Futureproofing hospital disinfection for sustainability and success
Environmental sustainability is a modern imperative. Recycling, plastic reduction and power conservation are practised in most organisations around the world. How will hospitals and aged care facilities balance infection prevention, financial performance and environmental responsibility in the future?
There is clear evidence that the risk of cross-infection is higher if a new patient is admitted into a bed previously occupied by an infected patient (Mitchell 2015). It follows that cleaning and disinfecting high-touch surfaces close to the patient is likely to have an impact on reducing cross-contamination. But what will disinfection look like by the end of this decade?
The science of cleaning is evolving. In recent years there has been an evolution from spray and wipe disinfectants to pre-wetted disinfectant wipes. The latter are popular but Sattar (2013) found that the wiping action and the pressure exerted can profoundly influence the outcome of decontamination. Even when the most effective chemistry is used, the degree of diligence by cleaning staff ultimately determines the success of wiping.
Prof Brett Mitchell’s REACH study (2019) was a major Australian randomised controlled trial of a cleaning bundle that measured the impact of staff training and technique on routine cleaning. There was a significant reduction in vancomycin-resistant enterococci infections. That underscores the premise that education and cleaning practice is related to improved clinical outcomes.
There is no magic bullet when it comes to disinfectant products. In Australia, the TGA ensures that all hospital grade disinfectants are fit for purpose in line with their label claims. The variable however, is the process by which those products are applied. Rutala and Weber (2019) suggest that a bundle approach is appropriate, and that the products chosen should be efficacious and easy to use. Importantly, they should be economical.
Otterspoor & Farrell (2019) compared three TGA registered disinfectant solutions in a South Australian Hospital. They evaluated a buffered peracetic acid product, a chlorine bleach product diluted to 1000 parts per million, and a 0.5% accelerated hydrogen peroxide product. The peracetic acid was found to have the broadest acceptance by staff and met the requirements for terminal cleaning. In terms of economics, chlorine bleach was the most inexpensive disinfectant. The most expensive was the accelerated hydrogen peroxide, being 397% more expensive per day than peracetic acid and 3300% more expensive in use per day than chlorine bleach.
The costs to the environment are another consideration. The accelerated hydrogen peroxide wipes evaluated in a recent prospective cluster controlled trial are composed of 100% meltblown polypropylene plastic (Boyce, 2017). Currently, polypropylene non-wovens are discarded into landfill where decomposition takes approximately 100 years (Keene 2013). Consequently, a large accumulation of these thermoplastic materials in the environment is an issue of increasing concern.
Rutala & Weber (2019) contend that “no touch” technologies may play a part in supplementing our approaches to cleaning in the future. For example, UV-C light irradiation kills prevalent healthcare bacteria in 5 to 25 minutes. Another no-touch method involves the aerosolisation of a disinfectant through a misting or fogging unit. Such systems are highly effective but they can be time consuming, as the time it takes for the vapour to settle — and render the room safe to enter — is dependent on gravity.
A means to deliver disinfectant vapour under high velocity was tested by Ellingson (2019) in two hospitals in Arizona, USA. An electrostatic sprayer forces liquid through an electrified circuit, rendering it negatively charged. It then binds equidistantly to all aspects of an uneven surface. Ellingson demonstrated significant reductions in microbial burden and HAI rates using electrostatic technology. Separately, Cadnum (2019) applied a sporicidal disinfectant using an electrostatic sprayer to wheelchair surfaces inoculated with Clostridioides difficile. The spray was equally as effective in spore reduction as wiping was, but it required only a quarter of the application time.
The early evidence points to low-waste, no-touch disinfection technologies being effective in reducing surface contamination and reducing cost, whilst simultaneously enhancing environmental sustainability targets. Further studies are required to investigate the potential for improved patient outcomes and healthcare economics.
1. Boyce JM, Guercia KA, Sullivan L, Havill NL, Feketia R, Kozakiewicz J & Goffman D. Prospective cluster controlled trial to compare the impact of an improved hydrogen peroxide disinfectant and a quaternary ammonium-based disinfectant on surface contamination and health care outcomes. American Journal of Infection Control, 2017; 45: 1006-10.
2. Cadnum S, Livingston S, Mana TSC, Jencson A, Redmond S & Donskey CJ. Evaluation of a novel sporicidal spray disinfectant for decontamination of surfaces in healthcare. Open Forum Infectious Diseases, 2019; 6:S438.
3. Ellingson, KD, Pogreba-Brown K, Gerba CP & Elliott SP. Impact of a novel antimicrobial surface coating on healthcare associated infections and environmental bioburden. Clinical Infectious Diseases, 2019; 1077.
4. Keene B, Bourham M, Viswanath V, Avci H & Kotek R. Characterisation of degradation of polypropylene nonwovens irradiated by y-ray. Applied Polymer Science, 2014; 10: 1002.
5. Mitchell BG, Dancer SJ, Anderson M & Dehn E. Risk of organism acquisition from prior room occupants: A systematic review and meta-analysis. Journal of Hospital Infection, 2015; 91: 211-217.
6. Mitchell BG, Hall L, White N, Barnett AG, Halton K, Paterson DL, Riley TV, Farrington A & Graves N. An environmental cleaning bundle and HAI in hospitals (REACH). The Lancet, 2019; 19: P410-P418.
7. Otterspoor S & Farrell J. An evaluation of buffered peracetic acid as an alternative to chlorine and hydrogen peroxide based disinfectants. Infection, Disease & Health, 2019; 24: 240-243.
8. Rutala WA & Weber DJ. Best practices for disinfection of noncritical environmental surfaces & equipment in health facilities: A bundle approach. American Journal of Infection Control, 2019; 47: A96-A105.
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