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Cover of No-Touch Modalities for Disinfecting Patient Rooms in Acute Care Settings

No-Touch Modalities for Disinfecting Patient Rooms in Acute Care Settings

Rapid Evidence Product

, M.D., M.Sc., , Ph.D., , M.L.S., and , Ph.D.

Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 20(21)-EHC021

Background and Purpose

Purpose of Review

To rapidly identify evidence assessing the effect of no-touch modalities for disinfecting acute care hospital rooms on contamination and infection rates.

Background

As of July 21, 2020, the COVID-19 pandemic has caused over 3.8 million infections and 141,000 deaths in the United States.1 Many patients with COVID-19 have required prolonged hospitalization for respiratory symptoms, along with cardiac, hematologic, neurologic, and other medical complications.2–4 Providing quality patient care while protecting healthcare personnel from infection is challenging due, in part, to lack of knowledge regarding the safest and most effective methods for environmental cleaning and disinfection of patient rooms.

Terminal cleaning of patient rooms (i.e., cleaning and disinfection of surfaces and the environment after a patient is discharged or transferred to another room) is typically performed by trained environmental services/housekeeping staff who manually clean and disinfect surfaces using wipes/cloths/sponges moistened with a chemical solution. After manual processes, no-touch disinfection modalities also may be used, including ultraviolet light (UVL) disinfection systems, hydrogen peroxide vapor (also referred to as vaporous hydrogen peroxide [VHP]), steam, ozone, and chlorine dioxide vapor. Environmental surfaces (e.g., tray tables, sink basins) made from solid copper alloy have also been used in healthcare facilities to decrease microbial burden. Several of these modalities have been assessed for mask decontamination.5–7

No-touch modalities disinfect through a variety of mechanisms.8 For instance, UV-C (200 to 280 nm) and UV-B (280 to 320 nm) radiation disrupt DNA/RNA replication and at high intensity can cause cell rupture through overheating. VHP systems coat surfaces with hydrogen peroxide droplets, which generate free radicals that are toxic to microorganisms and spores. Solid copper alloy surfaces generate reactive oxygen species but also may use other mechanisms.

Since data directly assessing no-touch modalities for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are not yet readily available, we conducted a rapid review of no-touch modalities for disinfecting other respiratory viral pathogens in patient rooms in hospital/acute care settings. We also included studies reporting the effect of these modalities on Clostridioides (formerly Clostridium) difficile (CD) environmental contamination or infection (CDI) rates. Since CD spores are easily transmitted to surfaces and difficult to eradicate,9 the no-touch modalities that are effective against CD spores may be effective against SARS-CoV-2.

Guiding Question

What data exist for the effectiveness of no-touch modalities for disinfecting patient rooms in hospital or acute care settings for:

  1. Respiratory viral pathogens
  2. Other pathogens with potential relevance to assessing effectiveness vs. SARS-CoV-2 (specifically CD spores)

Methods

We conducted a rapid review of peer-reviewed literature from the last 10 years to identify research on effectiveness of UVL, VHP, steam, ozone, chlorine dioxide, and solid copper surfaces for decreasing either patient infection rates or surface contamination of patient rooms in acute care settings. For studies assessing impact on severe acute respiratory syndrome coronavirus (SARS-CoV), which emerged in 2002, we searched the last 20 years. To complete the report in only 4 weeks, we took the following steps:

  • Defined a narrow scope
  • Included both data from relevant systematic reviews (SRs) along with primary studies as evidence
  • Limited data extraction and synthesis
  • Did not conduct formal risk-of-bias or strength-of-evidence assessment

We refined the scope in consultation with the Agency for Healthcare Research and Quality (AHRQ), discussion with experts, and early literature scoping. The protocol was posted on the AHRQ Effective Health Care Program website (https://effectivehealthcare.ahrq.gov/products/no-touch-disinfection/protocol). The final patient/intervention/comparators/outcomes/setting (PICOS) are found in Table 1.

