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Urgent action required

Diane Wake BSc RGN
Chief Operating Officer and Executive Nurse and Director of Infection Prevention & Control, Royal Liverpool and Broadgreen
University Hospitals NHS Trust,
Liverpool, UK
Healthcare-acquired infections (HAIs) are a major economic burden for healthcare systems globally, with estimated annual costs in the EU of €5.48 billion.(1) In the UK, more than 25,000 individual cases of Clostridium difficile (C. diff) were reported in 2009/10 with a further 2000 confirmed cases of meticillin-resistant Staphylococcus aureus (MRSA), resulting in an estimated cost to the NHS (for all HAIs) of £1 billion per year.(2) 
There is an increasing body of evidence to suggest that improved cleaning and disinfection of the environment can reduce transmission of HAIs. Infection control is a cornerstone of patient safety and requires a multidisciplinary team approach. In the modern NHS infection prevention and control faces many challenges. There is an ever-increasing list of infections which are deemed to be ‘epidemiologically important’ as defined in the Centers for Disease Control  and Prevention (CDC) guidelines(1) and potentially require isolation. Patient-flow models in most hospitals mean multiple locations for most patients during one admission, raising the importance of appropriate isolation early in the patient journey to minimise risk to other patients. There is published evidence to suggest that patient outcomes are better when they are treated in specialist units(2) and multiple authors have demonstrated a beneficial relationship between single rooms and a reduction in infection and non-infection- related adverse outcomes.(3) However in most medical units it can often seem an insurmountable task to get the potentially infective patient into an appropriate bed on an appropriate ward. 
Infections such as Norovirus and C. diff pose particular challenges in healthcare environments because of their transmission characteristics, because acquisition can be via the faecal–oral route, person-to-person spread (either directly or indirectly as environmental contamination is extensive)(4) or aerosolisation.(5) In the case of Norovirus, individuals incubate the virus for 24–48 hours and can shed virus before appearance of symptoms and long after their symptoms have resolved. All these factors, particularly its ability to aerosolise(7) and the potential to infect many patients quickly in a healthcare setting, make containment particularly difficult. It is also important to appreciate that there is nearly a five-fold increase in the risk to other patients in outbreaks where a patient is the index case compared with exposure of patients during outbreaks where a staff member is the index case.
The CDC infection control guidelines suggest that: ‘‘when there are only a limited number of single-patient rooms, it is prudent to prioritise these for those patients who have conditions that facilitate transmission of infectious material to other patients (for example, draining wounds, stool incontinence, uncontained secretions) and for those who are at increased risk of acquisition and adverse outcomes resulting from HAI (for example, immunosuppression, open wounds, in-dwelling catheters, anticipated prolonged length of stay, total dependence on health care workers for activities of daily living).”(1)
Before November 2008, The Royal Liverpool and Broadgreen University Hospital Trust was one of the poorest performing Trusts in the UK in terms of infection control. For example, during a prolonged outbreak of Norovirus, 1770 bed days were lost in three months (1 December 2007 to 1 March 2008). Patients with HAIs have extended stays in hospital, typically ranging from five to 40 extra days in hospital per infection.(6) The cost to an individual hospital depends on the type of infection, but broadly ranges from €694 to €13,880 per infected patient.(6) The majority of these costs (52%) are associated with extra nursing time and medical care. The Trust at the time was a national outlier for MRSA-B and C. diff.
Urgent action required
Following extensive research, Diane Wake, Chief Operating Officer and Director of Infection Prevention and Control (DIPC) at the Royal Liverpool and Broadgreen University Hospitals Trust, identified an interesting case history from Johns Hopkins Medicine, Baltimore, USA, that partly attributed a reduction in HAI rates to deep cleaning methods and area decontamination. After witnessing the process first-hand, she developed a business case for a cohort ward as an interim measure until a dedicated isolation ward was agreed by the trust executive team and commissioned. At the time, area decontamination was relatively new in the UK, but the circumstances warranted a new evidence-based approach, and the funding was approved. 
A multidisciplinary team, comprising infection prevention, hotel services, medical microbiology, patient flow, rapid response and the contract cleaning company, helped with the selection process for an area decontamination system. The chosen system was selected because of its effectiveness, affordability and ease of operation for domestic technicians. 
The system was introduced in November 2008, and from 1 December 2008 to 1 March 2009 only 418 bed days were lost to Norovirus. This reduction represented a saving to the Trust of 1352 bed days which equated to approximately £650,000 or £500 per day while also enabling an increased capacity for patient care during the busy winter months. 
While a range of methods were used at the Royal Liverpool University Hospital to ensure targeted reductions in infection rates, including antimicrobial prescribing, stool sampling and environmental cleaning, these measures did not prove effective against the eradication of Norovirus. However, there was a notable impact following the introduction of hydrogen peroxide technology resulting in reduced lost beds days due to C. diff and Norovirus.
Before hydrogen peroxide vapour machines, a combined disinfectant or detergent was used for cleaning and this was also used for cleaning and disinfection of items that were a nursing responsibility. 
