Environmental Disinfection ~
A Review of Hydrogen Peroxide
Vapor Technology
Lessons from a
Community Hospital
Nancy Iversen, RN, CIC
Director, Patient Safety & Infection Control
Billings Clinic
niversen@billingsclinic.org 406-657-4823
 Not-for-profit, community
owned and governed
 Multi-specialty Physician
Group Practice
 3,750 employees
 260 employed physicians
representing 50 specialties
 285-bed hospital, 90-bed LTCF
 7 regional branch clinic
locations
 Multi-state management
affiliations and support
services
 Member of Mayo Clinic Care
Network
Learner Objectives
1. Describe two unique characteristics, changing epidemiology, and
environmental persistence of Clostridium difficile bacteria
2. Discuss two strategies that prevent the transmission of
healthcare-associated Clostridium difficile and other pathogens
3. Describe the current environmental disinfection strategies and
application of hydrogen peroxide vapor ~ BIOQUELL
4. Discuss advantages and disadvantages of hydrogen peroxide
vapor disinfection technology
Health Care, Education and Research
Examples of The Unseen
What You Learn Will Creep You Out!
The Dust Mite
Photo courtesy of Janet Stout, PhD, Special Pathogens Lab
Health Care, Education and Research
About Unseen Dust Mites
• A typical mattress may
have anywhere from
100,000 to 10 million
mites inside.
• 10% of the weight of a
two-year old pillow can
be composed of dead
mites and their
droppings.
Photo courtesy of Janet Stout, PhD, Special Pathogens Lab
Health Care, Education and Research
Background
• Environmental contamination contributes
to transmission of healthcare-associated
pathogens1
• There is increased risk of acquisition of
multidrug-resistant organisms in rooms
where the previous occupant was
colonized or infected with the organism2,3,
1. Weber D et el. Am J Infect Control 2010;38:25-33
2. Drees M et al. Clin Infect Dis 2008;46:678-85
3. Datta M et al. Arch Intern Med 2011;171:491-494
4. Nseir S et al. Clin Microbiol Infect 2010;Nov 4
Background
• Standard methods of cleaning and
disinfecting surfaces in hospitalized
patient’s rooms are sub-optimal1,2
• Novel technologies used to
decontaminate patient rooms include3,4
– Hydrogen Peroxide Vapor (BioQuell)
– Ultraviolet Light (UV-C Radiation)
1. Boyce JM et al. Infect Control Hosp Epidemiol 2010;31:99-101
2. Carling PC. J Hosp Infect 2008;68:273-274
3. Nerandzic MM et al. BMC Infect Dis 2010;10:197
4. Boyce JM et al. Infect Control Hosp Epidemiol 2008;29:723-729
5. Havill NL. Infect Control Hosp Epidemiol 2012; 33(5):000-000
Contaminated Surfaces Can
Contribute to transmission
• Contaminated environmental surfaces can
contribute to transmission of pathogens
– By serving as a source from which healthcare
workers contaminate their hands or gloves
• Contaminated medical equipment that comes
into direct contact with the patient can serve as a
source of transmission
Boyce JM et al. Infection Control Hosp Epidemiology 1997; 28:1142
Bhalla A et al. Infection Control Hosp Epidemiology 2004; 25:164
Hayden MK et al. Infection Control Hosp Epidemiology 2008; 29:149
