Infection Prevention

Prevention of Infection: Selecting and Using Disinfectants

Disinfection Insights You Can Use Today

Part 2 of 3: Selecting and Using Disinfectants

According to a recent study reported by APIC, the significant presence of multidrug-resistant gram-negative bacteria (MDR-GNB), such as E. coli, among nursing home residents demonstrates the need for heightened infection control prevention and control measures in nursing homes. In the release, APIC President Linda Greene says, "This study underscores the importance of having strong infection prevention programs in all nursing homes and long-term care facilities."

A holistic industry-wide approach to infection prevention and control is paramount if healthcare-associated infections (HAIs) are to be eliminated. Bedrock measures are necessary to be effective.

Kelly M. Pyrek writes, "Education and training is the cornerstone of HAI prevention, and the WHO guideline recommends that IPC education should be in place for all healthcare workers by utilizing team- and task-based strategies that are participatory and include bedside and simulation training to reduce the risk of HAI and antimicrobial resistance."

The following brief by J. Darrel Hicks focuses on the selection and use of disinfectants.

Cleaning executives have trusted in the efficacy that an EPA registration implies for the disinfectants used by staff. But now users are being informed by the EPA Office of Inspector General — in the 2016 report — that, “Once the EPA tests a product and it passes, it is listed as Agency Confirmed Efficacy on the agency’s website and is typically not tested again; the long-term efficacy of the product cannot be assured.”

The IG also revealed that the EPA relies on manufacturers to voluntarily submit product samples for testing. And in the last three years, out of the approximately 300 registered disinfectant products yet to be tested, manufacturers submitted only 12 samples to the EPA for ATP efficacy evaluation.

However, this isn’t a new problem. In August 1990, the U.S. Government Accountability Office (GAO) released “Disinfectants: EPA Lacks Assurance They Work.” The report reads, “…historical enforcement and other data estimated that 20 percent of disinfectants on the market did not work as claimed, posing health risks to users.”

It was this report that launched the initial Antimicrobial Testing Report in 1991, and successes have been slow coming ever since. According to an IG report in 2010, “after nearly 19 years, over 40 percent of registered products have not been tested . . . [and] those that have been tested have experienced a consistently high failure rate.”

What does all this mean for environmental services managers today? Continue reading the full article here.

Selecting And Using Disinfectants. Reproduced and used with permission from CleanLinkFacility Cleaning Decisions. Copyright 2017 by CleanLink.

EMist is dedicated to infection prevention and control. The patented EM360™ Electrostatic Spray System coupled with the Health-E™ Certified Healthy Process make disinfecting better, easier and more cost effective. We help break the chain of infection. Visit our website for more information:

Electrostatic Technology for Surface Disinfection in Healthcare Facilities

Studies have shown that less than 50% of environmental surfaces in patient care rooms are properly cleaned and disinfected. Evidence strongly suggests that cross contamination of microorganisms from environmental surfaces is directly related to patient infections. High-touch surfaces such as bed rails, bed surfaces, tables, fluid poles, doorknobs, and supply carts have all been identified as having the greatest potential for transmission of pathogens. Current cleaning/disinfecting methods and procedures are critical to prevent the transmission of infectious diseases, yet, nearly 100,000 people will die this year directly attributable to HAIs. Electrostatically applied disinfectant may assist in the battle against preventable infections, improve patient experience, while increasing hospital revenues. Main Article:

One out of every 25 patients who are admitted to a hospital will contract a preventable healthcare-acquired infection (HAI). According to a 2002 study, approximately 1.7 million HAIs occur in U.S. acute care hospitals each year, resulting in 99,000 deaths at a total direct, indirect and non-medical social cost estimate of $96-147 billion per year.1,2 Study estimates did not include the more than 26,000 U.S. facilities such as ambulatory surgical centers, skilled nursing, long-term acute care, hospice, or dialysis centers. Obviously these HAI statistics are dated and may be vastly underestimated. In April 2016, the CDC approximated that the actual number of deaths from sepsis were as much as 140% higher than those recorded on death certificates, or as many as 381,000 deaths a year. Sepsis is just one subgroup of the infections.3 Healthcare-acquired infections continue to occur at alarming rates in U.S. hospitals and represent a significant cause of morbidity and mortality. HAIs have a devastating impact on people’s lives, the national economy, hospital reputations and financial sustainability.4


The physical environment is an important link in the chain of infection prevention and control. Contaminated environmental surfaces provide an important potential source for transmission of healthcare-associated pathogens.5 Cleaning and disinfecting of environmental surfaces in healthcare facilities is fundamental in healthcare facilities.6 The Centers for Disease Control and Prevention (CDC) Guidelines recommend that hospitals clean and disinfect all “high-touch surfaces.”7 High-touch surfaces include: bed rails, bed surfaces, supply carts, over-bed tables and intravenous pumps.8 Experts agree that monitoring terminal room cleaning and disinfecting practices in healthcare facilities is an important element of infection control programs.9 Still, studies have indicated that inadequate cleaning and disinfecting of surfaces is widespread with housekeeping wiping only 50% of surfaces targeted for cleaning.10,11,12

One way to break the chain of infection includes the use of innovative technology such as the application of EPA-registered disinfectants using electrostatic systems. As compared to traditional spray-and-wipe, fogging, and UV lighting, electrostatic disinfection application systems present a complementary and cost effective approach to healthcare facility environmental surface disinfection methods. Electrostatic spraying has been used in the agricultural and automobile industry for decades. In effect, a spray gun modified with an electrode charges the liquid particles, which are then guided to an oppositely charged target. Based on Coulomb’s law, an electrostatic disinfectant application system applies disinfectant more evenly to all surfaces. Coulomb’s law states that the magnitude of the electrostatic force of interaction between two point charges is directly proportional to the scalar multiplication of the square of the distance between them. The force is along the straight line joining them.13

Electrostatics is a proven technology in the agricultural and automotive industries. This technology is now being integrated into healthcare settings as a tool to break the chain of pathogen mobility.14 As an example, Creative Solutions in Healthcare owns and operates 46 skilled nursing and 13 assisted living facilities throughout the state of Texas. This top-50 ranked long-term care facility company uses electrostatic application technology in their efforts to prevent the transmission of dangerous pathogens. According to Gary Blake, President of Creative Solutions, this technology “has proven to be far more cost-effective than we ever dreamed possible. There’s a huge chemical cost savings, our employees are healthier – they’re staying at work, so our overtime is down in many markets during flu season. Our residents are returning home sooner from their rehab stays with us instead of going back into the hospital, and that’s gotten the attention of our managed-care insurance companies and even from Medicare.”

Most surface areas are neutral (uncharged) or negative. Electrostatic application for healthcare surface disinfection is a method of applying an EPA-registered disinfectant to a target surface area using electrostatic force of attraction. Using Coulomb’s law, these systems place a positive or negative charge on the chemical disinfectant as it leaves the spray nozzle.15,16 Because most surface areas are neutral or negative, a positively charged electrostatic spray application system optimizes adhesion and attraction (electromagnetic theory17). The dispersed droplets spread out more evenly and seek out the negative (-) or neutrally charged surface (neutral surfaces have the same number of protons as electrons – a neutral object can be polarized by a charged object and create attraction). The disinfectant is more targeted, provides more consistent coverage with less waste, and like two magnets, attracted to the oppositely charged surface with remarkable force.


Most common nosocomial pathogens can survive on surfaces for months18. These deadly bugs can become a continuous source of transmission. As such, regular, preventative surface disinfection is recommended. Wiping hard surfaces with contaminated cloths can contaminate hands, equipment, and other surfaces.19 Those involved in the prevention and control of infections require a balanced approach of cost and quality to improve outcomes. Existing healthcare disinfection methods including wipes, spray and wipe, fogging, and UV lighting all have their place in a multimodal IPC program, but may be ineffective or cost prohibitive for routine or comprehensive use. As environmental surface contamination and healthcare-acquired infections have become more defined, electrostatic disinfection application systems present a viable and cost effective tool in the environmental surface disinfection arsenal.