Table 1. PICOS.

Table 1

PICOS.

A master’s-level librarian searched PubMed, EMBASE, and clinicaltrials.gov for documents relevant to this topic and published between January 1, 2010, and April 22, 2020. Searches for SARS-CoV related literature extended back to 2000. The full search strategy is available in Appendix A.

Two analysts screened studies against prespecified inclusion/exclusion criteria (Table 2). Disagreements were resolved through discussion.

Table 2. Inclusion/exclusion criteria.

Table 2

Inclusion/exclusion criteria.

Evidence Summary

Evidence of Effectiveness for Hospital Room Disinfection

UVL

  • Respiratory viruses
    • 1 pre/post study found cleaning with quaternary ammonium agents + UVL was associated with a 44 percent unadjusted reduction on overall incidence of respiratory viral infection; however, the study was small, with potential confounding.
  • CDI
    • Meta-analysis of 11 studies of various designs found UVL was associated with lower CDI rates: relative risk (RR): 0.64 (95% confidence interval [CI]: 0.49 to 0.84). Pre/post studies had consistent positive results; however, controlled trials had conflicting results. One additional interrupted time series found no difference in infection rates for UVL + bleach compared with bleach.
    • Two small pre/post studies found UVL + standard cleaning lowered surface contamination, but a third small pre/post study found no difference between UVL + bleach vs. bleach. Another small pre/post study found that compared to standard cleaning (with bleach), UVL + standard cleaning was associated with non-statistically significant lower surface contamination on high-touch surfaces.

VHP/Aerosolized Hydrogen Peroxide

  • Respiratory viruses
    • No studies identified.
  • CDI
    • Pooled analysis of five noncontrolled studies found nonstatistically significant lower CDI rates: RR: 0.52 (95% CI: 0.15 to 1.81). One additional pre/post study also found VHP lowered CDI.
    • One small RCT study compared aerosolized hydrogen peroxide + silver ions to bleach and found no statistically significant difference in surface contamination.

Solid Copper Surfaces

  • Respiratory viruses
    • No studies identified.
  • CDI
    • One pre-post study of copper surfaces found copper surfaces reduced CDI infection rates: 2.4 versus 0.7 per 1,000 patient-days; however, authors noted serious potential confounding in the results. A second pre/post study also found lower CDI rates associated with copper surfaces + copper linens: incidence rate 4.1 (95% CI: 4.05 to 4.14) to 0.69 (95% CI: 0.65 to 0.73). However, serious potential confounders including differences in patient mix and room size were noted.

Steam, Ozone, Chlorine Dioxide

  • No studies identified for respiratory viruses or CDI.

Ongoing Research and Future Research Needs

One sham-controlled randomized controlled trial (RCT)10 underway (expected completion date May 2022) could provide important information regarding effectiveness of UVL to reduce hospital acquired infections including CDI (see Appendix D). Future controlled trials assessing impact (particularly on respiratory viral infections) are needed. Future trials will benefit from consistent reporting of standard terminal cleaning protocols and contextual factors (e.g., antimicrobial stewardship, hand hygiene) that could affect patient infection rates.

Evidence Base

Our searches identified 1,378 potential citations, of which 1,037 were excluded at the title level. We performed an abstract/full-text review of the remaining 341 (see Appendix E). Based on the abstract/full-text level review, we included one SR11 that covered both UVL and VHP (one RCT, one controlled trial [CT], one cohort study, 14 pre/post studies), one RCT,12 one interrupted time series,13 seven pre/post studies,14–20 and one secondary analysis21 of an RCT already included in the SR.

An overview of evidence and outcomes addressed is presented in Table 3.

Table 3. Overview of evidence and outcomes.

Table 3

Overview of evidence and outcomes.

