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Introduction to CDC

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Title: Introduction to CDC


1
Introduction to CDCs Guidelines for
Environmental Infection Control in Health-Care
Facilities
  • Lynne Sehulster, PhD, M(ASCP)
  • Division of Healthcare Quality Promotion
  • Centers for Disease Control and Prevention
  • Atlanta, GA 30333
  • Hosted by Paul Webber paul_at_webbertraining.com
  • Sponsored by 3M Canada
  • www.3m.ca

2
Objectives of Todays Presentation
  • After the completion of this session, the
    participant will
  • Be familiar with the overall content of the EIC
    guidelines
  • See how the guidance is applied to an airborne
    disease outbreak and
  • Be familiar with performance measures and
    standards on environment of care

3
Target Audiences for the EIC Guidelines
  • Hospital epidemiologists
  • Infection control practitioners
  • Laboratorians
  • Facility managers and engineers
  • Housekeeping and laundry staff
  • Administration

4
Where Can I Find the EIC Guidelines?
  • Part II Recommendations
  • MMWR 2003 52 (RR-10) 1-44
  • Errata MMWR 2003 52 (42) 1025-6
  • Full text version
  • http//www.cdc.gov/ncidod/hip/enviro/
  • guide.htm
  • Print version
  • ASHE will print in the near future

5
CDC Contributors to These Guidelines
  • Division of Healthcare Quality Promotion
  • Lynne Sehulster, PhD Matthew Arduino, DrPH Joe
    Carpenter, PE Rodney Donlan, PhD
  • Division of Bacterial and Mycotic Diseases
  • David Ashford, DVM, DSc, MPH Richard Besser, MD
    Barry Fields, PhD Michael McNeil, MBBS, MPH
    Cynthia Whitney, MD Stephanie Wong, DVM, MPH
  • Division of Parasitic Diseases
  • Dennis Juranek, DVM
  • Division of Oral Health
  • Jennifer Cleveland, DDS, MPH
  • HICPAC Sponsor
  • Raymond Chinn, MD, Sharp Memorial Hospital, San
    Diego

6
U.S. Organizations Whose Standards are
Incorporated into These Guidelines
  • American Institute of Architects (AIA)
  • American Society of Heating, Refrigeration, and
    Air-conditioning Engineers (ASHRAE)
  • Association for the Advancement of Medical
    Instrumentation (AAMI)

7
U.S. Federal Regulatory Agencies
  • Environmental Protection Agency (EPA)
  • Department of Labor, Occupational Safety and
    Health Administration (OSHA)
  • Food and Drug Administration (FDA)
  • Department of Agriculture (USDA)
  • Department of Justice (DoJ)

8
Air Section
9
Air Section Subtopics
  • Airborne microorganisms
  • HVAC components and function
  • Construction
  • Special care settings
  • Airborne infection isolation (AII)
  • Protective environment
  • Operating rooms
  • Other aerosol hazards (infectious)

10
Ventilation Specifications
Specifications Airborne Infection Isolation (AII) Protective Environment (PE)
Air pressure Negative Positive
Room air changes gt 6 ACH for existing areas gt 12 ACH for new construction or renovation gt 12 ACH
Sealed Yes Yes
Filtration on supply air 90 (dust-spot testing) 99.97 (HEPA)
Recirculation No Yes
11
Ventilation Specifications
Specifications Critical Care Room Operating Room
Air pressure Positive, negative, or neutral Positive
Room air changes gt 6 ACH gt 15 ACH
Sealed No Yes
Supply air filtration gt 90 (dust-spot testing) 90 (dust-spot testing)
Recirculation Yes Yes
12
Ventilation Specifications
Specifications Isolation Anteroom
Air pressure Positive or negative
Room air changes gt 10 ACH
Sealed Yes
Supply air filtration gt 90 (dust-spot testing)
Recirculation No
13
Construction Issues
  • Multidisciplinary team
  • Risk assessment prior to project start
  • External construction keep dust out!
  • Internal construction contain the dust!
  • Barriers
  • Surveillance and air sampling