The battle against nosocomial pathogens is costly. This has become even more pronounced in light of the Hospital Value-Based Purchasing (VBP) Program. VBP rewards or penalizes hospitals based on degrees of care quality. Centers for Medicare & Medicaid Services (CMS) bases hospital performance on an approved set of measures and dimensions grouped into specific quality domains.20 For 2017, The CMS has created a new safety domain that primarily measures infection rates. Yet, most infection prevention and environmental surface teams continue to use antiquated or cost prohibitive disinfection methods including labor-intensive hand-wiping or UV lighting.

As presented, research studies have shown that environmental cleaning and disinfection play important roles in the prevention and control of healthcare-acquired infections. Though prevalent and widely used in other industries, electrostatic technology is now being adopted in the application of disinfectants. This new, innovative technology may assist in the battle against preventable infections, improve patient experience, while also increasing hospital revenues.


  1. Klevens, Monina R., et al. (2002) Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals Center for Disease Control. Retrieved October 12, 2016, from
  2. Marchetti, Albert. Rossiter, Richard. (2013) Economic burden of healthcare-associated infection in US acute care hospitals: societal perspective. Retrieved October 12, 2016 from
  3. Epstein L, Dantes R, Magill S, Fiore A. (2016) Varying Estimates of Sepsis Mortality Using Death Certificates and Administrative Codes — United States, 1999–2014. MMWR Morb Mortal Wkly Rep 65:342–345.
  4. UMF Corporation. (2012) Doing Everything: Multimodal Intervention to Prevent Healthcare-Associated Infections. Retrieved October 12, 2016 from
  5. Donskey, C. J. (2013). Does improving surface cleaning and disinfection reduce health care-associated infections?. American journal of infection control, 41(5), S12-S19.
  6. Centers for Disease Control and Prevention. (2008) Guideline for Disinfection and Sterilization in Healthcare Facilities. Retrieved October 12, 2016 from
  7. Centers for Disease Control and Prevention (CDC). (2003) Guidelines for Environmental Infection Control in Health Care Facilities, Centers for Disease Control and Prevention. Retrieved October 12, 2016 from
  8. Huslage, K., Rutala, W. A., & Weber, D. J. (2010). A quantitative approach to defining “high‐touch” surfaces in hospitals. Infection control and hospital epidemiology, 31(8), 850-853.
  9. Carling, P. C., Briggs, J. L., Perkins, J., & Highlander, D. (2006). Improved cleaning of patient rooms using a new targeting method. Clinical Infectious Diseases, 42(3), 385-388.
  10. Carling, P. C., Parry, M. M., Rupp, M. E., Po, J. L., Dick, B., & Von Beheren, S. (2008). Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infection Control & Hospital Epidemiology, 29(11), 1035-1041.
  11. Goodman, E. R., Piatt, R., Bass, R., Onderdonk, A. B., Yokoe, D. S., & Huang, S. S. (2008). Impact of an environmental cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms. Infection Control & Hospital Epidemiology, 29(07), 593-599.
  12. Garrett, R. (2016) UV Light Disinfection And Other Alternative Methods. CleanLink. Retrieved October 12, 2016 from–19836
  13. Ida, Nathan, 2007, Engineering Electromagnetics, Springer, p. 126.
  14. E-Mist Innovations. (2016) Electrostatic Disinfection System. Retrieved October 12, 2016 from
  15. Bartlett, P.E. Goldhagen, and E.A. Phillips. (2016) Experimental Test of Coulomb’s Law. Oct. 12, 2016.
  16. Tang, K., & Smith, R. D. (2001). Physical/chemical separations in the break-up of highly charged droplets from electrosprays. Journal of the American Society for Mass Spectrometry, 12(3), 343-347.
  17. Maxwell, J.C., 1865, A dynamical theory of the electromagnetic field. Phil. Trans. R. Soc. Lond. 155, 459–512.
  18. Kramer, A., Schwebke, I., & Kampf, G. (2006). How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC infectious diseases, 6(1), 1.
  19. Hughes, R. (Ed.). (2008). Patient safety and quality: An evidence-based handbook for nurses (Vol. 3). Rockville MD: Agency for Healthcare Research and Quality. Chapter 41, Preventing Health Care-Associated Infections.
  20. Department of Health and Human Services. (2015) Hospital Value-Based Purchasing. Centers for Medicare & Medicaid Services.

Copyright © 2016 InfectionControl.Tips. All rights reserved. Used with permission. For more information, visit

Author: Joshua T. Robertson, President, E-Mist Innovations, Inc. Joshua is an entrepreneurial leader, experienced in growing organizations solving big issues within the healthcare space. Prior to joining E-Mist, Joshua launched National HME (NHME) in 2006. NHME partnered with over 500 hospice programs, served 500,000+ patients and created close to 500 jobs throughout the U.S. during his tenure at the company. In 2015, the company recapitalized and yielded a high rate of return for shareholders. Joshua also founded GrowCo Capital in 2014 that invests resources into entrepreneurial businesses and real estate projects throughout the United States. Joshua graduated from Texas Tech University receiving an Executive MBA and a double major in honors management and marketing. He is actively involved in GrowCo Capital, Project 4031, and founding President for the Rawls Raiders Alumni Network (Texas Tech Business School).

About E-Mist E-Mist helps healthcare organizations prevent and reduce HAIs. Founded on a legacy of electrostatic science and technology, the E-Mist Infection Control System and Process eliminates traditional disinfectant methods. The EM360 System is mobile, touchless, safer, cordless, and more cost-effective approach to environmental surface disinfection. E-Mist makes disinfection better, easier and more cost effective.

MRSA & Antibiotic Resistance: We’re on a collision course

By Rodney E. Rohde, PhD Abstract:

On any given day, approximately 1 in 25 inpatients in U.S. acute care hospitals has at least one healthcare–associated infection (HAI), adding up to about 722,000 infections in 2011. Pneumonia and surgical-site infection are the most common infection types, and Clostridium difficile is the most common pathogen. Practically, what this means is that over 200 patients will die the day you read this article and every day after that until the global community is able to address this healthcare crisis. If you do the simple math, you will realize that about 4% of hospitalized patients developed one or more HAIs due to the care received in the hospital, resulting in approximately 75,000 deaths. Imagine a jet airliner going down every day in this country and the American public accepting it without much notice. In reality, that is what is happening with HAIs. More Americans die every year from MRSA than from HIV/AIDS and H1N1 combined.

Main Article:

When I answered the phone at home one evening in late December 2007 and heard the voice of a worried woman, the genesis of an idea for my future research path began to take shape. She was concerned about her husband, she said. The retired couple from Utah had traveled over the holidays and the husband, a cancer patient, developed sores on his torso. They went to the emergency room, where a doctor diagnosed a staph infection and prescribed antibiotics. No laboratory tests were done. The man’s condition worsened, so when the couple returned home he went to his family doctor. After an examination and some laboratory tests, the doctor determined that the man had MRSA — methicillin-resistant Staphylococcus aureus — an infection that cannot be treated with most typical antibiotics.

MRSA became one of my primary areas of expertise after I became an assistant professor in Texas State’s Clinical Laboratory Science Program within the College of Health Professions back in 2002. I have since conducted numerous prevalence and incidence studies on MRSA in a variety of environments, including prisons, dormitories, recreation centers, physical therapy educational settings, and most recently in homes,1 as well as on nursing students and animals. In a sense, I am the classic clinical microbiologist and research scientist interested in documenting and discovering information about this dangerous microbe. However, it wasn’t until I started work on my PhD in 2006 that I revisited that “genesis of an idea” while receiving numerous “cold calls” and emails from concerned individuals who had been diagnosed with MRSA or had loved ones dealing with this deadly infection.

I remember it like yesterday – such a vivid reminder of the confusion, concern, and plight of these individuals dealing with such a difficult healthcare problem. The wife of the patient from Utah had some basic knowledge about MRSA from newspapers and other media coverage and she was very concerned about what had happened to her husband at the emergency room given his immunocompromised state because of the cancer. She just wanted to know why this had happened and whether she or anyone else they had been in contact with should be concerned about transmission.