For respiratory viruses, we identified only one pre/post study14 assessing UVL for inclusion. All other studies evaluated no-touch modalities for reduction in CDI or contamination. Studies identified assessed UVL, VHP, aerosolized hydrogen peroxide + silver ions, and solid copper surfaces; no studies assessed steam, chlorine dioxide, or ozone. Detailed descriptions of included studies are available in Appendix B.

Ultraviolet Light Disinfection Systems

Respiratory Viral Infection

One pre/post study (Pavia et al.)14 assessed UVL for reducing respiratory viral infections in the toddler unit of a children’s hospital (selected because it had the highest rate of hospital-acquired infections [HAIs] in the hospital). Toddler rooms/common areas were disinfected with quaternary ammonium agents followed by UVL (Optum Enlight, Clorox Healthcare) 2 to 3 times per week over 12 months. The study did not explicitly report what methods were used for cleaning in the prior 12 months. Compared with the prior 12 months, there was a 44 percent unadjusted reduction on overall incidence of respiratory viral infection (incidence rate ratio [IRR] of 0.56 [95% CI: 0.37 to 0.84]).

Clostridioides difficile Infection

Marra et al. (2018)11 performed pooled analysis of 11 studies (1 RCT, 1 controlled trial, 9 pre/post). Terminal cleaning with UVL was associated with lower CDI rates: relative risk (RR): 0.64 (95% CI: 0.49 to 0.84, I2=0%). However, pooled analysis limited to the two controlled studies found no significant reduction on CDI rates: RR: 0.65 (95% CI 0.26 to 1.62). One controlled study (which compared CDI for three units using UVL with three units using standard terminal cleaning over 6 months at a single hospital) reported benefit (11.2 infections/10,000 patient days [UVL] compared to 28.7 [control]). However, the second controlled study, a large, multicenter RCT (Benefits of Enhanced Terminal Room Disinfection [BETR]) did not show a clear benefit.22 BETR assessed infection rates in patients exposed to seed rooms (a room containing a patient with microbiologically proven current or history of infection or colonization with at least one target organism in the prior 12 months) across nine hospitals. Compared with disinfection with bleach, bleach + UVL was not associated with a difference in CDI in patients exposed to seed rooms: RR: 1.0 (95% CI: 0.57 to 1.75). However, some irregularities occurred with randomization (see Appendix C).

A prespecified secondary analysis of BETR data21 assessed hospitalwide infection risk with “target” organisms (CDI, vancomycin-resistant enterococci [VRE], methicillin-resistant Staphylococcus aureus [MRSA], or multidrug-resistant Acinetobacter). Compared to standard terminal cleaning (bleach for CD rooms, ammonium-based disinfectant for all others), a reduction occurred in all four “target” infections during the UVL study period: RR: 0.89 (95% CI: 0.79 to 1.0). This lower risk was driven by reductions in CDI and VRE (RR: 0.89 [95% CI: 0.80 to 0.99], RR: 0.56, [95% CI: 0.31 to 0.99], for CDI and VRE, respectively). However, if UVL was responsible for this reduction, it is unclear why CDI was not also lower during the bleach + UVL period (RR: 0.97 [95% CI: 0.84 to 1.12]).

One additional interrupted time series (Brite et al.)13 evaluated pulsed xenon UVL + bleach versus bleach alone for disinfecting a 25-bed bone marrow transplant unit. Over 20 months (704 admissions), no change in CDI was identified: trend incidence rate ratio (IRR): 1.08 (95% CI: 0.89 to 1.31).

