a virtual tour of an academic hospital: focus on …

A VIRTUAL TOUR OF AN ACADEMIC HOSPITAL:

FOCUS ON INFECTION PREVENTION ISSUES

David J. Weber, M.D., M.P.H.

Emily E. Sickbert-Bennett, PhD, MS, CIC

Department of Infection Prevention

University of North Carolina, Medical Center

Thanks to Ms. Melissa Englund for taking the pictures. Thanks to the following for slide or review of presentation: Mark Buchanan,

Jessica Clark, Lisa Teal

WELCOME

TO A VIRTUAL TOUR OF UNC MEDICAL CENTER

UNC Medical Center is an academic medical center;

it is part of the Medical School, University of North Carolina at

Chapel Hill; part of UNC Health (11 hospitals, 13 hospital

campuses, 33,0000 employees, 3.5 million clinic visits, 100,000

surgeries, 5,400 medical staff)

• Established 1952, public hospital

• Includes NC Memorial Hospital, NC Children’s Hospital, NC

Neurosciences Hospital, and NC Women’s Hospital

• ~950 beds

KEY INFECTION CONTROL PREVENTION INTERVENTIONS

Appropriate hand hygiene (WHO 5 moments)

Appropriate surface disinfection

Proper disinfection or sterilization of shared equipment and medical devices

◼ Separate clean and dirty utility rooms on clinical floors

Early identification and isolation of patients with known or suspected communicable diseases

Special infection prevention policies in operating rooms, pharmacy preparation rooms, procedure rooms,

and intensive care units

Use of standard precautions with ALL patients to prevent contact with potentially contaminated body fluids

(i.e., use of personal protective equipment; gloves, gowns, mask, and/or eye protection)

Healthcare personnel

◼ Pre-exposure prophylaxis of healthcare personnel (MMR, varicella, influenza, hepatitis B)

◼ Post-exposure evaluation for post-exposure prophylaxis

INFECTION PREVENTION:

CRITICAL AREAS OF THE HOSPITAL

Hospital rooms: Hand antisepsis, patient isolation, surface disinfection

Clean and dirty utility rooms

Airborne isolation rooms

COVID-19 high-risk containment area

Central sterile processing (sterilization, high level disinfection)

Operating rooms

Water damage remediation

Construction and renovation

Pharmacy

TYPICAL MEDICAL FLOOR

TYPICAL FLOOR ROOMS

Floor room, isolation sign on door, isolation cart containing PPE outside

the door, alcohol waterless product readily available

Sickbert-Bennett EE, et al. Emerg Infect Dis 2016;22:1628-1630

Transmission-Based Precautions SignsFollow the instructions on the door signs, and if you are unsure of what to do, please ask the patient’s nurse

ROLE OF CONTAMINATED ROOM SURFACES IN

HEALTHCARE-ASSOCIATED INFECTIONS

Surfaces are frequently contaminated-~25%

Key HAI pathogens can persist for days to weeks (for C.

difficile for months): MRSA, VRE, P. aeruginosa,

Acinetobacter

Contact with surfaces results in hand/glove contamination

Terminal room cleaning/disinfection frequently incomplete

leading to persistent surface contamination

Evidence demonstrates contaminated surfaces lead to HAIs

(patients admitted to a room where the previous patient had

a MDRO have a higher risk for an HAI with that pathogen)

Surface disinfection reduces contamination which then

reduces the risk of HAIs

Weber, Kanamori, Rutala. Curr Op Infect Dis 2016:29:424-431

TERMINAL ROOM DISINFECTION

Note “splash” shield next to sink to prevent contamination of

adjacent surfaces

OTHER IMPORTANT SURFACES

Curtains frequently contaminated with MDROs. Possible solutions: disposable

curtains, antimicrobial curtains, routine disinfection of grab area. Rutala WA, et

al. ICHE 2014;42:426

Shared patient items may transmit MDROs. Possible solution: Assess

cleaning (fluorescent dye, ATP) with feedback, UV-C disinfection.

Donskey C. AJIC 2019;47S:A90

Floors contaminated with MDROs. May serve as source for contaminating

socks and shoes leading to dissemination. Possible solutions: EVS

education, use disinfectant on floors, UV-C. Donskey C. AJIC 2019;47S:A90

Fabric covered chairs may be contaminated with MDROs leading to transmission

among patients. Possible solution: Use only non-porous furniture in hospital to

facilitate cleaning & disinfection. Noskins GA, et al. AJIC 2000;28:311.