I spent more than an hour on the phone explaining to her the difference between “regularStaph” and MRSA. I told her that it is very important to have a culture done so that a proper diagnosis and identification of MRSA can be made2. I also let her know that if the infection worsens, the patient might have to be admitted to a hospital and given strong antibiotics intravenously. I emphasized that it is always important to ask for a culture and antibiotic susceptibility test if her husband were to get another infection.

The man improved after being correctly diagnosed by his family physician. He received a combination of two powerful drugs and eventually recovered from the infection. To this day, that phone call remains a pivotal moment in my career. I realized that I needed to begin the process of understanding this disease from the perspective of those who had experienced it. I needed to begin delving deeper into the learning experiences of people who had lived through a MRSA infection in order to improve the practical management and outcomes of this disease. Simply put, I was becoming a more hybrid, translational researcher and it has become one of my primary passions.


Often acquired in healthcare facilities or during healthcare procedures, the extremely high incidence of MRSA infections and the dangerously low levels of literacy regarding antibiotic resistance in the general public are on a collision course3. Traditional medical approaches to infection control and the conventional attitude healthcare practitioners adopt toward public education are no longer adequate to avoid this collision. In many cases, the patient simply does not know what to even ask of their healthcare providers. I documented this time and again through patient interviews. We must all learn to take an active role to be an advocate for patients who do not understand what antibiotic resistance means to their health – whether it’s in the healthcare facility or at home in the community. MRSA and other resistant organisms are not only in healthcare. Community facilities and locations can be major reservoirs of resistant organisms like MRSA. Recently, I and colleagues completed a study that documented prevalence rates of Staphylococcus aureus (15%) and MRSA (2%) in a physical therapy multi-use educational room.4 The lines have blurred between healthcare and community-associated MRSA. Education, for both healthcare providers and the general public, has become critical. Health literacy regarding antibiotic resistance, HAIs such as MRSA, and one’s responsibility in this perfect storm must be a priority for global public health.

For several decades now, the high incidence of HAI and the dangerously low levels of literacy regarding antibiotic resistance in the general public have been on a collision course. The “Perfect Storm” has arrived and is painfully evident in the numbers of illnesses and deaths due to HAI. Moreover, the general public seems to be more worried about headline diseases such as Ebola and Zika than the one right under their noses (or their hospital bed). While global outbreaks such as Zika are worthy of our most heroic public health efforts, in reality more United States citizens will die this year and every year from HAI – a preventable infection!5,6

Progress is being made per CDC’s National and State Healthcare-associated Infection Progress Report such as these reported findings:

  • A 46 percent decrease in central line associated blood stream infection (CLABSI) between 2008 and 2013.7-9
  • A 19 percent decrease in surgical site infections (SSIs) related to the 10 select procedures tracked in the report between 2008 and 2013.7-9
  • A six percent increase in catheter associated urinary tract infections (CAUTI) between 2009 and 2013; although initial data from 2014 seem to indicate that these infections have started to decrease.7-9
  • An eight percent decrease in hospital-onset MRSA bacteremia between 2011 and 2013.7-9
  • A 10 percent decrease in hospital-onset difficile infections between 2011 and 2013.10

The ultimate goal, however, is zero preventable HAIs. It will take a multi-modal approach on multiple fronts of the battlefield.10-11 We are still experiencing thousands of needless deaths each year. It’s time for all of us – global healthcare professionals of all walks of life, private and public government agencies, professional organizations, and the general public – to join hands and confront this war head on! If we do not, the consequences will be tragic and potentially unwind all of the past public health advances that our parents, grandparents and great-grandparents enjoyed.


On this day – World MRSA Day – this editorial is aimed to inform laboratory professionals, business thought leaders, medical/health educators, healthcare professionals, healthcare facilities experts, EVS professionals, government agencies, professional organizations, philanthropists, and the clinical diagnostics field at large about MRSA awareness. We must all strive to do better regarding past, current and future paradigms for HAI detection, management and national and state strategies for reduction of these deadly infections.

Finally, medical laboratory professionals play an integral role in the healthcare system by providing diagnostic services that not only directly impact therapeutic management of patients, but also by offering their expertise in interpretation of the results in the mounting numbers and types of HAI identification. Further, medical laboratory professionals must inform physicians and others in the sometimes difficult and cloudy interpretation of antibiotic susceptibility assays and menus of tests available to physicians. In that light we should all have a basic grasp of the basis and rationale for interpreting HAI testing, and generally appreciate the downstream effects of reporting a result. Lastly, educators must become leaders in preparing clinically competent laboratory professionals, and other healthcare professionals, by providing them with opportunities to expand their training and understanding of antibiotic-resistant microorganisms in general, and HAI in particular.

We can and must be better. If not, we all fail. We fail ourselves. We fail each other. And, we especially fail those patients who need our voice and advocacy – even those who don’t know what questions to ask!


  1. Felkner M, Rohde R, Valle-Rivera AM, Baldwin T, Newsome LP. Methicillin-Resistant Staphylococcus aureus Nasal Carriage Rate in Texas County Jail Inmates. J. Corr HealthCare. 2007. 13(4), 289-295.
  2. Rohde, RE. Two Laboratory Tests you Must Demand: Advice from MRSA Survivors and a Scientist, 2016. 1(1-4)
  3. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of healthcare–associated infections. N Engl J Med 2014; 370:1198-1208.
  4. Rohde, R.E. Denham, R., & Brannon, A. Methicillin Resistant Staphylococcus aureus: Nasal Carriage Rate and Characterization in a Texas University Setting. Clinical Laboratory Science, 2009. 22(3): 176-184.
  5. Klevens RM, Morrian MA, Nadle J. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007; 298:1, 763-771.
  6. Bancroft EA. Editorial: Antimicrobial resistance — It’s not just for hospitals. JAMA 2007; 298:1, 803-804
  7. Rohde RE. A Secret Weapon for Preventing HAI: A scientist’s message to hospitals trying to rid themselves of healthcare-associated infections. Elsevier Connect, July 15, 2014. Available from Accessed 9/2/2016.
  8. Rohde RE. Healthcare Facilities Today – published written interview, Scholar bringing EVS role in infection prevention to the forefront. Q2, April 2015: pp. 11-13. Available from–9115 Accessed 9/2/2016.
  9. Rohde, RE, Felkner M, Regan J, et al. Healthcare-Associated Infections (HAI): The Perfect Storm has Arrived! R.E. Rohde – Invited Focus Series. Clin Lab Sci Winter 2016;29(1):28-31.
  10. Dhagat PV, Gibbs KA, & Rohde RE. Prevalence of Staphylococcus, including Methicillin Resistant Staphylococcus aureus (MRSA), in a Physical Therapy Educational Facility. Journal of Allied Health 12/2015; 44(4):215-218.
  11. Centers for Disease Control and Prevention. (2012) Healthcare-associated Infections (HAI) Progress Report. Available from Accessed 9/2/2016.

Copyright © 2016 InfectionControl.Tips. All rights reserved. Used with permission. For more information, visit

About Dr. Rohde Dr. Rodney E. Rohde is Professor, Research Dean and Chair of the Clinical Laboratory Science Program (CLS) in the College of Health Professions of Texas State University.

About E-Mist E-Mist helps healthcare organizations prevent and reduce HAIs. Founded on a legacy of electrostatic science and technology, the E-Mist Infection Control System and Process eliminates traditional disinfectant methods. The EM360 System is mobile, touchless, safer, cordless, and more cost-effective approach to environmental surface disinfection. E-Mist makes disinfection better, easier and more cost effective.

Infection Prevention: Touchscreens are contaminated

Touchscreens: The Mosquito of the Digital AgeBy Thomas Rolfe, Michael Nitti

Abstract The widespread and rapidly growing automation and digitization of our world has led to the installation of billions of touchscreens, both in our personal possession and in public use, such as at hospitals, airports, schools, restaurants, public transit, banks and government offices.

Warm touchscreens contacted by many people, or by individuals who themselves are in contact with potentially infected surfaces, are ideal hosts and transmitters of infectious disease. The touchscreen could be considered the mosquito of the digital age. In addition to being vectors of infectious disease, these tools are expensive devices and vulnerable to damage from cleaning protocols, vandalism and impact.