Clostridioides difficile Surface Contamination

Four small single-center pre/post studies15–17,19 assessed UVL for reducing surface contamination of hospital room surfaces with CD. Three studies16,17,19 found UVL interventions were associated with reductions in CD contamination. Wong et al. (2016)17 found fewer rooms were contaminated after terminal cleaning with UVL: 31.8 percent (7 of 22) at baseline, 22.7 percent (after standard cleaning with hydrogen peroxide), 0 percent (after UVL), p=0.07. The proportion of surfaces contaminated was also lower: 7.2 percent at baseline, 4 percent after standard cleaning, and 0 percent after UVL disinfection (p=0.07). Another pre/post study16 evaluated CD contamination at a hospital with high CDI rates after sequential implementation of three tiered interventions: tracking of fluorescent marker removal (after standard cleaning with bleach), UVL, and enhanced standard disinfection with daily disinfection supervision. A combination of fluorescent marker tracking and UVL was associated with a lower contamination rate, from 67 percent to 35 percent (prevalence ratio: 0.52, 95% CI: 0.43 to 0.52). A small pre/post study19 found that compared to no cleaning, UVL was associated with a lower rate of CD contamination (11.6% to 2.7%, p<0.01). When compared to standard cleaning (including bleach), UVL also was associated with lower CD surface contamination of high-touch surfaces (19.4% to 8%), but this result does not appear to have been statistically significant.

Another pre/post study15 compared UVL + standard cleaning (bleach) to standard cleaning and found no significant difference in surface contamination rates.

Vaporous Hydrogen Peroxide

One SR11 (with 1 prospective cohort study and 5 pre/post studies) assessed VHP for CDI reduction. Pooled analysis of five studies found nonstatistically significant lower CDI rates: RR: 0.52 (95% CI: 0.15 to 1.81), I2=0%. One additional pre/post study found VHP lowered CDI (no statistical testing performed).

Aerosolized Hydrogen Peroxide and Silver Ions

One small RCT12 randomized 28 hospital rooms from discharged CDI patients to terminal cleaning with aerosolized solution of hydrogen peroxide <8 percent and silver ions versus manual cleaning with 0.5 percent sodium hypochlorite. Surface contamination rates decreased from 13 percent to 0 percent in the aerosolized hydrogen peroxide + silver ions group, and from 20 percent to 3 percent for rooms cleaned with sodium hypochlorite. However, there was no statistically significant difference in CD surface contamination between groups (p=0.3).

Solid Copper Surfaces

One single-center pre/post study18 assessed impact of antimicrobial solid copper surfaces on CDI rates for three intensive care units (general, neurological care, and burn-trauma) after transition to a new building equipped with EOS Preventive/Biocidal Surface workstations, bedside and vanity tables, bathroom fittings, bedrails, and door handles. After the transition, CDI decreased: CDI: 2.4 versus 0.7 per 1,000 patient-days: IRR: 3.3 (95% CI: 1.4 to 8.7). Authors noted the new building was equipped with modern ventilation systems, which may have been a confounder.

A second pre/post study20 assessed CDI rates before and after transition to a new hospital wing equipped with antimicrobial solid copper surfaces + copper linens. All acute care rooms in the old and new wings received standard cleaning (quaternary ammonium, with hypochlorite for CDI rooms). Compared with the baseline CDI incidence rate (IR) 4.10 (95% CI: 4.05 to 4.14), the CDI rate in the new wing was lower (IR 0.69, 95% CI 0.65 to 0.73, p=0.048). Patients who continued to be hospitalized in the old wing (after the new wing had opened) had similar CDI rates compared to baseline. However, authors noted several potential confounders that may have played a role including a statistically significant difference in case mix between old and new wings. Patients housed in the old wing were more likely to be on medical services, with medical comorbidities, recent hospitalizations, and history of CDI in the past 6 months. Also, compared to the old wing, rooms in the new wing were larger.

