Services by external companies

Services in hospitals by external companies:
Requirements and issues from the perspective of hygiene
Düsseldorf, 11 April 2013
Walter Popp
Services by external companies
Laundry
Kitchen
CSSD
Cleaning
Doctors – surgeons
Anesthesia
Occupational medicine
Occupational safety
Recruitment agency – eg nurses
Pharmacy
Medical technology
Hairdresser, pedicurist
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Services by external companies
Where
Price
Quality
Laundry
Hospital


Kitchen
Hospital


CSSD
Hospital, resident doctor


Cleaning
Hospital, resident doctor


Bad quality
Doctors - surgeons
Hospital

Anesthesia
Resident doctor


Postoperative control?
Occupational
medicine
Hospital, resident doctor

Occupational safety
Hospital, resident doctor

Recruitment agency
– eg nurses
Hospital, resident doctor

Pharmacy
Hospital

Medical technology
Hospital
Hairdresser,
pedicurist
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Hospital
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Taste?

?
Infectious risks?
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Minimum
Is a hygiene plan available or written procedures?
Is the procedure described correctly?
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> 20 cfu, at least 2x
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40-100 cfu, at least 1x
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> 100 cfu
> 20 cfu, at least 2x
40-100 cfu, at least 1x
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Staph. aureus
MRSA
MRSA Patient
Abklatschuntersuchungen:
9 x MRSA
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3 x Staph.
aureus
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MRSA on ICU
Inves
n
n MRSA
n not in MRSA
room
Environment
140
9
2 rooms
Environment 14 days later
140
6
1 anteroom
1 hall
Staff
> 60
4
Environment 2 months later
140
0
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0
Cleaning in m2/h (Recommendation)
Patient´s room
Toilette /
bathroom
Hall
Hamburger Modell
(1978) (hospitals)
65
40
150
REFA
144 - 188
69 - 84
317 - 581
Neumann / Henning
170 - 220
90 - 180
300 - 500
Lutz (nursing
homes)
110-140
70-90
300 - 400
(nursing homes)
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(ward)
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Cleaning as usual:
2-3 hours daily in morning, especially floors and sanitary rooms.
No disinfectant.
Cleaning in study design:
One additional cleaner on ward daily for 8 hours.
Frequent cleaning of hand contact areas.
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Investigation committee of Bremische Bürgerschaft
(Bremen state parliament) - Recommendation
Also before the outbreak, there were hints to deficits in
cleaning.
But they were not recognized as it should have been
done.
In highly sensitive areas, there should be permanently
assigned cleaning staff.
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Typical problems in responsibility of nurses – cleaners –
service assistants
Making cupboards and shelfs empty before cleaning.
Medical products like ECG, perfusors, ventilation machines,
incubators.
Refill dispensers.
Cleaning of contaminations out of regular cleaning times.
Reprocessing of beds on wards:
- Rooms
- Hall
Patient beds are medical products.
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Typical problems of cleaning staff in service
companies
- Language problems
- Frequently leaving job
- Bad training
- High workload (m2)
- Missuse of disinfectants and cleaning agents if used in
parallel
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Carling und Bartley: Am J Infect Control 2010, 38, S41
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Misleading recommendations of the past
(Daschner, Rüden, 2000-2002)
No routine disinfection of sanitary rooms on normals
wards.
No routine disinfection of patient touch surfaces on
normal wards.
No routine disinfection of floors on ICUs.
No disinfection of incubator during patient change.
No disinfection of baby´s changing table during patient
change.
No routine disinfection of toys.
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Additionally:
Prevent contamination of cloths: No redipping of cloths in
cleaning solution – minimise redipping of cloths in disinfectant
solutions.
Cloths for reuse have to be washed thermically or
chemothermically by washing machines… dry them in a dryer
If washing of cloths is not possible, single-use cloths have to
be used.
Buckets have to be cleaned thoroughly after end of work shift.
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Single-use cloths in buckets, ready to use
Compatibility of cloths and disinfectant (VAH)
Loss of efficacy with time and by drying out (VAH)
Contamination of cloths standing out (VAH)
Growing of gram(-) bacteria in bucket, biofilms (VAH)
If Quats: chemothermical reprocessing of buckets (Bode)
Manual reprocessing is enough if aldehydes or alcohol (Bode)
No restriction re disinfectants (Merz)
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Investigation
Buckets for disinfectants during use
56 buckets of cleaning staff
50 buckets of other staff groups
Disinfectant solutions investigated
250 probes investigated
Bacteria positive n=9
N=6 gram(-) bacteria
Gloves of cleaning staff
27 gloves
13 in use, 14 not in use between shifts
2 disinfectants used
6 gloves with pathogenic bacteria, 4 of them in use:
Staph. aureus, enterobacteriae
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Preliminary conclusions
Permanent staff on ICUs and in OTs.
Quantification of time needed for cleaning of specific
areas, also including hygienic issues – increase of
technology on ICUs in last years!
Cleaning evidence based.
Training according to TRBA 250 and HygMedVO.
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Multiresistant bacteria
Growing problem:
Repeated outbreaks of same strain even after months´
breaks!
Air disinfection and more intensified cleaning might
increase!
Essen:
• RKI concentration and time
• „Air disinfection“
• VAH concentration and time
Mostly successful
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What the patient can see
Hand hygiene (disinfection, jewelry…)
Wound dressing
Cleaning of rooms
Isolation of patients
(cleaning of beds)
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Patient can make an
opinion on what is
going on in his/her
room – but not in the
operating theatre!
Deliver good cleaning
practice in the room!
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