As the economy heads further down the slippery slope of what promises to be a deep recession, and our healthcare infrastructure continues to grow and age, it is a natural progression to see more and more IAQ professionals turn to what some believe is a recession resistant market. From ambulatory facilities to long term care, the buildings that make up our healthcare infrastructure are constantly in need of renovations and repair. This new and promising opportunity for IAQ pros offers many long term rewards but is not without new and complex challenges that must be addressed.
Every IEP realizes the importance of appropriate use of antimicrobials, containment barriers and personal protection. Though often times IEPs find the regulations and guidelines they encounter in healthcare facilities to be daunting to say the least. In traditional remediation environments the focus is to ultimately provide an environment free of dangerous pathogens or contaminants. While attention is give to the methodology, often times the end results dwarf the means of acquiring those results. With a host of accepted methods to address indoor air quality in businesses, homes and public spaces the contractor finds themselves able to select from a variety of methods to deal with each issue. In the end it is the air clearance that counts, not so much which method was used to obtain it.
While the end results are just as, if not more important in healthcare environments; far more attention must be paid to the processes used. As many occupants of a healthcare facility cannot be moved and are highly susceptible to infection, there are very specific guidelines in place that govern all maintenance, repair and renovation work in a healthcare facility. Organizations like CDC, APIC and JCAHO have placed standards that apply to all activities that may have an impact on a healthcare environment. This is done with good reason considering the number HAIs (Hospital Acquired Infections) reported annually due to airborne pathogens like Aspergillus, which is disturbed during common daily maintenance. Nosocomial infections caused from routine maintenance reach into the hundreds of thousands each year. These guidelines and regulations are enforced in a facility by ICPs or infection control professionals.
Hospitals continually adapt to new, more stringent CMS guidelines limiting what medical treatments are reimbursable through Medicare or Medicaid, this has caused hospital administration to look more closely at every aspect of infection control in their facility. Beginning in October of 2008, Medicare and Medicaid began limiting payments made to facilities for the treatment of preventable nosocomial infections or conditions. These new CMS guidelines are driven by Section 5001(c) of the Deficit Reduction Act, which could mean that as deficits climb the list of non-reimbursable conditions are likely to grow. Infections like Aspergillosis, which is caused by airborne A.Fumigatus, are common in healthcare facilities. Aspergillus is one airborne pathogen that is commonly disturbed and distributed throughout a facility after maintenance work or renovations. The argument could be made that Aspergillosis is a preventable condition by ensuring appropriate containment and disinfection of disturbed areas.
Infection control professionals in healthcare environments have become increasingly diligent in monitoring the actions of contractors that work in their facilities. It is ICP’s responsibility to ensure all components of the infection control risk assessment are adhered to. While these key people can complicate the lives of the contractors working in healthcare facilities they are also actively saving lives by doing so. ICP’s will monitor and log details about each project to ensure that all compliance issues are being addressed. Two primary issues that impact infection control and prevention in healthcare settings are disinfection of contaminated surfaces with broad spectrum EPA registered disinfectants and appropriate containment of airborne particulate and pathogens.
Choosing the best disinfectant is one way to ensure the best possible level of microbial control during any abatement project in a facility. Healthcare facilities present the IEP with a unique set of challenges in regards to pathogens beyond the standard fungal and bacterial flora. Many of these pathogens can be highly infectious as well as drug resistant making them far more dangerous to the many immunocompromised patients housed in a healthcare facility. When selecting a hospital grade disinfecting it is imperative to keep several things in mind.
Does your disinfectant have sufficient kill claims to address the microbes you might encounter?
While no disinfectant can list every possible organism, it is important to find a disinfectant with the most possible EPA registered kill claims. Look for efficacy data. Disinfectants that do not show efficacy & testing data often have few or irrelevant kill claims and are not sufficient for the challenges found in healthcare facilities. It is also a positive if your disinfectant has EPA approved efficacy in the presence of 98% soil load as opposed to 5% which is required by the EPA. This higher soil load represents real world conditions. Beyond fungicidal kill claims, other claims that you might require involve infectious pathogens like MRSA, E-coli, HIV, Salmonella and Avian Influenza. You may also want to look for a product that can be used on both porous and non-porous surfaces and has disinfectant and sanitizing claims.