Discussion

Aside from three studies, the evidence base for no-touch modalities for disinfection of hospital rooms consisted of interrupted time series or single-center pre/post studies and primarily evaluated impact on CDI rates or room contamination. Only a single pre/post study14 assessed UVL disinfection systems for reducing respiratory infections. While a common study design for quality improvement initiatives in health systems, pre/post study designs (also referred to as “before and after” or “quasi-experimental”) lack a true control group, are limited by the Hawthorne effect, and often deploy interventions simultaneously with other quality improvement initiatives. These characteristics place these studies at high risk of bias and pose challenges for accurately assessing cause and effect and applicability.23

Of the modalities assessed, UVL systems have the most developed evidence base. UVL was associated with lower rates of respiratory viral infections in a single-center pre/post study14 and with lower CDI rates and surface contamination; a meta-analysis of 11 studies11 found statistically significant lower CDI rates. However, five of these studies did not report on compliance with alternative measures (hand hygiene, antimicrobial stewardship) potentially affecting CDI. Furthermore, the only RCT21 (also the sole multicenter study) did not find UVL was associated with lower CDI in patients exposed to rooms previously occupied by infected patients. Although UVL was associated with lower hospitalwide CDI (compared to standard cleaning), no effect was identified for bleach + UVL, raising doubt about whether results should be attributed to UVL. Collectively, these findings highlight the need for further well-designed RCTs. One sham-controlled RCT underway (expected completion date May 2022) could provide important information regarding effectiveness of UVL for room disinfection and reduction of hospital acquired infections including CDI.

For VHP, although meta-analysis of five studies11 found VHP was associated with lower CDI rates (RR: 0.52, 95% CI 0.15 to 1.81), interpreting these findings is challenging. Although the wide CI could simply indicate lack of power, the evidence base consisted of only single-center pre/post studies and a single prospective cohort study, two of which failed to report compliance to important measures, such as hand hygiene/antimicrobial stewardship. Only a single small RCT12 assessed aerosolized hydrogen peroxide + silver ions and found no difference in CD surface contamination compared to bleach.

Although two pre/post studies18,20 found that antimicrobial solid copper surfaces alone, or with copper linens were associated with lower CDI rates, both studies noted clear potential confounders. For both studies, introduction of copper interventions was associated with relocation to or opening of a new hospital care setting. Authors noted that differences in layout, size, and ventilation systems could have played a role. While one study20 did monitor hand hygiene and fidelity of standard cleaning, CDI rates may have been impacted by clear differences in case mix (patients hospitalized in the new wing had fewer comorbidities and lower rates of prior CDI).

As expected, we found a paucity of studies assessing no-touch modalities for hospital room disinfection assessing impact on respiratory viral infections that could be directly applied to managing COVID-19. However, there are studies assessing no-touch modalities for CDI. As CD spores are generally more difficult to eradicate than viruses, it is reasonable to expect that modalities that effectively reduce CD environmental contamination and CDI rates would also effectively reduce SARS-CoV-2 surface contamination and infection rates when used to disinfect hospital rooms. However, study designs and conflicting results in the evidence base make it challenging to draw firm conclusions.

Finally, as noted, most included studies primarily addressed efficacy of no-touch modalities for CD-related outcomes, with only a single study assessing efficacy for respiratory viruses. However, as CD spores are generally harder to eradicate compared to viruses, it is possible that findings from these studies could potentially underestimate efficacy of no-touch modalities for disinfecting hospital rooms against viruses.

Limitations

To complete this rapid review in a timely fashion, the scope was narrowly defined and did not include lab studies, studies of decontamination of masks or other items, studies in nonacute settings, or preprint studies. The literature search was confined to PubMed, EMBASE, and clinicaltrials.gov. Data extraction and synthesis were limited and no formal risk-of-bias or strength-of-evidence assessment was performed.

Conclusions and Future Research

The effectiveness of no-touch disinfection modalities for disinfecting hospital rooms to decrease respiratory viral infections and CDI remains unclear. Although more than a dozen studies of UVL disinfection systems exist, weak study design and conflicting results prevent definite conclusions. The evidence base for VHP and solid copper surfaces is also weak. For VHP, although five noncontrolled studies found an association with lower CDI, studies had important flaws. Only a single small RCT assessed aerosolized hydrogen peroxide vapor + silver, and only two pre/post studies assessed solid copper surfaces.

