SPORES ILLUMINATED Disinfecting rooms that have been exposed to Clostridium difficile is the top priority for the Lehigh Valley (Pa.) Health Network.

If it were up to her staff, they'd unleash a whole-room-disinfection robot in every room after every case. "But unfortunately, we don't have that luxury," says Terry Burger, MBA, BSN, RN, NE-BC, CIC, FAPIC, who oversees infection control and prevention for the 7-hospital Lehigh Valley (Pa.) Health Network. "We don't have enough machines or enough time in the day."

You'd like to be able to make sure every square inch of your facility is disinfected and pathogen-free. But as adjuncts to standard cleaning regimens, even the newest technologies need time, space and planning to work their magic. We talked to several healthcare pros about the strategies they use to get the biggest bang they can for the significant number of bucks they've invested in whole-room disinfection systems.

1. Identify the biggest risks. Ms. Burger says it starts with risk stratification. "We asked ourselves where our greatest challenges were," she says. "Everybody will tell you it's Clostridium difficile. So our machines are deployed first and foremost whenever a patient has been identified with C. diff. As soon as they're discharged, we terminally clean, then we use the machine."

Fighting back against notoriously stubborn C. diff spores is also the No. 1 priority at the University of Vermont Medical Center, says Manager of Infection Prevention Carolyn Terhune, MT (ASCP), CIC. "Our primary use is in our isolation rooms and we prioritize those rooms based on risk," says Ms. Terhune. "C. diff is the first priority. If we can get to other contact isolation rooms, we get to those as well."

At the Elmhurst (Ill.) Hospital, robots follow the trails of patients who've been infected with any of the common drug-resistant organisms, says Infection Control Manager Annemarie Schmocker, BSN, RN, CIC, whether that trail leads to the OR, the cath lab or some other procedure room. "We try to schedule those cases at the end of the day, because then we take the room down," says Ms. Schmocker. "It takes a lot of coordination."

2. Make ORs and procedure rooms a priority. Of course, the more ORs there are in a given facility, the more planning goes into making sure they all get frequent doses of germ-killing UV light or hydrogen peroxide.

At Mission Hospital in Mission Viejo, Calif., 2 robots carry the load for 13 ORs, 3 Ob-gyn ORs and 3 procedure rooms. "We can't hit all 19 rooms in one evening," says Wendy Ferro-Grant, MSN, MBA, CNOR, the hospital's executive director of perioperative services and endoscopy. "So we rotate the units through, and we're able to hit them every other night."

To pull it off, they have environmental services do a ceiling-to-floor terminal cleaning in each targeted room, then push the robot in, close down the room, turn on the machine and move on to start terminal cleaning other rooms. "So they're processing one room while they're terminally cleaning another," says Ms. Ferro-Grant.

An automatic reporting system lets her confirm that the schedule is being followed correctly. "I have a portal I can go to every Monday morning and get a report for the week on how many rooms were completed," she says. "So I can determine if there was a fallout, and if so, I can work with environmental services to determine why. Was the room closed? Were there trauma cases in the OR? Sometimes there are reasons you can't get into a room."

All of the ORs at Lehigh Valley are done on a rotational basis, too, says Ms. Burger. "It can take us a week to get through all of them, but we know that every week, they get at least get one exposure."

IMPORTANT TECHNOLOGY
Whole-Room Disinfection: Coming Soon to an OR Near You?

COMBINED EFFORT Robots are a useful adjunct, but staff need to clean blood and bodily fluids off surfaces before the robots can do their job.

In my experience as a consultant, it's rare for surgical centers to be 100% satisfied with their outsourced environmental cleaning services. Regardless of whether that's true in your center, whole-room disinfection is an important technology to consider. We may soon see the day when surgical centers will be able to use a staff of dedicated personnel to do their own terminal cleaning, bolstered by automated whole-room disinfection. In the meantime, if you're considering augmenting your disinfection regimen with one of the whole-room systems on the market, here are some things to keep in mind:

1. Regardless of which machine you choose, have the manufacturer come in and spend the time to show your staff exactly what to do, and what not to do. Studies have shown that the technology is extremely effective, but this isn't like wiping down a counter. The technology is complex, and several steps may be required to make sure you hit all targeted surfaces.