Done at UNC-MC

SURFACE DISINFECTION BUNDLE

Standardize cleaning/disinfection of patient rooms and shared equipment/devices throughout the hospital

Develop check list for who is responsible for c/d of room surfaces and devices (i.e., EVS and nursing)

All touchable room surfaces disinfected daily, when spills occur and when the surfaces are visibly soiled

Terminal disinfection when patient discharged from room: Complete cleaning/disinfection

All noncritical medical devices should be disinfected daily and when soiled

Clean and disinfectant sink and toilet

Damp mop floor with disinfectant-detergent

If disinfectant prepared on-site, document correct concentration

Address treatment time/contact time for wipes and liquid disinfectants (e.g., treatment time for wipes is the

kill time and includes a wet time via wiping as well as the undisturbed time)

Monitor cleaning effectiveness (e.g., fluorescent dye) with immediately feedback

Consider use of room disinfection devices (e.g., UV-C) for MDROs

“NO TOUCH” METHODS OF TERMINAL ROOM

DISINFECTION

Methods: UV devices, Hydrogen peroxide systems

Advantages of “no touch” terminal disinfection

◼ Demonstrated to decrease microbial contamination on surfaces and medical devices

◼ Demonstrated to reduce HAIs (UV only)

◼ Eliminates human failure to disinfect all surfaces

◼ Residual free and safe for the environment

Disadvantages

◼ Room cleaning still required

◼ Substantial purchase costs

◼ Cannot be used with persons in the room

◼ Slows room turnoverWeber DJ, et al. Opin Clin Infect Dis 2016;29:424-431

PREVENTING TRANSMISSION

OF AIRBORNE PATHOGENS

Key infections: Measles, varicella, pulmonary

tuberculosis; highly communicable emerging

infections – COVID-19, MERS, avian influenza

Key mitigation: Use of an airborne isolation room

for patients AND proper use of personal

protective equipment (PPE)

◼ US room standards: >12 air exchanges per hour, direct out-exhausted air, negative pressure,

anteroom

◼ PPE for healthcare providers: N95 respirator (for

some diseases eye protection may be added, e.g., COVID-19) or an air purified respirator

CDC, https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf

AIRBORNE ISOLATION ROOM WITH ANTEROOM

TISSUE TEST TO ASSESS WHETHER A ROOM IS

NEGATIVE OR POSITIVE PRESSURE

If tissue blows into the room, the room

has negative pressure

If tissue blows out of the room, the room

has positive pressure

“CLEAN” UTILITY ROOM

No contaminated materials allowed in the room

All shelves wire mesh to prevent dust buildup on

flat surfaces

Bottom shelf above the floor to allow cleaning

Top shelf below the ceiling so as not to obstruct

the fire suppression system

“DIRTY” UTILITY ROOM

No clean/sterile supplies allowed

Hopper for disposal of liquid wastes (e.g., body

fluids)

Handwashing sinks should NEVER be used to

dispose of body wastes or contaminated fluids

Note “splash” shield next to sink to prevent

contamination of adjacent surfaces

COVID HIGH-RISK CONTAINMENT AREA

KEY ISSUES INFECTION PREVENTION OF HIGHLY

COMMUNICABLE DISEASES

Environmental survival

Germicide susceptibility

Isolation recommendations: Special units; hot, warm

and cold zones; donning and doffing areas

Recommended personal protective equipment (including

PPE monitors)

Pre-exposure prophylaxis (availability, efficacy, safety)

Post-exposure prophylaxis (availability, efficacy, safety)

Recommended biosafety level in the laboratory

Recommended waste disposal (liquids and solids)

Weber DJ, et al. Am J Infect Control 2016;44:e91-e100; Gosden C, Gardner D. BMJ 2005;331:397

COVID-19 UNIT

Hallway to COVID-19 restricted area Donning area prior to entering COVID-19 area Doffing area after leaving COVID area

PANDEMIC PLANNING: NEED TO CONSIDER LOCATIONS FOR EVALUATING &

TREATING PATIENTS WITH HIGHLY COMMUNICABLE DISEASES AS OUTPATIENTS

Clinic rooms with variable airflow, positive or negative;

meet criteria for airborne isolation rooms

Ideally, should have direct access to outside the

hospital to minimize risk of transmission

CENTRAL STERILE PROCESSING

DESIGN OF A CENTRAL STERILE SERVICES AREA

https://www.sehd.scot.nhs.uk/publications/dsmid/dsimd-02.htm

See also: https://healthcarearchitecture.in/central-sterile-supply-department-planning-considerations/

CSS is divided into 3 zones to accomplish the

functions of decontamination, assembly and

sterile processing, and sterile storage and

distribution

◼ Decontamination zone

◼ Assembly/sterilization zone

◼ Storage and distribution zone

A distinct separation must be maintained between

the soiled and sterile areas. The technical staff

works on either the soiled side or the sterile side

and cannot cross from one side to the other

CENTRAL STERILE PROCESSING AREA:

MANUAL CLEANING & WASHER DISINFECTOR

Washer-disinfector superior to manual cleaning. Eliminates

>7-log10 of bacteria and 4.8-log10 of spores

Rutala WA, Gergen MF, Weber DJ. ICHE 2014;35: 883-5

Sink for instrument cleaning


STEAM AND LOW TEMPERATURE STERILIZERS

Steam sterilization is the most robust method (i.e., fewest failures). Low temperature methods

may fail in presence of salt and serum: One study demonstrated that steam sterilization is the

most effective and had the largest margin of safety, followed by ethylene oxide and hydrogen

peroxide gas plasma, but vaporized hydrogen peroxide showed much less efficacy.