The use of an antimicrobial protective screen could be the simple, inexpensive solution to the problems faced by touchscreen users.

Main Article Touchscreens are everywhere: on your phone, tablet and car dashboard; and at the bank, the movie theatre, the airport and your hospital room. The pervasive use of smartphones, tablets and other touchscreen devices, both in healthcare settings and the general public, presents at least three issues:

1. Disease transmission Touchscreens are ideal media for pathogens of all kinds to flourish on, due to their regular contamination by unclean human hands and body fluids and their warm operating temperature. Bacteria thrive at 35˚C. Touchscreens in hospitals are well-known potential sources of infection (Shakir, 2015).

A significant infectious disease problem in healthcare today is nosocomial infection, an infection that originates in hospitals. An increasingly prevalent infectious disease problem is arising in schools, restaurants and elsewhere, due to the increasingly diverse sources of pathogens outside of healthcare settings and the increasing public use of touchscreens.

The infectious disease problem is better documented in the healthcare sector than in public areas.  Scientific reports have found that patients admitted to rooms that were previously occupied by patients infected with common multidrug resistant organisms (MDROs) have been found to be at a 1.5 to 2.5 times increased risk for developing the same infection (Stibich, 2016). Since there is no direct contact between the two patients, this risk of infection is almost exclusively associated with the environment. If not properly disinfected, these MDROs can linger on high touch surfaces for weeks to months, serving as a continued transmission risk for many future patients (Otter, 2013).

Studies conducted to determine contamination levels on smartphones have concluded that a smartphone is highly contaminated with the same microbes that are found on the hands of the user (Beckstrom, 2013).


Several studies have concluded that cell phones are excellent transmitters of infectious disease between individuals commuting between hospital wards, and the community at large (Tatem, 2011). Evidence from the healthcare environment suggests that all touchscreens in public use should be considered potential hotspots for the transmission of infectious diseases. A 2013 project at the University of Surrey tested a large sampling of smartphones and found fecal coliforms, Streptococcus, Staphylococcus aureus and much more (Ulgar, 2009).

2. Challenges of cleaning Healthcare environments have implemented aggressive cleaning protocols for high-touch surfaces (Weber, 2005), with the unfortunate side effect of damage to screens from the harsh chemicals. Alcohol, ammonia and bleach can ‘etch’ the surface of a screen and make it appear cloudy. Residue from cleaning products can crystallize and, when touched or rubbed, scratch the touchscreen surface. In non-healthcare settings, fear of damaging the screens means they are rarely cleaned with the vigor needed to remove pathogens.

3. Implications of impact Hospital environments are unusually rough on equipment and operating room monitors due to the frequent movement of equipment and the nature of an emergency environment. As a result, many touchscreen devices are physically damaged or destroyed unnecessarily because they have minimal impact resistance. Likewise, touchscreens in public spaces are subject to vandalism and abuse that could damage the screen.

Replacing or repairing touchscreens from damage is expensive, ranging from $100 for a smartphone to thousands of dollars for specialized equipment found in hospitals, airports, schools, restaurants, public transit, banks and government.

Although some newer smartphone screens incorporate an improved level of impact resistance, the bane of smartphone owners has been broken touchscreens. This has driven a massive business for aftermarket screen protectors, which to some degree protect the owner’s significant investment in their smartphone.

Protective Films Provide a Solution Today, hospitals are facing several threats that are driving their search for touchscreen protectors, which incorporate high quality, long lasting antimicrobial properties, impact resistance, privacy features and resistance to strong chemical sanitization protocols. (University of Surrey, 2013)

The ideal feature-set for such a multi-layered product would be:

  • broadly acceptable antimicrobial technology
  • maintenance of near 100% capacitance for continued functioning of touchscreens
  • proven impact resistance
  • availability of a privacy layer, and
  • resistance to chemical damage

Spyder Digital Research Inc. (SDR) offers a patented antimicrobial screen protector that meets all of these criteria and is FDA listed, EPA registered and REACH compliant. Available in any size, from smartphones to 60″ display screens, the protectors have a multi-year guarantee.

The active ingredient of the antimicrobial additives in the SDR solution is silver, a metal known to have antimicrobial properties (Fong, 2006).  Chemists are able to create glass with a low chemical inertness while still retaining antimicrobial metal ions, such as silver. With the presence of water or moisture, the glass will release these metal ions gradually to function as antimicrobial material.

Silver ions are able to bond strongly to the cellular enzymes of microbes and inhibit enzyme activity of the cell wall, membrane, and nucleic acids. Silver, with its positive charge attracts the negatively-charged microbes, thus disturbing their electric balance. The result is that the microbes burst their cell walls and are extinguished. Otherwise, silver ions are taken into the microbes, where they react and bond to the cellular enzyme microbes, thus inhibiting enzyme activity and multiplication of microbes. (Borrelli, 2015).

Conclusion Regulators, health care professionals and corporate leaders are just beginning to recognize the increased threat of infectious disease epidemics facilitated by touchscreens, both from a liability perspective and from a social responsibility perspective.  An opportunity exists now to prevent widespread illness and death from infectious disease contracted in public places.

Hospitals currently employ increasingly aggressive sanitizing protocols because of well-defined threats and substantial liabilities (Weber, 2005). In addition to touchscreens being an ideal environment for the spread of infectious diseases, they are also expensive devices that would benefit from protection from damage due to cleaning protocols or impact.

Promoting prophylactic measures for both healthcare and public use touchscreens is a simple, yet effective solution for a problem that promises to grow as touchscreens become used more and more extensively in our everyday lives.

Copyright © 2016 InfectionControl.Tips. All rights reserved. Used with permission. For more information, visit

References Beckstrom, A. C., Cleman, P. E., Cassis-Ghavami, F. L., & Kamitsuka, M. D. (2013). Surveillance study of bacterial contamination of the parent’s cell phone in the NICU and the effectiveness of an anti-microbial gel in reducing transmission to the hands. J Perinatol Journal of Perinatology, 33(12), 960-963. doi:10.1038/jp.2013.108

Borrelli, N. F., Senaratne, W., Wei, Y., & Petzold, O. (2015). Physics and Chemistry of Antimicrobial Behavior of Ion-Exchanged Silver in Glass.ACS Appl. Mater. Interfaces ACS Applied Materials & Interfaces, 7(4), 2195-2201. doi:10.1021/am508159z

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Hu, H., Johani, K., Gosbell, I., Jacombs, A., Almatroudi, A., Whiteley, G., . . . Vickery, K. (2015). Intensive care unit environmental surfaces are contaminated by multidrug-resistant bacteria in biofilms: Combined results of conventional culture, pyrosequencing, scanning electron microscopy, and confocal laser microscopy. Journal of Hospital Infection, 91(1), 35-44. doi:10.1016/j.jhin.2015.05.016

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Julian, T., Leckie, J., & Boehm, A. (2010). Virus transfer between fingerpads and fomites. Journal of Applied Microbiology, 109(6), 1868-1874. doi:10.1111/j.1365-2672.2010.04814.x

Otter, J. A., Yezli, S., Salkeld, J. A., & French, G. L. (2013). Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. American Journal of Infection Control, 41(5). doi:10.1016/j.ajic.2012.12.004

Peasah, S. K., McKay, N. L., Harman, J. S., Al-Amin, M., & Cook, R. L. (n.d.). Medicare Non-Payment of Hospital-Acquired Infections … Retrieved July 21, 2016, from

Routes for Spread of Infections. (n.d.). Retrieved July 21, 2016, from

Scott, R. D., III. (2009, March). The Direct Medical costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Retrieved July 21, 2016, from

Shakir, I. A., Patel, N. H., Chamberland, R. R., & Kaar, S. G. (2015). Investigation of Cell Phones as a Potential Source of Bacterial Contamination in the Operating Room. The Journal of Bone & Joint Surgery, 97(3), 225-231. doi:10.2106/jbjs.n.00523

Shen, V. (2010, October 21). Technology goes viral, literally. Retrieved July 21, 2016, from