14
External Construction
  • Keep the facility air pressure positive to the
    outside
  • Ensure that roughing filters are changed
    frequently
  • Seal and caulk windows, especially in PE
  • Keep doors closed as much as possible
  • Wet dust surfaces
  • Protect immunocompromised patients from dust
    during transfers

15
Internal Construction
  • Dust containment, removal and moisture control
  • Educate construction workers and staff
  • Prepare the site
  • Notify staff, visitors, patients re precautions
  • Relocate patients and move staff as needed
  • Monitor for adherence to infection control
  • HVAC system maintenance water system
  • Daily clean-up and removal of debris

16
Particle Sampling
  • Simple to perform, immediate results
  • Verify HVAC system performance
  • Filtration efficiency
  • Rank order from dirty to clean
  • Verify infection control measures during
    construction
  • Construction barrier and dust containment

17
Aspergillosis Outbreak
18
Impact of Aspergillosis, 1996
  • 10,190 hospitalizations average length of stay
    17.3 days
  • 1970 deaths mortality rate 19.3
  • Economic burden in health care 633.1 million
  • Conditions associated with secondary diagnosis of
    aspergillosis
  • pneumonia, other respiratory infections, cancer
    or leukemia, HIV infection

Dasbach EJ, Davies GM, Teutsch SM. Clin Infect
Dis 2000 31 1524-1528
19
Impact of Aspergillosis, 1996
  • When there is a secondary diagnosis of
    aspergillosis in cancer or leukemia patients
  • 26 more hospital days
  • 115,262 in additional costs
  • 4 times the mortality rate compared to similar
    patients without aspergillosis

Dasbach EJ, Davies GM, Teutsch SM. Clin Infect
Dis 2000 31 1524-1528.
20
Healthcare-Associated Outbreaks of IPA
  • Activities that cause increases in counts of
    airborne Aspergillus spores
  • Building demolition, construction, renovation,
    repair
  • Bird droppings in air ducts supplying high-risk
    patient care areas
  • Contaminated fireproofing material
  • Damp wood, sheet rock

21
Aspergillosis Outbreak Hospital A
  • February, March 1996 September 1996
  • 940 bed facility Oncology Center is a 3-story
    building connected to the hospital
  • Pressure differentials, HVAC system checked
    monthly
  • Construction immediately adjacent to the Oncology
    Center
  • A. flavus emerges, previously A. fumigatus

22
Investigative Findings 1996
  • 21/29 surveillance-identified patients met case
    definition of definite or probable
  • Housekeeping procedures inadequate clean wet
  • Univariate analysis location near the stairwell
  • Large volume samplers detected A. flavus, while
    small volume samples were negative

23
Thio CL, Smith D, Merz WG, et al. Infect Control
Hosp Epidemiol 2000 21 18-23
24
Investigative Findings 1996
  • Pressure differentials
  • 25 PE rooms, 3 of which were negative relative to
    the corridor (-0.35 to 3.2 Pa)
  • Air pressure in the central stairwell was
    positive relative to the corridor of the unit
  • Oncology Center was neutral negative compared
    to the adjacent hospital

25
Environmental Control Measures Spring 1996
  • Reviewed the function of the HVAC system
  • Doors engineered to close automatically kept
    closed at all times
  • Wet dusted and cleaned surfaces
  • Sealed windows, exterior walls

26
Environmental Control Measures Spring 1996
  • Closed nearby entrance redirected pedestrian
    traffic
  • Construction policy
  • Air sampling for fungal spores
  • N95 respirators for high-risk patients

27
Environmental Control Measures Fall 1996
  • Closed the stairwell between the HSCT and
    leukemia units
  • Conducted case-control studies
  • Additional environmental cultures
  • Reviewed housekeeping procedures
  • Large volume air sampling
  • Supplemental HEPA filtration when structural
    modification not feasible

28
Water Section
29
Water Section Subtopics
  • Waterborne microorganisms
  • Facility water systems
  • Strategies for controlling Legionella spp.
  • Cooling towers
  • Hemodialysis and water quality
  • Ice machines
  • Hydrotherapy
  • AERs and dental unit water lines (DUWLs)