Understand what the active ingredients are in your disinfectant
It is essential to know what type of disinfectant is appropriate. Most common disinfectants are formulated using Alcohol, Phenol, Chlorine or a Quaternary Amine Base. There are arguments for each type of disinfectant and it is important to know the facts about the products you are working with. Each has advantages, but some have dramatic disadvantages that might make you think twice about using them.
Quaternary Ammonium Chloride (Quats) -
Examples Shockwave Disinfectant/Sanitizer, IAQ 2000/2500
Quats are often considered easier to use and safer than other disinfectant bases because they are less corrosive, non-carcinogenic and maintain efficacy for extended periods of time. Not all quat based disinfectants are equal though. There are a variety of products with EPA registered kill claims ranging from just a few all the way to over 130. In a healthcare environment it is important to seek out the latter, as the spectrum of microbes likely encountered in a hospital will be much broader than in common remediation situations. Unlike many other disinfectants quats based disinfectants are excellent cleaners making them ideal for surfaces with a large amount of biomaterial like fungi, blood or human waste. As many MDROs like C-DIFF, MRSA and VRE are transmitted by contaminated bodily fluids and waste this is an important factor in the equation to finding the ideal disinfectant for healthcare environments. Quats are highly stable and maintain efficacy even in the presences of high soil load. This makes them ideal for mold remediation as well as blood or bodily fluid spills.
Many IEPs as well as ICPs prefer the use of a quats because they not only offer a broad spectrum of kill claims, but are easy to work with and more cost effective than other options. In addition most quats do not have the drawbacks associated with chlorine, alcohol or phenol based products on the market.
While not as user friendly as quats, alcohol based disinfectants are considered by many to be easier to use than chlorine or phenol based products. High concentration alcohol based disinfectants can however be dangerous in a healthcare environment because of its tendency to open pores and dry skin. This can create openings for microbes to enter the body if not properly protected.
Though high concentration alcohol based disinfectants are generally highly effective against lipophilic viruses they are less active against non-lipid viruses and ineffective against bacterial spores. Generally alcohol disinfectants are not used for equipment immersion due to diminishing efficacy as the alcohol volatilizes. Alcohol disinfectants cannot be used as cleaners thus making them less effective for practical use on many surfaces. Even though some Alcohol based disinfectants can offer a broad spectrum of kill claims, it can be difficult to maintain appropriate wet contact time due to the rapid evaporation rate.
These corrosive oxidizers are known for cidal action against a wide variety of gram-negative and gram-positive bacteria as well as many viruses. Difficult to work with, these disinfectants are rapidly neutralized in the presence of organic matter making them less than ideal for healthcare and remediation environments.
While chlorine disinfectants are currently used in many facilities, future use of halogens is expected to decline as options like quats and alcohols become more abundant with appropriate kill claims. Sodium hypochlorite is known for causing significant corrosion to metals and other common materials. Chlorine disinfectants are considered toxic, and in 1994 the Clinton Administration called for the ban of all chlorine and chlorine based products.
Phenol is one of the oldest known disinfectants still in use today and is both commercially manufactured and naturally occurring. Phenols are often effective for use on vegetative bacterial, lipid containing viruses and Mycobacterium tuberculosis but have limited or no efficacy for use against spores or non-lipid viruses. While these disinfectants are effective over a relatively large PH range, their limited solubility makes product residue difficult to clean. These disinfectants cannot be used on food contact surfaces and often require additional PPE like goggles, face shields gloves and protective clothing for application. Phenols cannot be used in many parts of a healthcare facility like neonatal, pediatric ICU or any infant contact surface due to toxic residue. Reports of eye irritation, contact dermatitis/utricaria, and depigmentation of the skin have been tied to phenol and phenol residue contact.
