778 infection control & hospital epidemiology july 2017, vol. 38, no. 7


cleaning based on fluorescent marker removal and effective- ness of surface disinfection based on cultures.4 Second, the use of automated room-disinfection devices (eg, hydrogen peroxide vapor, ultraviolet-C light) as an adjunct to standard cleaning has been shown to reduce levels of C. difficile spores and other pathogens on surfaces.8,9 Although interventions have been shown to improve


eradication of C. difficile spores, there remains an urgent need for high-quality evidence regarding whether such efforts are effective in reducing the incidence of healthcare-associated CDI. Reductions in CDI have been reported with adjunctive use of automated room disinfection devices.10–13 However, confounding factors and regression to the mean cannot be excluded given the quasiexperimental design of the studies, and there is a potential for reporting bias because ineffective interventions may not be submitted for publication. More- over, Valiquette et al14 reported that an intensive effort to improve environmental disinfection by EVS personnel was


ineffective in controlling an outbreak of CDI. Here, we report findings of a multicenter, randomized trial to determine the effect of an environmental disinfection intervention on the incidence of healthcare-associated CDI. The intervention focused on improving environmental disinfection by monitoring EVS performance and providing feedback.


methods Study Setting and Design


We conducted a multicenter, randomized trial in 16 north- eastern Ohio hospitals to determine the effect of an environ- mental disinfection intervention on the incidence of healthcare facility–onset, healthcare facility–associated (HO-HCFA) CDI.15 The intervention focused on improving environmental disinfection by monitoring EVS performance and providing feedback to EVS and infection control staff. Monitoring and feedback were performed using a fluorescent marker method to improve the thoroughness of daily and postdischarge cleaning of high-touch surfaces and using cultures of high- touch surfaces after patient discharge to assess the effectiveness of disinfection.4,5 Daily disinfection of high-touch surfaces in CDI rooms was emphasized given recent evidence that daily cleaning can be useful to reduce acquisition of spores on hands of personnel.16 Of the 16 acute-care hospitals enrolled in the study, 8 were


randomized to the intervention arm and 8 were randomized to the control arm. Each of the hospitals was stratified according to healthcare-associated CDI incidence into 4 groups. For each group of 4 hospitals, 2 hospitals were randomly assigned to the intervention group and 2 were assigned to the control group using software available at www.randomizer.org. A single intervention hospital dropped out prior to the start of the study. Thus, the study included 7 intervention and 8 control hospitals. The institutional review boards for each of the study facilities approved the study protocol. Informed consent was


not obtained from patients or EVS personnel because the study procedures were deemed standard practice and no identifying information was collected. Diagnostic testing and infection prevention strategies for


CDI were similar for all facilities. All hospitals used nucleic acid amplification tests for diagnosis of CDI. All hospitals used commercially pre-prepared bleach wipes for daily and terminal disinfection of CDI rooms; 4 of 8 control hospitals (50%) and 2 of 7 intervention hospitals (29%) used bleach in all rooms after patient discharge. Also, 4 control hospitals and 4 intervention hospitals maintained CDI patients in contact precautions until discharge. Moreover, 6 control hospitals and 4 intervention hospitals stated that they conducted intermittent monitoring of cleaning using either fluorescent markers or adenosine triphosphate (ATP) testing, but none reported routine monitoring with regular feedback to EVS personnel. The policies of all hospitals included preemptive isolation of suspected CDI patients, but the timing of isolation was not monitored.


Intervention


A 12-month intervention was conducted in the 7 intervention hospitals. The start dates of the intervention were staggered for the different hospitals based on the preferences of the facilities and availability of study coordinators (ie, the initial months of the study required much more intensive education and training than later months). The first intervention began in February 2013 and the last began in November 2013; 5 of the interventions began between May and August 2013. During a 3-month period before the start of the intervention, post- discharge cultures of high-touch surfaces (ie, 5×10-cm areas of the bed rail and bedside table and entire surface area of the call button and telephone) for C. difficile were collected using premoistened BBL Culture Swabs (Becton Dickinson, Cockeysville, MD) from CDI and non-CDI rooms in control and intervention hospitals; the goal was to collect cultures from 10 CDI rooms if available and from 10 or more non-CDI rooms. In intervention hospitals, the fluorescent marker method was used to assess thoroughness of daily and post- discharge cleaning of high-touch surfaces in CDI rooms and of post-discharge cleaning of non-CDI rooms.4,5 Five surfaces were monitored for daily cleaning and 10 for postdischarge cleaning (the number of actual sites varied based on availability of the surfaces for marking). For the 7 intervention hospitals, the intervention began with


a meeting with infection control personnel, EVS supervisors, and hospital administrators. The study team presented an overview of the purpose of the study and a summary of the baseline marker removal and culture data for the facility. During a 1-month wash-in period, study staff worked with EVS supervisors to provide education to EVS personnel including demonstrations of how monitoring would be conducted and the sites that would be monitored. During the subsequent 12 months, study personnel provided aggregate


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