GERM ZAPPERS Whole room disinfection systems like this ultraviolet light device target surfaces that manual cleaning might have missed.

The manual cleaning of OR surfaces is effective when done right, but its inherent challenges make it an imperfect science. That's where whole room disinfection comes into play. Today's systems rely on various antibacterial agents — ultraviolet light, aerosolized hydrogen peroxide, hydrogen peroxide vapor, cluster ions and ozone gas — to target areas your staff might have missed. Finding the right system ultimately comes down to balancing cost with the practical benefits of attacking the pathogens prevalent in your facility.

Airborne aids
Jon Otter, PhD, a research fellow at the Centre for Clinical Infection and Diagnostics at Kings College in London, co-authored a study published in the Journal of Hospital Infection (tinyurl.com/n9a56rc) that explores the differences among several available technologies.

The report says aerosolized hydrogen peroxide (aHP) has been shown in clinical studies to reduce Clostridium difficile and methicillin-resistant Staphylococcus aureus contamination on hospital surfaces, but has not been proven to eradicate pathogens in clinical practice. For example, notes the study, at least 1 positive C. diff culture was collected from 20% of 15 and from 50% of 10 rooms studied after an aHP process.

The technology is straightforward to use and relatively inexpensive, according to the study, which notes room doors and vents must be sealed before running disinfection cycles, which range from 2 hours in smaller rooms to 3 to 4 hours in larger rooms. Dr. Otter's study says some research suggests the devices don't achieve uniform distribution of the active agent because aHP is delivered through a unidirectional nozzle and affected by gravity.

Hydrogen peroxide vapor systems send heated vapors of aqueous hydrogen peroxide through high-velocity air streams for uniform surface coverage in enclosed rooms. The study points to clinical research that has shown these systems eradicate pathogens from targeted surfaces and are effective in removing clusters of pathogens during outbreaks of C. diff, MRSA and methicillin-susceptible S. aureus and A. baumannii.

QUICK WIPE Whole room surface disinfection goes where sprays and wipes can't.

The study notes these systems require generators and aeration units to decontaminate a single room, making them a little more complicated to use than aHP. Like aHP, the room's doors and air vents must be sealed during cycles.

The makers of a system that emits a continuous stream of balanced ions into a room say the technology safely, continuously and effectively rids the air and surfaces of existing pathogens without use of ultraviolet light, oxidizers and chemicals. Ozone-based systems offer another option. A study in the American Journal of Infection Control (tinyurl.com/okatz5o) says an ozone hydrogen peroxide vapor system provides a "very high level of disinfection of steel and gauze surfaces against healthcare-associated bacterial pathogens."

Lighting the way
There are 2 types of whole room disinfection systems that deliver UV light to targeted areas: the quick pulses of pulsed-xenon UV (PX-UV), some of which are in the germicidal range, and the continuous doses of ultraviolet C radiation (UVC), which are all in the germicidal range.

There's a reduction in surface contamination when UVC systems are used, explains Dr. Otter, but if you swab surfaces after cycles, some pathogens will remain. His study notes that previous research has indicated the technology can significantly reduce surface contamination, but doesn't fully inactivate C. diff, VRE, Acinetobacter or MRSA. Dr. Otter's study says pulsed-xenon ultraviolet systems emit broad spectrum UV in short pulses. Research has shown one leading system significantly reduced vancomycin-resistant enterococci contamination on a room's surfaces after a 12-minute cycle.

UV light aimed at 12 surfaces in 2 ORs for 4- to-5-minute cycles reduced contamination by 81%, according to Lou Ann Bruno-Murtha, DO, medical director of infection prevention and division chief of infectious diseases for the Cambridge (Mass.) Health Alliance.

Although bleach is used in her ORs, it requires 10 minutes of drying time for adequate sporicidal effect, says Dr. Bruno-Murtha. "UV light is able to penetrate spores that are quite hardy," she adds. "If a surface is missed, or not wiped properly with chlorine bleach, UV provides another level of security."

UV light travels in straight lines, so there's reduced efficacy in areas that are out of the unit's direct line of sight. That's partially mitigated by shooting from multiple locations throughout the room to triangulate targeted surfaces, points out Dr. Otter, but, he says, UV systems still might result in less than uniform efficacy compared with the vapor systems. However, UV systems are easier to use, don't require rooms to be sealed off and run relatively shorter cycles. That said, having to position a single unit in multiple areas to target several surfaces could add to disinfection times.

Assessing the need
Staff charged with manually cleaning OR surfaces have a lot to consider, according to Dr. Otter's study: Ensuring adequate amounts of the active cleaning agent reach target surfaces and remain for the intended contact time; maintaining a systematic approach and constant compliance with facility protocols; ensuring the correct formulation of disinfectant is used; allowing enough time between cases to do the job properly; and monitoring the overall efficacy of the surface cleaning.

There are no microorganisms these systems attack that proper manual cleaning would not, says Dr. Otter. "If manual cleaning were done properly all the time, you wouldn't need an automated system," he continues.

The problem with manual cleaning is not the efficacy or the agents used — it's about ensuring adequate formulation, distribution and contact time occur repeatedly in a busy healthcare environment.

There are limitations to no-touch decontamination, too, says Dr. Otter: You have to vacate rooms and it takes longer than manual cleaning. "It's adjunctive," he explains. "It's unlikely you'll do this for every room after every procedure. Instead, you'll focus on high-risk applications."

He says the systems are best suited for terminal cleaning at the end of the surgical schedule, and occasionally after cases involving high-risk patients with microorganisms you don't want subsequent patients exposed to.

Dr. Bruno-Murtha's facility uses the technology during end-of-day terminal cleaning of ORs where total joints were performed, or after particularly dirty cases when enhanced cleaning is needed to protect the next patient. The technology is not routinely used in the ORs; instead, it's mainly used to target C. diff in inpatient rooms, according to Dr. Bruno-Murtha.

"Efficiency is part of the issue," explains Dr. Bruno-Murtha, referring to using UV systems in a busy surgical facility. "The time you need to disinfect a room depends on its dimensions. The more locations you need to shoot from, the longer you'll have to run the device."

She says it might be time to reevaluate your environmental cleaning and consider the potential of enhanced disinfection with a whole room device if you're experiencing SSIs from specific organisms, particularly if you know the organisms are the same clones you've had in other cases, or if your staff is doing everything they're supposed to — if hand hygiene, skin prepping and antibiotic administration are ideal — and you're still seeing infection rates higher than benchmarking standards.

Pricing peace of mind
The upfront costs of whole room disinfection systems range from $50,000 to $150,000, according to Dr. Otter. Ultraviolet units are the more expensive option, followed by hydrogen peroxide vapor and aerosolized hydrogen peroxide systems, notes his study, which also points out the running costs associated with UV — basically the cost of the bulbs — would be lowest.

Whichever system you consider, the expenses are manageable when considered in relation to a hospital's overall budget, says Dr. Otter, who adds, "If the need is established, cost is not going to be a major barrier to implementation."