Passaretti CL, Clin Infect Dis; 2013; 56(1): 27-35
Survival of Pathogens in
the Environment
Pathogens that survive well
in the environment include:
 Clostridium difficile
 MRSA
 VRE
 Acinetobacter
 Norovirus
Hota B., et al. Clin Infect Dis 2004; 39:1182
Kramer A., et al. BMC Infect Dis 2006; 6:130
CDI Epidemiology / Issues
• Rates Increasing world wide and in US
– Outpacing MRSA Healthcare-associated Infections
• Common epidemic C. difficile strain continues to be
reported from hospitals in expanding list of states
• More severe disease with
– higher mortality – 6.9% (30 days), 16.7% at one year
– higher readmissions
– higher rates of colectomy in the elderly continues
• Point-source outbreaks well described
• Environment plays a role in transmission to other patients
– Environmental survival of C. difficile spores is 5 months
Problem / Opportunity
Clostridium difficile Infection (CDI)
2007 – December 31, 2014
Cost: $7179 / case (Scott, DR, Direct Medical Costs of HAI in US Hospitals, CDC, March 2009)
Published incidence rate: 3.8-9.5 cases per 10,000 patient days
(SHEA / IDSA Practice Guideline 2010).
Vancomycin Resistant Enterococcus (VRE)
1997 – March 31, 2011
VRE Cases
(Community Acquired, Healthcare-associated Colonizations,
Healthcare-associated Infections, Other Facility-Acquired)
10
10
# VRE Cases
8
6
6
6
5
4
4
4
4
3
3
2
2
1
1
1
0
0
0
0
1997
1998
1999
2000
2
2
1
1
2
2
1
1
22
1
1
0
3
0
1 1
00
0
0
0
Community
Acquired
2001
2002
2003
2004
Healthcare-associated
Colonizations
2005
2006
2007
2008
Healthcare-associated
Infections
2010 VRE Outbreak Investigation
6 new HA VRE cases June 2010 – October 2010
(no HAI VRE cases Jan – June ’10)
• 3 HA colonizations (transmissions)
• 3 HA infections
PFGE Typing conducted suggested cross-transmission
2009
OFA
2010
CYTD
2011
(3mos)
Billings Clinic Hospital Study
(August 2010)
Phase 1: Baseline Environmental Cleaning Evaluation
Study Design:
Cleaned & empty
room identified
•
Terminal cleaning after 2 patient cycles
Rooms marked with
fluorescent marker
DAZO, (Ecolab)
Room evaluated
Marked 120 high-touch surfaces in 10 Patient Rooms
IPS
IPM
ICC
ATU
ICU
ICC
SSU
ED
(2 rooms, N & S)
(2 rooms, N & S)
(1 room)
(1 room)
(1 room)
(1 room)
(1 room)
(2 rooms)
Study Results
High Touch Surfaces Cleaning Study – Hospital
Baseline ~ August 2010
High Touch Surfaces cleaned
61% (73/120)
High Touch Surfaces not cleaned
39% (47/120)
Ongoing Performance ~ January - December 2013
High Touch Surfaces cleaned
93.2% (2116/2270)
High Touch Surfaces not cleaned
6.8% (154/2270)
Health Care, Education and Research
Footboard Control Panel
After Cleaning ~ Fluorescent marks remain
Computer Keyboard
After Cleaning ~ Fluorescent marks remain
High Touch Environmental Surfaces
Cleaning Verification
January – April 15, 2014
98.0% (1505/1536)
Currently, DAZO fluorescent marking system is being used for EVS training and
patient room disinfection verification. Process improvement ongoing.
High Touch Environmental Surfaces
Cleaning Verification
Comparison of Disinfection Technology
Hydrogen Peroxide Vapor
(BIOQUELL)
Efficacy


