SSI rate, both surgeons and OR leadership will embrace [UV disinfection]," says Dr. Bruno-Murtha, who presented her study findings during the Association for Professionals in Infection Control and Epidemiology (APIC) annual meeting. "But I think it's premature to tell surgeons this will decrease SSIs but increase turnover time. It's not a routine process in every OR, but it can be used selectively," she says. Example: Tomorrow's first case of the day is a patient with a history of multiple prosthetic joint infections and you want to do everything possible to optimize environmental cleanliness in the OR. So set the system that night to cap off a terminal cleaning.

"We demonstrated that while between-case contamination continued to rise from case to case with standard cleaning, it was reduced to almost zero with [UV disinfection]," says Dr. Bruno-Murtha. "This suggests that enhanced disinfection in a busy OR could improve patient safety. Further investigation, however, is necessary to determine whether UV disinfection can reduce surgical site infections."

ANTIMICROBIAL ADVANCES
Solutions for Safer Surgical Surfaces

CU THERE Antimicrobial copper has potential applications throughout the clinical environment.

Beyond the basics of sprays and wipes, research has developed high-tech solutions for surface disinfection. We asked infection prevention experts to weigh in on some of the latest options.

• Washable keyboards. Studies have shown that anesthesia providers who neglect hand hygiene present a significant infection risk to patients by transferring bacteria from contaminated surfaces to the bloodstream via IV lines. Computer keyboards on anesthesia workstations are one of the surfaces they touch most frequently during a case.

Disinfecting keyboards isn't easy, though, and harsh products can damage electronic components inside and out, says L. Silvia Munoz-Price, MD, medical director of the infection control department of Jackson Memorial Hospital in Miami. "It would be helpful to have keyboards that were washable," durable and sealed single-piece devices that are easily and thoroughly wiped down, she says. "But would they be comfortable for practical use? Keyboard covers are not very comfortable, for instance, and when something limits use, people stop using it."

• Copper surfaces. Surface disinfection is usually an interventional act, notes Michael G. Schmidt, PhD, vice chair of the microbiology and immunology department at the Medical University of South Carolina in Charleston. While those interventions reduce the presence of bacteria on a surface, bacteria quickly rebound. What if high-touch surfaces helped themselves out?

"Copper is inherently antimicrobial and continuously active," says Dr. Schmidt, due to sub-atomic conductivity that leaches electrons from bacterial cells to inactivate them. Routinely cleaned copper alloy surfaces kill 99.9% of MRSA, VRE and other superbugs within 2 hours of exposure. A study he co-authored in the July 2012 Journal of Clinical Microbiology found that hospital ICU rooms equipped with copper surfaces — such as stretcher-bed rails, tray tables, IV poles, call buttons and door hardware — showed a 58% lower infection rate than rooms without copper. The strategic use of copper in rapid-patient-turnover environments could bolster infection prevention efforts without even requiring changes to standard practice, he points out.

• Disinfection monitoring. Dr. Munoz-Price questions whether it's economically practical to retrofit your facility with such solutions if your staff still has room for improvement in hand hygiene compliance and proper disinfection product use. She led a study in the September 2012 Infection Control and Hospital Epidemiology demonstrating the positive impact of feedback on OR cleaning.

Ann Marie Pettis, RN, BSN, CIC, director of infection prevention at the University of Rochester (N.Y.) Medical Center, agrees. She monitors the thoroughness of surface disinfection with electronic technology. Swab a surface after cleaning and slide the swab into a handheld meter, which calculates the amount of adenosine tri-phosphate (ATP) — a compound found in all organic matter — on the swab. Displayed as a number, the result indicates how much bioload remains on the surface.

Another option involves applying a transparent fluorescent gel to surfaces before cleaning, then viewing the surfaces afterward under ultraviolet light to see if it's still there. It's a less expensive option, but requires a bit more effort, says Ms. Pettis, and a qualitative solution as opposed to the ATP reader's quantitative results.

Either way, she says, such disinfection monitoring "lends itself to competition. It can be used non-punitively, not to single-out negatively, but to train positively," and ultimately to build a bridge between infection preventionists and the housekeeping or nurse-and-tech crews on whom clean environments depend.

— David Bernard