Higher quality studies, particularly RCTs, are needed to assess the impact of these no-touch modalities for disinfecting hospital rooms. Also, studies directly assessing efficacy for respiratory viruses are vital. Future studies should include detailed descriptions of what procedures “standard” terminal cleaning involves along with the degree of adherence or efforts to monitor fidelity. Studies should also describe other quality-improvement interventions initiated around or during the study period and other potential confounders (e.g., antimicrobial stewardship, compliance with hand hygiene and isolation precautions) that potentially could affect infection rates.

References

1.
COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Baltimore, MD: Johns Hopkins University; 2020. https://coronavirus​.jhu.edu/map.html. Accessed July 21, 2020.
2.
Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Apr 30;382(18):1708–20. 10.1056/NEJMoa2002032. PMID: 32109013. [PMC free article: PMC7092819] [PubMed: 32109013] [CrossRef]
3.
Shi S, Qin M, Shen B, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. 2020 Mar 25;e200950. 10.1001/jamacardio.2020.0950. PMID: 32211816. [PMC free article: PMC7097841] [PubMed: 32211816] [CrossRef]
4.
Helms J, Kremer S, Merdji H, et al. Neurologic features in severe SARS-CoV-2 infection. N Engl J Med. 2020 Jun 4;382(23):2268–70. 10.1056/NEJMc2008597. PMID: 32294339. [PMC free article: PMC7179967] [PubMed: 32294339] [CrossRef]
5.
Ma QX, Shan H, Zhang CM, et al. Decontamination of face masks with steam for mask reuse in fighting the pandemic COVID-19: Experimental supports. J Med Virol. 2020 Apr 22. 10.1002/jmv.25921. PMID: 32320083. [PMC free article: PMC7264583] [PubMed: 32320083] [CrossRef]
6.
Cadnum JL, Li DF, Redmond SN, et al. Effectiveness of ultraviolet-c light and a high-level disinfection cabinet for decontamination of N95 respirators. Pathog Immun. 2020;5(1):52–67. 10.20411/pai.v5i1.372. PMID: 32363254. [PMC free article: PMC7192214] [PubMed: 32363254] [CrossRef]
7.
Fischer RJ, Morris DH, van Doremalen N, et al. Effectiveness of N95 respirator decontamination and reuse against SARS-CoV-2 virus. Emerg Infect Dis. 2020 Jun 3;26(9). 10.3201/eid2609.201524. PMID: 32491983. [PMC free article: PMC7454118] [PubMed: 32491983] [CrossRef]
8.
Leas BF, Sullivan N, Han JH, et al. Environmental cleaning for the prevention of healthcare-associated Infections. Technical Brief No. 22 (Prepared by the ECRI Institute-Penn Medicine Evidence-based Practice Center under Contract No. 290-2012-00011-I.) AHRQ Publication No. 15-EHC020-EF. Rockville, MD: Agency for Healthcare Research and Quality; August 2015. https:​//effectivehealthcare​.ahrq.gov/products​/healthcare-infections​/technical-brief. [PubMed: 26290935]
9.
Barbut F. How to eradicate Clostridium difficile from the environment. J Hosp Infect. 2015 Apr;89(4):287–95. 10.1016/j.jhin.2014.12.007. PMID: 25638358. [PubMed: 25638358] [CrossRef]
10.
University of Michigan. Pulsed UV xenon disinfection to prevent resistant healthcare associated infection. In: ClinicalTrials​.gov. Bethesda, MD: National Library of Medicine (US); 2000- [accessed 2020 May 28]. https://clinicaltrials.gov/ct2/show/NCT03349268 NLM Identifier: NCT03349268.
11.
