The first thing to know — and to always keep in mind — about whole-room disinfection systems is that they don't replace traditional cleaning methods. They don't take the elbow grease out of wiping down high-touch areas or eliminate the need to clean floors with hospital-grade cleaner and disinfectant.

The key word is augment. In the increasingly challenging battle against pathogens, whole-room systems give you an added layer of security on top of the standard cleaning and disinfection policies and procedures you already have in place. But if you don't use traction and friction to remove the dirt first, neither UVC light, hydrogen peroxide, ozone nor anything else can get through the cover that dirt provides, to actually disinfect target surfaces.

Finding the time
The biggest challenge in outpatient environments — beyond the cost — is likely to be incorporating such systems into your routine. Because all require a chunk of time to do the job (15 minutes at minimum), a typical busy outpatient surgical facility probably isn't going to find it realistic to use them before or after every case.

With UVC light systems, you may have to move equipment around, or even out of the room, to eliminate shadowing. If the light doesn't hit a particular spot, it doesn't disinfect it. With all the equipment present in a typical OR, that can be a challenge.

With machines that use chemicals like hydrogen peroxide and various other combination mists and vapors, you may have to tape up air vents to prevent dangerous concentrations of chemicals from getting into HVAC ducts. Time may also be needed for chemicals to sufficiently dissipate before people can re-enter a disinfected room.

Down the road, new technology may allow for disinfection to occur without having to seal or vacate rooms. A recent study (osmag.net/9wwzxm) found that a passive light-emitting diode (LED) disinfection system used in an environment that couldn't be closed off (a level II trauma room) significantly reduced microbial surface contamination over time, even when room usage increased. The room was cultured 3 times in 5 different spots — before the system was installed, after 2 weeks, and again after 15 weeks. The impact was minimal after 2 weeks, but surface contamination was significantly reduced after 15 weeks.

So while implementing an LED system wouldn't be expected to deliver dramatic results immediately, over time, it would likely be effective at reducing overall microbial contamination. In the meantime, manufacturers are doing their best to make whole-room disinfection as quick and efficient as possible, and appear to be making progress. But terminal cleaning at the end of the day is likely to be the most practical application for most outpatient facilities.

Pick your poison
The active agents and delivery mechanisms in whole-room disinfection systems vary widely. Here's a rundown of the most common approaches.

• UV light. UV-C light, the high-energy portion of the ultraviolet spectrum, has been used for decades to disinfect industrial surfaces and sanitize drinking water. It is especially advantageous for use in hospitals because it kills the spore-forming bacterium Clostridium difficile, which is a major source of hospital-acquired infections. UV-C systems deliver specific doses of continuous ultraviolet light, which causes changes in the DNA and RNA structure of bacteria and spores, rendering them incapable of replicating.
• Pulsed xenon. Broad-spectrum UV light is emitted in powerful short pulses, so disinfection is fast. The broad-spectrum UV light is capable of damaging microorganisms 4 different ways, virtually ensuring that pathogens are destroyed.
• Vaporized hydrogen peroxide. Hydrogen peroxide vapor systems deliver heat-generated vapor, which uses oxidative processes to kill microorganisms through a high-velocity air stream, thereby achieving even distribution throughout enclosed areas.
• Aerosolized hydrogen peroxide. AHP systems deliver hydrogen peroxide via pressure-generated aerosol. The solution is usually about 5% to 6% hydrogen peroxide along with a very small percentage of silver. A unidirectional nozzle distributes the aerosolized droplets.
• Cluster ions. These use a germicidal mix of pure cluster ions, which actively seek out pathogens via electromagnetic charge. On contact, their stored energy is unleashed through the pores of cell walls, destroying bacteria from the inside out.
• Ozone gas. These use electricity to turn oxygen into ozone, which is a highly effective oxidant that kills all microorganisms. Ozone naturally turns back to oxygen after reacting with pathogens and other pollutants. A fan circulates the air in the room, bathing all exposed surfaces and helping to penetrate hard-to-reach areas.
• High-intensity narrow-spectrum (405 nm) light. Used in light fixtures, visible violet-blue light in the range of 405 nanometers targets intracellular porphyrins, which absorb it and produce reactive oxygen species. It's not as effective as UV-C light, but it can be used in areas occupied by patients.

Customer support
Besides how well the system disinfects, factors like price, support and service should help guide your buying decision.

Are maintenance contracts built into the price? Is the vendor going to spend time in your facility and explain how best to use the equipment in your environment? Will you have access to expert advice on the best place to position the device, and how long you need to run it? Each manufacturer has its own specific recommendations as to what needs to be done to prepare and disinfect a given area and to protect staff and patients.

Some vendors may say, thanks for buying our machine, see you later. So it's important to find someone who's willing to work with you — to say, the best way to disinfect this room is to run the machine here for 5 minutes, then over in this corner for 5 minutes, then here for 5 minutes, and so on. That level of support can make the difference between a good investment and a bad one. OSM

Altapure
AP-4
altapure.com
(574) 485-2145
Price: $84,000
FYI: The AP-4 uses EPA-approved chemistry that ends green and leaves no residue, while delivering a 100% kill of spores, viruses, bacteria (MRSA, C. difficile, VRE, CRE) and others. Using ultrasonic technology, it produces submicron-sized droplets, so it requires a lower percentage of chemicals (1.6%) and covers the entire room, including vertical surfaces. Turnaround time is less than an hour and it's proven safe for fabrics, electronics and people, says the company. It's also fully automatic and can be operated by a tablet that includes multiple languages and data capture.