Phenols are commonly found in a host of consumer products and are not dangerous in very low concentrations. Disinfectant strength phenols however are considered a health risk by EPA and NIOSH. OSHA recommendations state that employee exposure to phenol in the work place should be controlled to less than 20 mg/cu m in air determined as a time-weighted average (TWA) concentration for up to a 10 hour work day or 40 hour work week. The NIOSH guidelines also limit exposure to phenols to 60 mg phenol/cu m of air as a ceiling concentration for any 15 minute period. Phenols generally enter the blood stream via ingestion, respiration or skin contact. NIOSH recommendations are just one indicator of the need for PPE when using Phenolic disinfectants. Disinfectants with a concentration of 1% phenol or greater are considered an extreme skin and inhalation hazard and are moderately combustible.
Containment plays a key roll in infection prevention.
While disinfection of surfaces, equipment and touch points plays one of the most critical roles for infection control in a health care facility; another primary responsibility of the IEP working in a healthcare facility is containment. The containment of harmful pathogens and particulate during work in a healthcare facility is essential, especially when working in areas near immunocompromised patients.
Regulations set by CDC & Joint Commission are clear in dictating specific criteria for the elimination of airborne Aspergillus, asbestos and dust. A term that IEPs will hear all to frequently as they make their transition into a healthcare environment is ICRA or infection control risk assessment. These operating guidelines are critical to any maintenance work done in a healthcare facility. APIC has developed guidelines assisting healthcare facilities in developing their ICRA to specifically mandate that dust and airborne particulate must be contained under negative pressure in Kontrol Kube like containment or by using other solid barrier methods.
For many years hospitals were forced to either temporarily close an entire wing or build temporary solid barriers during mold remediation or asbestos abatement jobs to prevent airborne particulate from escaping the work area. In recent years a new method of mobile containment has been made available making daily remediation, repair and renovation faster and far more cost effective. Kontrol Kube type containment essentially revolutionized the way hospital maintenance was being done by allowing an IEP to quickly roll tools, ladders, chemicals and other equipment into a location and then isolate that area for the duration of the work.
Infection control professionals prefer contractors to use methods like portable containment when possible for several reasons. Mobile containment units are easy to set up and inspect, this not only makes use of the unit easier for the IEP but also makes the inspection process much faster and efficient for the ICP. Knowing that all materials are fire rated and meet NFPA 701 is also important with any sort of temporary barrier material you use. Fire codes and standards are extremely critical in healthcare situations and are a focal point during Joint Commission inspections.
When selecting a mobile containment unit be sure to consider if the unit is made of durable components that will hold up under rigorous daily use. It is also important to know that the unit is easily cleaned and is capable of providing all the functionality needed. Will the unit accommodate an eight foot ladder effectively? Does the unit have a solid yet mobile working platform? Is it highly adjustable, durable and lightweight?
Disinfectants and Kontrol Kube type containment are used in almost every type of daily work an IEP might encounter in a healthcare facility; both are key components to any comprehensive infection control plan. For the individual contractor working in a healthcare facility, understanding what is expected of you could make all the difference between winning a bid and being passed over. The knowledge and expertise shown while in the facility can also ensure future jobs in that facility.
As IEPs progress into the healthcare arena to reap the benefits of this relatively protected market they are not only assuming the role of IAQ professional; they are also assuming the role of infection control professional helping to maintain safe, clean and infection free environments. While the challenges they face are unique and in some cases daunting, the benefits exceed a simple increase in business. When we stop to consider the impact of the work they do in the facilities that care for our sick, our elderly and our very young we can see how each of us does our part to win the battle against infection and disease. With proper education and training, IEPs can make the leap from the private or public sector into the highly lucrative and relatively stable market of healthcare remediation, abatement and repair with ease. Knowing the facts about not only the rules and regulations in healthcare facilities, but also the tools available can help ensure a successful transition into IAQ in healthcare environments.