Emphasis was placed on thorough cleaning before the use of the hydrogen peroxide vapour machines to ensure optimum benefit from the vapour. Owing to the difficulties experienced in freeing-up bays for decontamination, these were made a priority and a record kept which allowed for a catch-up programme with single rooms that were not immediately available.
The trust introduced a Deep Cleaning Programme that was planned so that wards which regularly cared for patients with C. diff were decanted and the whole environment cleaned and hydrogen peroxide vapour used before the patients were transferred back to the ward.
The programme commenced at a time of intense pressures on ward staff, domestic contractors and the Infection Prevention team as a result of the  Norovirus, which is prone to outbreaks in institutional settings and households during the winter months. 
The optimum arrangements for completing a deep clean is to have a vacant equipped ward into which patients from the area to be deep cleaned can be moved, while cleaning, repairs and equipment replacement are completed on the empty ward.
Patients are reassured that we are continuing to ensure a clean, safe environment and are reminded of the importance of maintaining effective infection control precautions, through the Trust communication strategy which includes posters, telephone messages and patient information leaflets.
HAIs can be contracted from one of three contaminated sources: other humans; medical instruments; or the environment. Cross-contamination can occur between these three sources, making infection control extremely difficult. 
There is a growing body of evidence that suggests the hospital environment plays an important part in the transmission of HAIs, including infections caused by pathogens such as MRSA, Acinetobacter baumannii, C. diff and Norovirus.(8) 
Recent evidence suggests that traditional manual disinfection often results in incomplete cleaning and poor decontamination, particularly in high-touch and hard-to-reach areas, and may not be sufficient to kill MRSA.(9) In one study, 74% of the 359 swabs taken from the hospital rooms were positive for MRSA before manual cleaning. 
After manual methods were applied, 66% of the 124 samples were still MRSA-positive.(10) Even when stringent cleaning regimes are implemented, it is a constant challenge to maintain a pathogen-free environment in a healthcare setting.  This is why the Royal Liverpool and Broadgreen University Hospitals NHS Trust embraced low concentration hydrogen peroxide mist vapour technology as part of its rapid response initiative to prevent and, as necessary, control outbreaks as they occur and as an element of a major ward deep clean programme.
Annual deep clean
Led by the Hotel Services Manager, the annual deep clean initiative involves selecting wards based on previously high HAI infection rates. Patients in a selected ward are then moved into a ‘decant’ ward. Once this is complete, a three-week rolling programme begins including two weeks of estates work (for example, minor refurbishment of walls, floors, doors) and one week of area decontamination and deep cleaning. 
The Trust contracted out all support services, including area decontamination 15 years ago, and implemented a robust monitoring regime, that includes auditing the contractor to ensure national standards are met, that is, Health Act, CQC. 
As part of their facilities contract, the Trust purchased five hydrogen peroxide area decontamination units which are operated by a 24/7 rapid response team working under the direction of a patient flow team.
The trust has seen a significant reduction in rates of C. diff, Norovirus and MRSA-B. From 1 April 2008 to 31 March 2011 there was an 80.5% reduction in hospital-acquired C. diff cases. There was also an 86% reduction in hospital-acquired MRSA cases during the same time period. However, there are still improvements to be made and they cannot be made by using a single strategy approach. 
Hydrogen peroxide vapour methods have most definitely contributed to the Trust’s reduction in infection rates, but this system is an extension of the importance of environmental cleanliness  and it is vitally important that the area is thoroughly cleaned prior to its use. 
The Trust continues to address this important patient safety agenda to ensure patients have a clean safe environment in which to be cared for and that there is zero tolerance of rates of infection. 
  1. Siegel JD et al. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June (accessed 20 February 2012).
  2. Mulin B et al. Association of private isolation rooms with ventilator-associated Acinetobacter baumanii pneumonia in a surgical intensive-care unit. Infect Control Hosp Epidemiol 1997;18(7):499–503.
  3. Chaudhury H, Mahmood A, Valente M. Advantages and disadvantages of single-versus multiple-occupancy rooms in acute care environments. Environment Behavior 2005;37(6): 760–86.
  4. Cheesbrough JS et al. Widespread environmental contamination with Norwalk-like viruses (NLV) detected in a prolonged hotel outbreak of gastroenteritis. Epidemiol Infect 2000;125(1):93–98.
  5. Marks PJ et al. Evidence for airborne transmission of Norwalk-like virus (NLV) in a hotel restaurant. Epidemiol Infec 2000 Jun;124(3):481–87.
  6. Europa. The Official Website of the European Union. Questions and answers on patient safety, including the prevention and control of healthcare associated infections.… TML&aged=0&language=EN (accessed 20 February 2012). 
  7. National Institute for Health and Clinical Excellence. NICE consults on new advice on preventing and controlling healthcare-associated infections. (accessed 20 February 2012). 
  8. Falagas M et al. Airbourne hydrogen peroxide for disinfection of the hospital environment and infection control: a systematic review, J Hosp Infect 2011; doi: 10.1016/jhin.2010.12.006.
  9. Carling PC, Parry MF, Von Beheren SM. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. ICHE 2008;29(1):1–7. 
  10. French GL et al. Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination. J Hosp Infect 2004;57:31–37.