Rutala WA, Gergen M, Sickbert-Bennett EE, Weber DJ. ICHE 2020;41:391-395Low Temp Sterilizers

Steam sterilizers


INSTRUMENT ASSEMBY AND STORAGE

Equipment assembly Packaging of surgical trays


STORAGE OF SURVERY TRAYS AND TRANSPORT

Storage of surgical trays (wire mesh shelves to prevent accumulation of dust,

off the floor to allow dust to settle down, and allow cleaning of the floor Transport of surgical trays to OR (close cabinet)

SATELLITE PHARMACY, UNC CANCER CENTER

Clean zone for donning/doffing, view into medication preparation area Sterile zone, pharmaceutical preparation area divided

into hazardous and non-hazardous drugs

OPERATING ROOMS

SURGICAL AREA:RESTRICTED ENTRY: CORRIDORS ARE SEMI-RESTRICTED AREA

PPE required to enter semi-restricted zone {Clean scrubs (or “bunny suit”), shoe covers, and hair covered}

Additional PPE (mask) required to enter restricted area (i.e., OR) if sterile trays open or procedure in progress

SURGICAL AREA:

HAND HYGIENE SINKS FOR SURGICAL PERSONNEL AND OR

The OR is a “sterile” area: PPE (within the surgical field) includes pre-surgical scrub, sterile gloves and gown, all facial hair covered,

shoe covers, eye protection

OR: Should be easy to clean and disinfect; all equipment in closed cabinets; “sterile” items opened just before surgery

SURGICAL AREA:

POST-ACUTE CARE RECOVERY AREA AND ISOLATION ROOMS

PACU should have isolation rooms for patients requiring contact or

droplet/airborne isolation

PACU bays

WATER DAMAGE AND REMEDIATION

CONSTRUCTION AND RENOVATION MANAGEMENT

WATER DAMAGE WITH MOLD:

BEFORE AND DURING REMEDIATION

Mold on drywall (under wallboard) Bathroom tile and drywall removed. Leaking water pipe replaced

Pictures curtesy of Mark Buchanan, RN

WATER DAMAGE WITH MOLD:

AFTER REMEDIATION

Final remediation

REMEDIATION AFTER SEWAGE INTRUSION, FLOODING,

OR OTHER WATER-RELATED EMERGENCIES

Close off affected areas during cleanup procedures. Category II

Ensure that the sewage system is fully functional before beginning remediation so contaminated solids and standing

water can be removed. Category II

If hard-surface equipment, floors, and walls remain in good repair, ensure that these are dry within 72 hours; clean with

detergent according to standard cleaning procedures. Category II

Clean wood furniture and materials (if still in good repair); allow them to dry thoroughly before restoring varnish or other

surface coatings. Category II

Contain dust and debris during remediation and repair as outlined in air recommendations (Air: II G 4, 5). Category II

Regardless of the original source of water damage (e.g., flooding versus water leaks from point-of-use fixtures or roofs), remove wet, absorbent structural items (e.g., carpeting, wallboard, and wallpaper) and cloth furnishings if they cannot

be easily and thoroughly cleaned and dried within 72 hours (e.g., moisture content ≤20% as determined by moisture

meter readings); replace with new materials as soon as the underlying structure is declared by the facility engineer to

be thoroughly dry. Category IB

https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf

CONSTRUCTION SITES, UNC:

OUTSIDE (NEW SURGICAL TOWER), INSIDE (RENOVATION)

Outside construction; major building project Inside renovation area

HEALTHCARE-ASSOCIATED ASPERGILLOSIS

OUTBREAKS AND UNDERLYING CAUSE

Kanamori H, et al. Clin Infect Dis 2015;61:433-44; CDC - https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf

CONTAINING INSIDE RENOVATIONS/CONSTRUCTION

Signage for construction/renovation sites; tacky floor mat for dust control

USE OF A MOBILE DUST-CONTAINMENT CART TO REDUCE RISK OF

FUNGAL INFECTIONS DUIRNG ABOVE CEILING WORK

Buchanan MO, et al. ICHE 2020;9 Oct (on line)

RISK MITIGATION

Kanamori H, et al. Clin Infect Dis 2015;61:433-44

See also: https://www.google.com/search?q=icra+construction+checklist&tbm=isch&ved=2ahUKEwiA6o3A2ZnvAhUCXlMKHZ1EAQwQ2-

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D1ijZWDwdWgIcAB4AIABTYgBzguSAQIyNZgBAKABAaoBC2d3cy13aXotaW1nwAEB&sclient=img&ei=SG1CYICmDoK8zQKdiYVg&bih=805&biw=1600&client=firefox-b-1-d#imgrc=halPvcEddV5_VM

THANK YOU FOR TOURING OUR

ACADEMIC MEDICAL CENTER!

UNC Medical Center

Devoted to excellent patient

care, research and teaching

a virtual tour of an academic hospital: focus on …

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