American Ultraviolet
UVC OR Package
americanultraviolet.com
(800) 288-9288
Price: based on room size
FYI: The OR package consists of multiple ultraviolet fixtures that are mounted to ceilings and walls and above the doors of the OR, with the goals being to eliminate shadowed areas and to treat air, as well as surfaces. The system can be used during orthopedic procedures — including total joints — and before or after any other procedure. A touch-screen interface allows operators to monitor lamp intensity and fixture functionality. It also provides data logging. The mounting system eliminates the need for multiple positions, is always available, and requires no extra staff to operate, says the company. When used as part of a terminal-cleaning protocol, its typical disinfection cycle takes 5 to 10 minutes.

Bioquell
Z-2 (pictured), FS-1, and BQ-50
bioquell.com/en-us
(215) 383 0873
Price: $40,000 to $80,000
FYI: The 3 Bioquell models — which depend on usage and room size — use a hydrogen peroxide vapor solution that can achieve repeatable results with complete coverage of every exposed surface and 99.9999% efficacy, says the company. The technology reaches pathogens — including fungi, bacteria, viruses and difficult-to-kill spores — from ceiling to floor, decontaminating even difficult-to-clean areas and leaving them residue-free.

E-Mist
EM360 ?Disinfectant Spray System
emist.com
(817) 349-3519
Price: not disclosed
FYI: Designed to complement existing disinfection application methods, E-Mist's cordless backpack system uses electrostatic application technology to apply disinfectants to every touchable surface, including those in tight spaces. The delivery system requires far less disinfectant to do the job, says the company, and one person can disinfect up to 100,000 square feet in an hour, or an entire room in seconds, while killing up to 99.9% of pathogens. It's compatible with all water-soluble liquid agents, including disinfectants, sanitizers, deodorizers and cleaners, and its rechargeable lithium ion battery provides 2 hours of continuous use.

Halosil
Halo Disinfection System
halosil.com
(302) 454-8102
Price: $10,000 to $12,000
FYI: A lower-cost alternative, the no-touch aerosolized hydrogen peroxide fogging system uses a proprietary formulation of 2 active ingredients: 5% hydrogen peroxide and 0.01 % ionic silver. The technology ensures uniform delivery of disinfectant throughout every room, says the company, and is EPA-proven to kill 99.9999% of C. difficile spores, as well as 99.99% of Staphylococcus aureus and other bacteria. Case studies show impressive reductions in hospital-acquired infection rates. The price includes disinfectant and room-preparation accessories.

Skytron
IPT 1140, 2280 and 3200 (pictured)
infectionpreventiontechnologies.com
(800) SKYTRON
Price: not disclosed
FYI: Skytron's family of mobile robots, which are designed to meet different budgets and requirements, use continuous UV-C light and proprietary technology to automatically calibrate run time and ensure disinfection of entire rooms without re-positioning, says the company — including shadowed and indirect areas. Each is also equipped with a cloud-based system to document treatments for data storage and statistical analysis.

Steris
Pathogon UV Disinfection System
steris.com
(800) 548-4873
Price: not disclosed
FYI: Designed to be used after manual terminal cleaning, the easy-to-use, lightweight, remote-controlled system automatically delivers a calculated dose of germicidal UV-C energy, altering the DNA of aggressive pathogens, and disinfecting clean, dry surfaces in less than 30 minutes. The system doesn't produce ozone or secondary contaminants, so rooms can be reoccupied immediately after treatment. It's effective against C. difficile, Staphylococcus aureus, MRSA and VRE, among others.

TOMI
SteraMist
tomimist.com
(800) 525-1698
Price: not disclosed
FYI: SteraMist BIT (binary ionization technology) uses a patented 2-step process to activate and ionize a 7.8% hydrogen peroxide solution, converting it to reactive oxygen species that disinfect by damaging pathogenic organisms through oxidation of proteins, carbohydrates, and lipids, including C. difficile spores. The company offers both a hand-held point-and-spray system that enables disinfection of all hard non-porous surfaces, including high-touch, sensitive equipment and electronics, as well as a transportable remote-controlled system that provides complete disinfection of large closed spaces.

Tru-D
Smart UVC
tru-d.com
(800) 774-5799
Price: not disclosed
FYI: The remote-controlled Smart UV-C uses 8 sensors to scan a room's size, geometry, surface reflectivity and contents, so it can deliver a measured dose of UV-C, and consistently disinfect the entire room without repositioning. Once the cycle is complete, it notifies the operator via audio and/or text message. Validated by more than a dozen independent studies, it also comes with cloud-based usage tracking software, which is accessible through the system's remote control.

Xenex
LightStrike
xenex.com
(888) 966-9753
Price: starts at $100,000
FYI: The "germ-zapping robot" quickly destroys microorganisms by pulsing xenon (not mercury bulbs) to create intense UV light and leverage the full germicidal UV spectrum. It can be used throughout healthcare facilities and has been shown to be effective against C. difficile, MRSA and VRE, among others. A cloud-based reporting portal tracks both usage and operators. The company points to multiple peer-reviewed studies showing that it has helped hospitals reduce SSIs in amounts ranging from 46% to 100%.