Complete surface sterilization ensuring
total elimination of pathogens
EPA-registered room sterilant
UV-C Radiation (Tru-D)


Inactivates
Validation
Methodology
Sporicical
Compatibility
Literature
Support


Inactivates bacteria, virus’, fungi
C. difficile (20 minutes), VRE,
Norovirus, MRSA, Acinetobacter (60
minutes), other Gram negs.

No verification of complete
surface sterilization ~ 2- 4 log
kill (no higher than 4)
Not EPA registered
Log reduction of bacteria, virus’,
fungi
Yes. Inactivation of 6-log Geobacillus
stearothermophilus biological
indicator (same method used to
validate steam sterilizers)
No. Biological Indicators not used to
verify efficacy.
Reference published studies to
verify efficacy
Yes ~ Kills C. difficile in 20 minutes
No. 4 log reduction C. difficile in 50
minutes
Safe for porous (fabrics, curtains) and nonporous materials & electronics
Safe for porous (fabrics, curtains)
and non-porous materials &
electronics
Substantial peer-reviewed, published
scientific papers, abstracts
Little scientific evidence. Limited
application in HC
Comparison of Disinfection Technology
Hydrogen Peroxide Vapor
(BIOQUELL)
UV-C Radiation (Tru-D)
Purchase Price /
Lease Option
$56k
(lease to own option available)
Includes Training
$125k
Ongoing
Operational
Expense
$20k
Hydrogen peroxide
Tape
$5k
Bulbs
Data Tracking
System Included
Yes
No
Education &
Training
Provided
On-site Support
Provided
On-site Support
Additional Uses
Safe in REI / IVF Laboratories
Does not produce off-gassing ~
will not harm embryos
Safe in REI / IVF Laboratories
Does not produce off-gassing ~
will not harm embryos
Odor
Light hydrogen peroxide odor
Lingering odor ~ electrical fire
Bacterial Growth Before & after
Decontamination ~ HPV vs. UV-C
68
Number of positive samples
70
N = 75
33
5
HPV vs. UVC (p <0.0001)
Havill NL, Moore BA, Boyce JM, Infect Control Hosp Epidemiol 2012;33(5):000-000
Bacterial Growth After Decontamination
5 Surfaces using HPV vs. UV-C
Number of positive samples
Shadowed
12
10
Non-shadowed
5
4
2
2
0
1
1
1
HPV: Shadowed vs. non-shadowed (p =1)
UVC: Shadowed vs. non-shadowed (p <0.0001)
Cultures with no growth before decontamination excluded
Havill NL, Moore BA, Boyce JM, Hosp Infect Control Epidemiol 2012;33(5):000-000
Log reductions
C. difficile Log Reductions
Achieved
3.0
2.5
2.2
1.7
1.8
Havill NL, Moore BA, Boyce JM, Infect Control Hosp Epidemiol. 2012;33(5):000-000
Hydrogen Peroxide Vapor
(Bioquell) Process
Evaluation Period Feb. 2011
• Room cleaned of visible soil
• Ventilation & doorways sealed
• Generator creates HPV from
35% Hydrogen Peroxide
• Aeration unit catalytically
converts HPV to oxygen and
water vapor
• Computer allows for process
control and auto shut off
BioQuell Q-10 Room Sterilization System
Hydrogen Peroxide Vapor (HPV)
Biological Indicator ~ Test Organism
Geobacillus stearothermophilus
• Purchase HPV 106 BI’s from
outside lab
• Run quarterly testing to verify
efficacy
• Expose 4-5 HPV BI discs to
10 grams Hydrogen Peroxide
• Incubate at 55-600 C for 7
days
• Chemical indicator pilot
Ongoing verification of 106 log reduction
BIOQUELL Unit ~ Vent Sealing Device
One to three units per room
BioQuell Unit in Use ~ ICU Room 2117
10 min. set-up; 90 min. cycle time; 5 min. tear down
BioQuell Trial ~ ICU Room 2117
10 min. set-up; 90 min. cycle time; 5 min. tear down
(ICC Room ~ 4466 = 2 hrs, 40 min. / ICU 2114 = 75 min.)
Consumables (tape) from one room
UV-C Process
• Room cleaned of visible soil
• UVC device placed in the
center of the room
• Door closed
• UVC (254 nm range) delivers
22,000 uW sec/cm2
• Hand held device controls
settings monitors the process
Tru-D Unit Setup ~ ICC Room 4465
5 min. set-up; 90 min. cycle time; 10 min. tear down
Tru-D Unit In-Use ~ ICU Room 2121
12 min. set-up; 54 min. cycle time; 10 min. tear down
Conclusions
• HPV and UV-C significantly reduce
bacterial contamination in patient rooms
• HPV is significantly more effective than
UV-C for the eradication of bacteria,
including spores
• UV-C is significantly less effective in
shadowed areas from the device
Recommendation
• Acquire BioQuell Q-10 Unit (HPV) technology for
terminal room disinfection
• Adopt objective measurement for cleaning &
disinfection processes (e.g. fluorescent marker, ATP)
– CDC recommendation, CMS requirement
• Priority Applications ~ Terminal Disinfection
–
–
–
–
–
–
C. difficile rooms
VRE rooms
IVF Laboratory
Equipment Disinfection ~ create BioQuell Room
Norovirus
Unused supplies in isolation rooms
Current Applications
• Priority Applications ~ Terminal Disinfection
– Clostridium difficile rooms (20 minute kill time)
– VRE rooms
– Norovirus
– Emerging Multi-drug Resistant Organisms (MDRO)
• ESBL, CRE
• Acinetobacter (BIOQUELL kill time 60 minutes)
• Other Resistant Gram-negative bacteria
– IVF Laboratory in Surgery Center
– Disinfection of Equipment / Unused Supplies
• Unused medical supplies in isolation rooms
Otter JA, Infect Control Hosp Epidemiol May 2013, Vol. 34, No.5.