30
Modes of Transmission of Microorganisms in Water
  • Direct contact (hydrotherapy)
  • Ingestion of water (drinking water, ice)
  • Indirect contact (improperly reprocessed medical
    device)
  • Inhalation of aerosols (showers)
  • Aspiration of contaminated water

31
Updates on Air and Water
  • Updated recommendations for air and water
    infection control measures
  • Guidelines for Preventing Health-Care-Associated
    Pneumonia, 2003
  • Available at http//www.cdc.gov/ncidod/hip/pneu
    monia/ default.htm

32
Environmental Services Section
33
Environmental Services Section Subtopics
  • Principles of cleaning and disinfection
  • Cleaning spills of blood/body substance
  • Carpeting, cloth furniture
  • Flowers and plants
  • Pest control
  • Special pathogen concerns and cleaning

34
Should Environmental Sampling Be Done?
  • NO, not routinely
  • Environmental sampling may be useful
  • To verify the effectiveness of a new cleaning
    and disinfecting process
  • To identify environmental reservoirs during
    outbreak situations
  • Coordinate sampling with the laboratory

35
Environmental Sampling Section
36
Environmental Sampling Section Subtopics
  • Principles of environmental sampling
  • Air sampling
  • Water sampling
  • Environmental surface sampling

37
Laundry and Bedding Section
38
Laundry and Bedding Section Subtopics
  • Epidemiology
  • Collecting and sorting soiled linens
  • Laundry processes
  • Antimicrobial-impregnated articles
  • Pillows, mattresses
  • Air-fluidized beds

39
Animals in Healthcare Facilities Section
40
Animals in Healthcare Facilities Section Subtopics
  • Animal-assisted activities, animal-assisted
    therapy, resident animals
  • Service animals
  • Animals as patients in healthcare facilities
  • Research animals in healthcare facilities

41
Regulated Medical Waste Section
42
Regulated Medical Waste Section Subtopics
  • Epidemiology
  • Categories of medical waste
  • Management of waste
  • Treatment of waste
  • Discharge of blood, body fluids to the sanitary
    sewer
  • CJD issues

43
EIC Guidelines Performance Measures
  • Document infection control professionals
    involvement in all phases of construction
  • Monitor and document airflow for AII and PE,
    especially when occupied
  • Monitor water in hemodialysis settings monthly
    for endotoxin and bacteria
  • Determine source(s) of NTM
  • Identify and respond to water damage

44
JCAHO 2004 Standards for the Management of the
Environment of Care
  • Planning and Implementation Activities
  • EC 1.10 EC 1.30 safety risks, smoking policy,
    safe environment
  • EC 2.10 security risk management
  • EC 3.10 hazardous materials and wastes
  • EC 4.10 EC 4.20 emergency management

45
JCAHO 2004 Standards for the Management of the
Environment of Care
  • Planning and Implementation Activities
  • EC 5.10 EC 5.50 fire safety and Life Safety
    Code issues
  • EC 6.10 EC 6.20 medical equipment
  • EC 7.10 EC 7.50 utilities management
  • EC 8.10 EC 8.30 environmental management

46
JCAHO 2004 Standards for the Management of the
Environment of Care
  • Measuring and Improving Activities
  • EC 9.10 EC 9.30 monitoring and analyzing
    environmental conditions implementing
    recommendations to improve the environment of care

47
JCAHO 2004 Standards for the Management of the
Environment of Care
  • Standard
  • Performance expectation
  • Rationale
  • Background, justification
  • Elements of Performance
  • Steps needed to achieve the standard

48
Thank You!
  • Protect patients, protect healthcare personnel,
    and promote safety, quality, and value in the
    healthcare delivery system

49
Continuing Education Certificate
  • To learn how to apply for a Continuing Education
    Certificate for this teleclass . . .
  • www.webbertraining.com/help.cfm
  • Or contact . . .
  • certificate_at_webbertraining.com
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