Stibich, M. (2016, May 13). Reduction of HAIs through the use of Pulsed Xenon UV Disinfection. Retrieved July 21, 2016, from

Tatem, A., Rogers, D., & Hay, S. (2006). Global Transport Networks and Infectious Disease Spread. Advances in Parasitology Global Mapping of Infectious Diseases: Methods, Examples and Emerging Applications, 293-343. doi:10.1016/s0065-308x(05)62009-x

The hidden life on your phone – the bacteria that lurk on your mobile. (n.d.). Retrieved July 21, 2016, from

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Weber, J., Nell, M., Fortna, S., Neely, A., Lighter, D., & Group, I. C. (2005). Computer equipment used in patient care within a multihospital system: Recommendations for cleaning and disinfection.American Journal of Infection Control,33(5). doi:10.1016/j.ajic.2005.04.031

Why your clinical display should have a fully cleanable design. Retrieved July 21, 2016, from papers/D-F/BARCO whitepaper eonis-medical_LR pdf.pdf

E-Mist Selected: Top Innovation of the Year

E-Mist's Technology, used in the control and prevention of the 1.7 million healthcare-acquired infections in U.S. hospitals, receives Top Innovation of the Year Award. E-Mist announced today that (ICT), an internationally recognized Pan-Access collective, has selected the company as a Top Innovation of the Year. ICT is dedicated to infection control and prevention and actively publishes peer-reviewed research articles and perspective pieces focused on the topics of infection control and prevention.

ICT selected E-Mist on the basis of exceptional innovation. The highly sought after awards, which are given out annually, are based on innovation and breakthrough technology.

“We are very proud of our organization and our ability to save lives, improve outcomes, and reduce costs through effective environmental surface disinfection,” stated Joshua Robertson, President of E-Mist. “Those involved in the prevention and control of preventable infections require a balanced approach of cost and quality to improve outcomes. Existing healthcare disinfection methods including wipes, spray and wipe, fogging, misting, and UV lighting are ineffective or expensive. As environmental surface contamination and healthcare-acquired infections have become more defined, the E-Mist electrostatic disinfection application system presents an effective, approved, and cost effective alternative to health care facility disinfection procedures.”

According to George Robertson, Chairman of E-Mist, “Studies have shown that less than 50% of environmental surfaces in patient care rooms are properly cleaned and disinfected. Evidence strongly suggests that cross contamination of microorganisms from environmental surfaces is directly related to patient infections. High-touch surfaces such as bed rails, bed surfaces, tables, fluid poles, doorknobs, and supply carts have all been identified as having the greatest potential for transmission of pathogens. Current cleaning/disinfecting methods and procedures are critical, yet, 100,000 people will die this year directly attributable to HAIs. Housekeeping is allocated insufficient time for cleaning/disinfecting resulting in inadequate chemical disinfection contact time as specified on disinfectant product labels. E-Mist helps healthcare organizations prevent and reduce HAIs. Founded on a legacy of electrostatic science and technology, the E-Mist Infection Control System eliminates traditional disinfectant methods by providing a mobile, touchless, safer, and more cost-effective approach to environmental surface disinfection. E-Mist helps hospitals and other healthcare institutions break the chain of pathogen mobility.”

“Electrostatics has been around and used for decades in the automotive, agriculture, inkjet and photocopier industries,” said Brandi Whitely, Infection Control Specialist of E-Mist. “Electrostatics is easily understood: opposite charges attract and like charges repel. Two positively charged things ( + and + ) will repel each other. Two negatively charged things ( – and – ) will repel each other. Using this natural electrostatic phenomenon, E-Mist developed and patented a breakthrough disinfectant application technology and system. The E-Mist Electrostatic Systems place a positive ( + ) charge on the liquid droplets as they leave the spray nozzle. The dispersed droplets spread out more evenly and seek out a negative ( – ) or neutrally charged surface. The end result is that the disinfectant is more targeted, provides more uniform coverage with less waste, and like a magnet, attracted to a surface with remarkable force.”

Healthcare-Acquired Infections (HAIs) Environmental surface disinfection can impact both HAI and patient perceptions. With more than 700,000 HAI events and nearly 100,000 HAI deaths in the U.S. each year, E-Mist is dedicated to mitigating risk and reducing the number of preventable HAIs that unnecessarily endanger patients.

Key HAI Facts (World Health Organization)

  • Health care-associated infections, or infections acquired in health-care settings are the most frequent adverse event in health-care delivery worldwide.
  • Hundreds of millions of patients are affected by health care-associated infections worldwide each year, leading to significant mortality and financial losses for health systems.
  • Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection.
  • The endemic burden of health care-associated infection is also significantly higher in low- and middle-income than in high-income countries, in particular in patients admitted to intensive care units and in neonates.
  • While urinary tract infection is the most frequent health care-associated infection in high-income countries, surgical site infection is the leading infection in settings with limited resources, affecting up to one-third of operated patients; this is up to nine times higher than in developed countries. In high-income countries, approximately 30% of patients in intensive care units (ICU) are affected by at least one health care-associated infection.
  • In low- and middle-income countries the frequency of ICU-acquired infection is at least 2─3 fold higher than in high-income countries; device-associated infection densities are up to 13 times higher than in the USA.
  • Newborns are at higher risk of acquiring health care-associated infection in developing countries, with infection rates three to 20 times higher than in high-income countries.

The Impact of Healthcare-Acquired Infections (World Health Organization) As is the case for many other patient safety issues, health care-associated infections create additional suffering and come at a high cost for patients and their families. Infections prolong hospital stays, create long-term disability, increase resistance to antimicrobials, represent a massive additional financial burden for health systems, generate high costs for patients and their family, and cause unnecessary deaths. Such infections annually account for 37,000 attributable deaths in Europe and potentially many more that could be related, and they account for 99,000 deaths in the USA. Annual financial losses due to health care-associated infections are also significant: they are estimated at approximately €7 billion in Europe, including direct costs only and reflecting 16 million extra days of hospital stay, and at about US$ 6.5 billion in the USA.

About E-Mist Innovations E-Mist’s patented electrostatic disinfectant application systems improve outcomes, save lives, and reduce costs through effective environmental surface disinfection. Using the E-Mist System and Process, users can kill up to 99.999 percent of pathogens, reduce labor costs up to 45 percent, and reduce chemical costs as much as 50 percent. Headquartered in Fort Worth, Texas, E-Mist is focused on improving the ability of professionals to stop the unnecessary spread of sickness and infection.

Seven Aspects of Surface Selection in Healthcare

Choosing the right materials can help prevent healthcare-associated infections

By Linda Lybert

Healthcare acquired infections (HAIs) are the third leading cause of death in the US, behind heart disease and cancer. One in every 25 inpatients will acquire an infection while being treated. These infections lead to the loss of tens of thousands of lives and cost billions of dollars every year. Since these infections are largely preventable, the federal government has added significant penalties to facilities with high infection rates. The pressure is on to address this issue now.


Foundational Issue: The science of surfaces as a fomite (object or material that is likely to carry infection) is just now maturing. Research has shown that microbes can live on “clean and disinfected” surfaces for days, weeks and even months. How is this possible when surfaces are being regularly cleaned and disinfected? The goal of this article is to present seven aspects of surface selection and to gain an understanding of why facilities must set surface criteria to not only minimize financial risk, but also to prevent harm to patients, healthcare workers and the general public.

Surfaces are a complicated subject. Most people think of surfaces as part of the design and construction process and not as part of an infection prevention and control program. When selecting materials, a lot of focus tends to be given to colours and textures that create “a healing environment.” Although these aspects of a surface material are certainly important, there are many other surface properties that are of critical importance, yet are not thought about or given proper evaluation. In order for an environment to be “healing” it need to also not introduce the potential for detrimental effects, like infections. After all, the most soothing colour and texture is of little value to a surface that cannot be cleaned or disinfected properly.

People interact with surfaces throughout the day without a second thought. If hands are washed regularly, a person with a healthy immune system has a good chance of reducing his risk of infection. This is not necessarily true for someone with a compromised immune system.