7-9% contamination VRE/MDRO, None of the items were contaminated after HPV (p<.02)
Annual cost of supplies discarded at hospital discharge was $387,055.
– Currently run cycles in equipment storage rooms, gait belts.
BIOQUELL Cost Per Patient Room
•
•
•
•
$56.00 per 500ml bottle of peroxide
2 – 500ml bottles per room
1 tech at $17.00/hour plus benefits
Average time per room start to finish 3.5 hours
(set up 30 minutes)
• Total cost per room = $185.00
• Updated 2014 : $220.00 new larger rooms
– Room size ranges 40-172 m3
Health Care, Education and Research
BIOQUELL ~ 1 Year Cost
Internally Managed Program
• 281 patient rooms
• 281 rooms at $185
per room
• $51,985.00
• $5,000 Annual P.M.
and training
• Total Annual Cost:
$56,985.00
BIOQUELL Managed Program
• $13,500/month or
• Total Annual Cost:
$162,000
Projected 2014 cost (larger rooms)
 25 rooms / month ~ 300 / year
 $220.00 per room + $5,000 annual P.M.
 Total Annual Cost: $71,000
Health Care, Education and Research
BIOQUELL Use Summary
• Began November 1, 2011
• 793 applications
–
–
–
–
75% C. difficile rooms
20% cycle cleans
4% other MDRO’s ~ VRE, Norovirus, ESBL
1% other (IVF, equipment rooms)
• Average cycle time 3.5 - 4 hours, 30 min. set-up
• Perform initial terminal clean with bleach disinfectant
• Run BI’s quarterly, evaluating CI’s (12 rooms)
Lessons Learned
Advantages
Disadvantages

Efficacy

Customer service decline

Efficacy validated

Recent breakdowns

Retain EVS personnel

Longer room turnover
Decontamination Specialists
 Substantial salary increase
 Missed decontaminations
 High census, velocity
 Breakdowns
 Staff acceptance high



Gait belts
Equipment storage areas
Learner Objectives
1. Describe two unique characteristics, changing epidemiology, and
environmental persistance of Clostridium difficile bacteria
2. Discuss two strategies that prevent the transmission of
healthcare-associated Clostridium difficile and other pathogens
3. Describe the current environmental disinfection strategies and
application of hydrogen peroxide vapor ~ BIOQUELL
4. Discuss advantages and disadvantages of hydrogen peroxide
vapor disinfection technology
Health Care, Education and Research
Questions?
Hand Hygiene Study
Inter-rater Reliability Study
November 2013 – February 28, 2014
Unit
Results
ATU
56% (51/91)
ED
71% (85/119)
FBC/LDRP
73% (19/26)
ICC
66% (59/89)
ICU
71% (49/69)
IPM
74% (185/250)
IPS
63% (95/150)
NICU
76% (25/33)
SSU
75% (53/71)
Aspen
81% (44/54)
TCU
33% (22/67)
Dialysis
69% (20/29)
Radiology
45% (5/11)
Surgery Center
58% (11/19)
Overall Performance
67% (712/1058)