2. Spend time with staff members who are responsible for using the technology, which is still very new to most people. Everyone who'll use it needs to feel comfortable with both the operation and the safety features.

3. If your goal is to disinfect every room in your facility, plan to do it at the end of the day as an adjunct to terminal cleaning. However, if you have a slower day and can spare 10 or 20 minutes, that can be enough time to run the machine in a given room. Manufacturers are working on making machines that cycle faster, so between-case disinfection may soon be feasible, but busy facilities that depend on super-fast turnovers will still probably need to hold off until day's end.

4. Pre-cleaning remains vital. You can't penetrate protein material with any chemical or UV lights without removing the coating material first. Staff need to perform the actual physical cleaning with a wet cloth or mop head, and they need to wipe blood and bodily fluids off surfaces before they begin to disinfect.

5. It makes sense to concentrate, as hospitals do, on rooms that have housed patients with multidrug-resistant organisms, like C. diff, CRE and MRSA, and to disinfect them as soon as patients are discharged. C. diff spores, in particular, can survive for many months.

6. If you're having outbreaks with the 3 most common gram-negative organisms that can contaminate the environment — Escherichia, Pseudomonas and Acinetobacter — bring a machine in, at least on a trial basis, and see if it makes a difference.

— Phenelle Segal, RN, CIC, FAPIC

Ms. Segal ([email protected]) is the founder and president of Infection Control Consulting Services in Delray Beach, Fla.

3. Fight clusters. At Lehigh Valley, any time there's a cluster outbreak — which they define as 3 or more cases in a given unit of methicillin-resistant Staphylococcus aureus, Acinetobacter or some other infection — a robot is put into action until that cluster is eliminated. "We have clear evidence that when we use the robot along with other interventions, we're able to stop a cluster outbreak," says Ms. Burger.

4. Take advantage of downtime. When the OSS Health Ambulatory Surgery Center in York, Pa., closes down for the night, the center's 2 disinfecting robots light up the night, hitting all 4 OR suites, as well as pre-op, PACU, breakrooms, restrooms and lounges — with the help of environmental services, of course.

The process takes about an hour and 20 minutes and some extra labor, but it helps provide peace of mind, says Director of Ancillary Services Mike Nestlebush, MBA, CMRP. "We do a tremendous amount of manual cleaning, but that gets you to a certain place and then kind of hits a wall," he says. "The technology behind the UV robots allows us to not be limited by what the environmental services staff can clean. It can hit areas that they may not be hitting as well as they should, or that they can't reach."

5. Be creative. At Elmhurst, they devised a test before they bought their robots, to see whether the aerosolized agent employed by the robot actually worked. "We challenged the company," says Ms. Schmocker. "We worked with microbiology and inoculated a patient room with everything you can think of — vancomycin-resistant enterococci, carbapenem-resistant Enterobacteriaceae, MRSA, C. diff — and we documented where we had done the culturing. After the whole procedure, we cultured again and honest to goodness, there was no growth. They had eradicated everything."

Impressed and emboldened, they also now use the robots in the fight against the bedbugs, scabies and lice that patients sometimes carry into the hospital. The aerosolized format takes longer to set up and carry out, because vents and doors have to be sealed off, but they've also begun using the robot to disinfect pharmacy compounding and, when there's time, virtually everything else they can think of.

One of the advantages of the system is that it disinfects everything in range, says Ms. Schmocker. "We love that we can wheel it into a room, and also take equipment, IV pumps, glucometers, stethoscopes — whatever we want — and pack as much as we can in there," she says, "and it will disinfect everything." OSM