Ironically, surfaces are often cleaned and disinfected based on visual inspection, even though it is commonly understood that microbes cannot be seen. Research has shown that at the microscopic level, microbe counts can quickly rebound, often times to levels seen prior to cleaning and disinfection. This leaves patients, healthcare workers and the general public at constant risk of acquiring and spreading infection. In fact, studies show that patients are at risk of contracting an infection, such as MRSA or C. Difficilie from the patient who previously occupied the same room at a rate of 35% to 50%, depending on the infection, despite routine and terminal cleaning and disinfection.

Selection of Surfaces: Currently, the surface evaluation and selection process is predominately based on specific design criteria established before any construction or renovation project. The look, feel and where the surface is located are all based on creating a homelike, healing environment. While this is important, the selection of surfaces is complicated and the evaluation process must go far beyond the way it looks and feels. As I see it, the goal is to evaluate ALL surfaces, taking into consideration seven different aspects that contribute to the spread of infection. Ultimately, it is important that surfaces are capable of being effectively cleaned and disinfected. Unfortunately, the majority of surfaces being used in healthcare today are difficult – if not impossible – to clean effectively.

There is a science around the spread of infection via surfaces. It is not enough to learn every physical characteristic of a given surface and surface material, nor to become an expert in the latest disinfection agents and protocols. This data must be combined with an understanding of microbiology, the physical environment and insight into human behaviour. Taking into consideration all seven of the following aspects and entrenching surface selection criteria within healthcare facility construction and renovation specifications will begin to address the critical role surfaces play in reducing HAIs.

1) Materials and Healthcare facilities are full of many different surface materials, textiles and products. Necessary products, such as chairs, beds, sheets, privacy curtains, and bedside tables are selected by looking at sample books or swatches of material, in addition to special features any of these products may offer. While these properties are important, they are only the tip of the iceberg, providing only a small glimpse of what is truly needed in any healthcare setting.

Project managers, architects and designers must be aware of textured surface materials, such as brushed stainless steel, pebble texture acrylic wall surfaces, fabrics with tight or open weave, and vinyl and plastic materials. These types of finishes may create additional challenges during the cleaning and disinfection process.

There are many critical questions to be asked and answered regarding each surface material being considered. A few important ones are:

  • What will it take to clean this surface?
  • Can it be cleaned with the products the facility is currently using?
  • Has it been tested to verify hospital grade disinfectants can be used without causing damage?
  • How often will it need to be cleaned and disinfected to reduce bio-burden and prevent cross-contamination?
  • Will the use of UV light damage cause cracking and damage?

2) Surface Assemblies Selecting a surface based on sample swatches alone does not provide enough insight into what the potential challenges might be. It is critical that during the evaluation process, the assembly of surfaces is understood. Different materials and textiles are often combined into a single product, making the final product difficult (or even impossible) to clean/disinfect. It is true that some of this is completely unavoidable. However, it is possible to reduce the number of products in a room that present difficult or impossible disinfection challenges.

Studies have shown that the area within three feet of the patient in a hospital room is typically heavy with bio-burden, due to patient shedding (see Microbiology section). Cross-contamination can easily occur if levels of bio-burden are not continually reduced to safe levels by cleaning and disinfection. An evaluation of assembled surfaces surrounding the patient will provide insight into the challenges faced when trying to clean and disinfect the many combinations of materials, textures and textiles. Seams, baton strips and connects between surface materials create additional microbial reservoirs that often can be completely avoided when this problem is understood.

3) Microbiology A person typically sheds some 37 million bacteria every hour into the surrounding air and onto environmental surfaces that are continually being touched. Patients are a major source of contamination, and bio-burden is heaviest within three feet of the patient. If the patient is mobile, the patient bathroom is also an area where bio-burden is high. With the knowledge that pathogens survive for days, weeks and months, these areas absolutely need to be able to be effectively cleaned.

Patient shedding is not the only contamination threat. Toilet spray (also referred to as “toilet plume”) plays a major role in the transmission of infectious diseases. Ironically, patient toilets do not typically have lids, due at least in part to the difficulty in cleaning them. After discarding objects laden with viruses and bacteria into a toilet, the toilet is flushed. As a result, these microbes are released into the air and land on surfaces at a relatively high concentration within a three-foot radius of the toilet. This area typically includes a variety of ceramic tiles and many grout lines. Other materials assembled in this area include towels, shower curtains, sinks with faucets. As a result, these surfaces become microbial reservoirs that provide safe harbor where disinfectant products cannot reach their intended target.

4) Location The location of a surface matters. Different departments within the hospital require different surface selection criteria. In areas such as the Emergency Department or Surgery, healthcare professionals are faced with the need to turn over rooms quickly. Often this means that healthcare workers with a primary responsibility for patient care must also clean, disinfect and turnover a room.

I have had many discussions with these professionals who do not understand how critical it is to effectively clean/disinfect all surfaces. A quick tour of these areas immediately reveals a plethora of mixed surface materials and, ultimately, microbial reservoirs. The requirement to turn over rooms quickly in high traffic, highly contaminated areas sets healthcare professionals up for failure.

Recently, a facility was confronted with a community-based outbreak of C. Difficle that had started in the ER and was spreading through the facility. The Infection Prevention staff sent out a protocol that covered personal protective equipment (PPE), hand hygiene, patient assessments and disinfection protocols, but failed to address the evaluation of surfaces and the manner in which they are cleaned. These surfaces may have been a major contributor to persistence of the outbreak.

5) Human Behaviour Patients, healthcare workers and visitors interact with surfaces in many ways. Clothing, equipment and hands become contaminated and move pathogens throughout the patient room and the entire facility.

While being an advocate for a patient during a 3-day acute care hospital stay, I took the opportunity to observe and document human behaviour around surfaces. The behaviour of healthcare workers was fairly common. “Pumping in” by using the hand sanitizer was routine and a good start. However, the very next action was, nearly universally, to reach into a pocket in their scrubs to retrieve a pen and paper. I am sure this happened in every patient room.

Most healthcare workers interacted with surfaces in similar ways and in usually in the same order: computer, mouse, nurse call button, controls on the IV and IV pole, catheter bag, bed, bedding, etc.

Visitors interacted with many of the same surfaces, but they also used areas, such as the windowsill, bed and chair next to the patient bed, which was often covered with a blanket for the patient to sit on. Visitors also used the patient bathroom.

From my observations, specific surfaces that should have been considered “high touch” were not easy to identify, since many people touched virtually every surface within three feet of the patient frequently. On a side note, it is interesting to note that my observation of Environment Services staff in that facility revealed that they cleaned only a few surfaces and ignored other highly touched surfaces during the daily cleaning process. In the absence of thorough cleaning and disinfection, bioburden would have continued to accumulate for days.

6) Cleaning and Disinfection This is an aspect that is obviously critical, but is often misunderstood. Everyone knows it is important to clean and disinfect everything. However, can each surface be cleaned and disinfected effectively in the timeframe set for completing that task? The typical response a manufacturer would give is “yes, you can use anything to clean all surfaces.” Clearly, this is not the case. Not all surfaces of a bed, for instance, can be effectively cleaned and disinfected the same way. Further questioning often begins to reveal a lack of understanding of infection prevention protocol and cleaning and disinfection products that are being used at different times and in different situations.

Surface manufacturers don’t know what they don’t know, particularly when it comes to infection control strategies, processes and products. The recent issue faced by manufactures of ERCP scopes has sent some back to find ways to effectively sterilize their products.

Many different cleaning products are used, some of which can cause serious damage to surfaces. Often, this damage is unseen and creates a microbial reservoir that harbors pathogens that can proliferate, untouched by disinfection products.


7) Manufacturer Warnings Finally, it is extremely important to request and understand manufacturer warnings. Surface materials often come with warnings about using cleaning and disinfection products commonly used in healthcare facilities. Unfortunately, this information is often not documented properly and the knowledge is not passed down to those in charge of cleaning staff. Even with this information, it is important to test surface materials as an assembly, not just the individual components. Testing individual materials will give one result but combined materials cleaned and disinfected can produce an entirely different result. Equipment may include many different surfaces that cannot be cleaned and disinfected the same way. If they are damage could occur, thereby opening areas for microbes to harbor and hide from biocides.

It is not unusual to find that a manufacturer has tested specific chemicals on their product, but has not tested disinfection products. Results can vary when an actual disinfectant product is tested, since it may be composed of multiple active and inactive chemicals. Even if your cleaning products are not called out in manufacturer warnings, make sure to confirm that they are safe to use for each product and surface.

Conclusion: Clearly, environmental surfaces play a critical role in the transmission of HAIs. By being aware of the seven aspects presented here, my hope is to provide a clear understanding of why facilities must set surface criteria to minimize risk and prevent harm to patients, healthcare workers and the general public. By using the seven aspects to create surface selection criteria, facilities will lay the foundation for sustainable reductions in the number of HAIs.


References: Curtis J. Donskey MDa, b. (n.d.). Does improving surface cleaning and disinfection reduce health care-associated infections?

David J. Weber, M. W.-B. (n.d.). Role of hospital surfaces in the transmission of emerging health care-associated pathogens: Norovirus, Clostrimdium difficile, and Acinetobacter species.

J.A. Otter a, b. K. (n.d.). Surface-attached cells, biofilms and biocide susceptibility: implications for hospital cleaning and disinfection.

Jonathon Sexton, P. R. (n.d.). Rapid Microbial Tracer Movement to Soft Surfaces Throughout Patient Care Areas and the Role of Mixed Surfaces in Infection Prevention. AJIC Journal.

Vickery K, D. A. (n.d.). Presence of biofilm containing viable multiresistant organisms despite terminal cleaning on clinical surfaces in an intensive care unit.

Copyright © 2016 InfectionControl.Tips. All rights reserved. Used with permission. For more information, visit

About: Linda Lybert For the past 17 years Linda has passionately crusaded for surfaces that are cleanable leaving little room for human error when cleaning. As a former member of the FGI Guidelines for Design and Construction of Healthcare Facilities Revision Committee, Linda was instrumental in the creation of the first definition of the ideal surface characteristics for healthcare facilities, published in 2006. Her understanding of surfaces, infection control, regulatory agencies, and the needs of customers creates a communication bridge when working with all stake holders to develop solutions to mitigate the spread of infections. She can be reached at

Insurance Companies Pay the Price for HAIs

Abstract:Hospitals continually publicize their levels of quality and safety, but there is still a steady increase in occurrences and fatalities due to infections transmitted within their four walls. In an industry where hospitals can work around punitive measures for their lack of prevention, the true burden of all hospital acquired infections really lies on those paying the final bill, health insurers.

Introduction: Hospital acquired infections (HAIs) range between $28 billion and $45 billion in annual direct hospital costs in the US alone.[i] But how much did HAIs cost health insurers (insurers), including Centers for Medicare and Medicaid Services (CMS)? Surprisingly, nobody can really say anything, except that it is certainly in excess of the hospital financial impact from direct costs and the penalties being applied.

Infections that are acquired in hospitals or healthcare facilities result in patients with significant post-discharge insurance claims related to medications, primary care follow-up, lab work, rehab and homecare.[ii] In some cases, this is drawn out over the course of years, depending on the infection, severity and patient health status. Therefore, insurers have a real and compelling financial incentive to make investments and drive improvement in hospital safety, focused on the serious and grave problem of HAIs.

Little Evidence of Hospital Infection Rate Reduction There have been years of research and countless quality initiatives developed by insurers and hospitals around the United States with no conclusive evidence suggesting interventions lead to improvements in infection prevention. These recent conclusions were reached by the Government Accounting Office (GAO) and leading third party experts such as The Leapfrog Group, and support the claim that very few of these programs were successful.[iii][iv] In fact, properly reported HAIs are listed among the most prevalent sources of hospital discharges, accounting for nearly two million discharges per year.[v]

In 2008 Medicare stopped reimbursing hospitals for certain hospital-acquired outcomes. These changes deny payment for select conditions occurring during the hospital stay and are not present on admission, including some healthcare-associated infections.[vi] The idea was to hit careless hospitals where it hurt and give them a financial incentive to improve their standards and behaviors. This approach was adopted, over time, by private insurers, reflected in various Performance Improvement Plan (PIP) initiatives tied to financial awards given to the hospital for success.[vii]

While financial penalties suggest a strong economic incentive for hospitals, it is important to note that an interrupted time series analysis of the impact of CMS penalties on infection rates over the first four years of CMS penalties found no significant effect of penalties on reduction of HAIs.[viii] Additionally, Stanford University recently reported new evidence that demonstrates penalties have had a significant effect on hospital up-coding for reimbursement, and therefore have increased the direct cost of hospital coverage, with very little effect on actual infection rates.[ix] Up-coding is the practice of upgrading the seriousness of a medical malady and treatment by entering the Diagnosis Related Group (DRG) code that will carry the highest reimbursement. This study, released in March 2016, offers an insightful explanation. “Instead of spurring tighter standards of care, the penalties are prompting hospitals to simply ’up-code’ their records and claim that patients were already infected at the time they were admitted,” which is a likely driver in the declining infection case reporting.[x]

These findings, in some ways counter-intuitive, suggest that preventing many HAIs may be far more difficult for hospitals to accomplish than by incentive alone, or that hospitals are avoiding the intended goal of reducing infections by placing the financial burden on the insurers. Both possibilities imply a pressing need for innovative, evidence-based and faster approaches to drive new prevention strategies.

Insurers, who currently incentivize hospital improvement initiatives and who would directly benefit financially, are therefore uniquely placed to seriously drive these strategies.

Correlating Infection Reduction Savings for Health Insurers Infonaut has worked with medical insurers to estimate that inpatient stays could account for anywhere between 60% and 80% of a member’s claims expenses on an annual basis. The remaining 20% to 40% are incurred outside of a hospital setting in places such as primary care offices, labs, pharmacies, or any other types of specialist settings.

A pilot study over a two-year period at a hospital in New York state, allowed us to develop an initial estimate of the growing costs of HAIs to insurers, with the goal of sparking future investment and discovery in the area of HAI post discharge cost.[xi]

Below are the high-level financial results from the pilot hospital’s ICU and Step-down Unit. The baseline cost is the three-year period leading up to the pilot. The example includes the cost related to all cases that went through those units, regardless of admission or discharge location. It is important to note that the pilot study results are limited by the length of the study period, the lack of available information on other safety initiatives in the hospital and that the pilot was not designed to be a clinical trial with a control population. There are currently several follow on study opportunities that are being explored to provide further validation.


Hospitals have historically coded to increase the severity weight of cases with HAIs in order to cover expenses. This “up-coding” creates a higher reimbursement amount than would normally be constituted by the original admission diagnosis. Carving out the average severity weight increase of roughly 35%[xii] of the hospital savings will show the Insurer’s portion of inpatient savings. When you add the hospital portion to the estimated post discharge expenses (conservatively at 20%), the insurer’s burden could have been lowered by up to $1 million dollars by reducing the number of observed HAIs in two units, in one hospital.


A significant reduction in infections revealed a correlated Return on Investment (ROI) in excess of 700%. This demonstrates small investments in a widespread and costly problem could generate significant ROI.

If you were to extrapolate this example across the nation where one in every twenty-five hospital visits (4%)[xiii] results in an infection being acquired, according to coding, the results begin to approach billions of dollars in claims savings every year. A very conservative estimate can be established using the chart below showing the average hospital based cost per HAI as calculated by the CDC and JAMA.


If hospitals were to reduce a single instance of infection, the weighted average hospital cost reduction would be roughly $15,000. Using the same formulas as the above example, this would create a claims expense savings for insurers of about $9,000 per HAI prevented.

Therefore, if every hospital in the US were to reduce only a single infection per year insurers would conservatively see a $52 million reduction in claims expense. If HAIs were lowered by a mere 5%, the claims expense reduction increases to almost $325 million.

Rewarding Hospital Change: Pay for Performance / Shared Savings Programs Insurers have increasingly adopted financial incentive programs to drive hospital improvement in quality and safety. There are two common (sometimes interchangeable) terms used for these programs, that reflect the growing trend of rewarding healthcare providers for increased quality and safety, as it relates to infections.

Pay for Performance in healthcare gives financial incentives for better health outcomes. Clinical outcomes, such as longer survival, are too difficult to measure, so pay for performance systems usually measure process outcomes. Also known as “P4P” or “value-based purchasing,” this payment model rewards hospitals and other healthcare providers for meeting certain performance measures and penalizes caregivers for poor outcomes, medical errors, or increased costs.[xiv] Unfortunately, many of the identified process outcomes that can be rewarded are ineffective in producing better patient outcomes (i.e. staff hand hygiene compliance), or are poorly executed or are not sustainable beyond the focus of the intervention.[xv]

Shared Savings is a more common term among insurers and Accountable Care Organizations (ACOs). Shared Savings Program reward ACOs and healthcare providers that lower their growth in health care costs while meeting performance standards on quality of care.[xvi] However, the Stanford study demonstrates the risk of up-coding and data manipulation to shared savings tied to performance standards – at least in how they are applied to infection prevention and control.

The US Government and Accountability Office (GAO) reported in February 2016 that CMS and some private insurers have adopted pay-for-performance programs that provide financial incentives for hospitals based generally on improving the quality of their care, which include measures of adverse events. This includes some that have nonfinancial programs that provide technical assistance and other nonfinancial support to help hospitals improve patient safety.[xvii]

According to CMS officials, the agency spent approximately $461 million on the 3-year Partnership for Patients program between 2011 and 2014, and established program goals of reducing certain preventable adverse events—including Central Line-associated Blood Stream Infection (CLABSI), Catheter-Associated Urinary Tract Infections (CAUTI), and Vancomycin-Resistant Enterococci (VRE) —by 40 percent and reducing hospital readmissions by 20 percent.[xviii] While the agency’s expense of $461M is probably accurate, the program outcomes as they relate to the goals should certainly be called into question with greater scrutiny to validate the data and claimed results.

An Ongoing Challenge: Current practices and improvement initiatives, be they rewarded financially or otherwise, seem to have had little impact or effect. In fact, careful study of many best practices, such as staff hand hygiene compliance, suggests they are not evidence-based at all.[xix]

Leah Binder, President and CEO of the Leapfrog group summarizes the challenge of HAI prevention and control, based partly on the GAO findings, and partly on the company’s years of HAI and safety measurement as follows:

  1. Hospitals can’t find the problem.Hospitals cannot identify in their own records all their errors, accidents and infections, even though they are required to report many of them to the federal government.
  2. Hospitals can’t figure out how to solve the problem.Despite a large body of research about how to address most safety problems, hospital leaders can’t seem to find the time to read it. Some hospitals even admit to throwing a bunch of ideas at a problem at once. It becomes nearly impossible to tease out which ones worked, and which did not.
  3. Nobody does what they are told anyway. Even when hospitals identify a problem that is hurting patients, and commit to an evidence-based solution to stop the harm, they can’t get their staff on board.[xx]

Binder’s third point really hits the nail on the head. Even if the hospital can find the problem(s) and match an evidence-based solution, it is unlikely they will have any effect because of poor adoption, if at all. Most executives, regardless of industry, will agree that culture eats strategy for lunch. Despite the best planning and implementation of patient safety interventions in hospitals, quality improvement initiatives frequently fail or fall short of internal targets. Organizational resistance to change is a well understood phenomenon, but one that is poorly applied to healthcare.

If insurers are intent on driving change in hospitals for their own financial benefit, there has to be consideration of changing attitudes and culture within a hospital as part of any Pay-for-Performance / Shared-Savings Programs. This requires attention and investments that ultimately drive real, persistent and sustainable improvement.

Conclusions / The Opportunity for Insurers

  • Current financial penalties driven by CMS and insurers have had no significant effect of penalties on reduction of HAIs.[xxi]
  • There is compelling proof that reports of improvements in HAI prevention and control is skewed through hospital up-coding, and in all likelihood is getting worse.[xxii]
  • Best practices are sometimes anything but, and there is a disturbing lack of real, evidence-based practices in some areas of patient safety.
  • Leading industry watchdogs, like The Leapfrog Group, have found a disturbing lack of urgency among insurers, with only a small portion supporting or rewarding any efforts to improve safety.[xxiii]
  • Insurers can gain financially, at a very significant level, by compelling and ensuring that hospitals make significant steps to reducing infections acquired in their environment – not only in claims expense reductions, but also in having programs to entice large, self-insured groups to use their services and take advantage of their network’s lower HAI rate.

Suggested Path Forward It is paramount for insurers to properly understand their financial burden from HAIs so they are better prepared to understand their baseline costs and the potential impacts of the interventions and innovations they can drive. Patient cohorts can be isolated based on those who acquired an infection while in a healthcare/hospital setting (HAI cohort) and comparing them to their general population (regular cohort). By comparing the cost per member per month ($PMPM) between the two cohorts for a period of 3 years post-discharge, the increased cost to the insurer can be established. You may also be able to track the resulting premium increases to the patient.

Going forward, payers can adopt the $PMPM as an outcome, as part of a Hospital Pay-for-Performance program(s). The measureable success metric moves from unsubstantiated process improvement outcomes to a real patient improvement outcome: the reduction in infection cases/rates. Adoption of the $PMPM outcome model will ensure that the programs are focused on a real measure that is the result of better patient outcomes.

If insurers are intent on driving change in hospitals so they benefit financially, there has to be consideration of changing attitudes and culture within a hospital as part of any Pay-for-Performance / Shared Savings Program.

References: [i] Stone, P., The Economic Burden of Healthcare Associated Infections: an American Perspective (2009) [ii] Nelson, R.E. PhD, Estimating the Cost of Healthcare-Associated MRSA Infections in the VA – page 11. [iii] United States Government Accountability Office (GAO) – Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices February 2016 [iv] [iv] Binder, Leah, President and CEO of The Leapfrog Group – Forbes Online March 15, 2016 [v] CDC HAI Prevalence Survey (2016) [vi] CMS Changes in Reimbursement for HAIs, NCBI 2010 [vii] How Hospitals Avoid Penalties for Making Patients Sick: Lax reporting requirements make it easier to change records. – Edmund L. Andrews 2016 [viii] CDC HAI Prevalence Survey (2016) [ix] Evidence of Strategic Behavior in Medicare Claims Reporting – Hamsa Bastani et al 2015 [x] Stanford Graduate School of Business How Hospitals Avoid Penalties for Making Patients Sick: Lax reporting requirements make it easier to change records. March 8, 2016 [xi] 2014-2015, Infonaut Inc commercial pilot study at hospital in NYS [xii] Evidence of Strategic Behavior in Medicare Claims Reporting – Hamsa Bastani et al 2015 [xiii] CDC HAI Prevalence Survey (2016) [xiv] Wikipedia: Pay for performance (Healthcare) [xv] DiDiodato, G (2013, June). Has improved hand hygiene compliance reduced the risk of hospital-acquired infections among hospitalized patients in Ontario? Analysis of publicly reported patient safety data from 2008 to 2011. Infection Control and Hospital Epidemiology 34(6):605-10. [xvi] Centers for Medicare and Medicaid Services (CMS) [xvii] United States Government Accountability Office (GAO) – Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices February 2016 [xviii] United States Government Accountability Office (GAO) – Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices February 2016 [xix] Furness, C., Wallace, N. (2015) Hand Hygiene Compliance Auditing Does Not Work [xx] Binder, Leah, President and CEO of The Leapfrog Group – Forbes Online March 15, 2016 [xxi] Lee GM, Kleinman K, Soumerai SB, Tse A, Cole D et al. (2012). Effect of nonpayment for preventable infections in US hospitals. New England Journal of Medicine 367, 1428-1437. [xxii] Stanford Graduate School of Business How Hospitals Avoid Penalties for Making Patients Sick: Lax reporting requirements make it easier to change records. March 8, 2016 [xxiii] Binder, Leah, President and CEO of The Leapfrog Group – Forbes Online March 15, 2016

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