Marra AR, Schweizer ML, Edmond MB. No-touch disinfection methods to decrease multidrug-resistant organism infections: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2018 Jan;39(1):20–31. 10.1017/ice.2017.226. PMID: 29144223. [PubMed: 29144223] [CrossRef]
12.
Mosci D, Marmo GW, Sciolino L, et al. Automatic environmental disinfection with hydrogen peroxide and silver ions versus manual environmental disinfection with sodium hypochlorite: a multicentre randomized before-and-after trial. J Hosp Infect. 2017 Oct;97(2):175–9. 10.1016/j.jhin.2017.06.010. PMID: 28610932. [PubMed: 28610932] [CrossRef]
13.
Brite J, McMillen T, Robilotti E, et al. Effectiveness of ultraviolet disinfection in reducing hospital-acquired Clostridium difficile and vancomycin-resistant Enterococcus on a bone marrow transplant unit. Infect Control Hosp Epidemiol. 2018 Nov;39(11):1301–6. 10.1017/ice.2018.215. PMID: 30226124. [PMC free article: PMC8524758] [PubMed: 30226124] [CrossRef]
14.
Pavia M, Simpser E, Becker M, et al. The effect of ultraviolet-C technology on viral infection incidence in a pediatric long-term care facility. Am J Infect Control. 2018 Jun;46(6):720–2. 10.1016/j.ajic.2018.01.014. PMID: 29550083. [PubMed: 29550083] [CrossRef]
15.
Ghantoji SS, Stibich M, Stachowiak J, et al. Non-inferiority of pulsed xenon UV light versus bleach for reducing environmental Clostridium difficile contamination on high-touch surfaces in Clostridium difficile infection isolation rooms. J Med Microbiol. 2015 Feb;64(Pt 2):191–4. 10.1099/jmm.0.000004-0. PMID: 25627208. [PMC free article: PMC4811651] [PubMed: 25627208] [CrossRef]
16.
Sitzlar B, Deshpande A, Fertelli D, et al. An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile isolation rooms. Infect Control Hosp Epidemiol. 2013 May;34(5):459–65. 10.1086/670217. [PubMed: 23571361] [CrossRef]
17.
Wong T, Woznow T, Petrie M, et al. Postdischarge decontamination of MRSA, VRE, and Clostridium difficile isolation rooms using 2 commercially available automated ultraviolet-C-emitting devices. Am J Infect Control. 2016 Apr 1;44(4):416–20. 10.1016/j.ajic.2015.10.016. PMID: 26684367. [PubMed: 26684367] [CrossRef]
18.
Marik PE, Shankaran S, King L. The effect of copper-oxide-treated soft and hard surfaces on the incidence of healthcare-associated infections: a two-phase study. J Hosp Infect. 2020 Jun;105(2):265–71. Epub 2020 Feb 14. 10.1016/j.jhin.2020.02.006. PMID: 32068014. [PubMed: 32068014] [CrossRef]
19.
Nerandzic MM, Thota P, Sankar CT, et al. Evaluation of a pulsed xenon ultraviolet disinfection system for reduction of healthcare-associated pathogens in hospital rooms. Infect Control Hosp Epidemiol. 2015 Feb;36(2):192–7. 10.1017/ice.2014.36. PMID: 20191210. [PubMed: 25633002] [CrossRef]
20.
Sifri CD, Burke GH, Enfield KB. Reduced health care-associated infections in an acute care community hospital using a combination of self-disinfecting copper-impregnated composite hard surfaces and linens. Am J Infect Control. 2016 Dec 1;44(12):1565–71. 10.1016/j.ajic.2016.07.007. PMID: 27692785. [PubMed: 27692785] [CrossRef]
21.
Anderson DJ, Moehring RW, Weber DJ, et al. Effectiveness of targeted enhanced terminal room disinfection on hospital-wide acquisition and infection with multidrug-resistant organisms and Clostridium difficile: a secondary analysis of a multicentre cluster randomised controlled trial with crossover design (BETR Disinfection). Lancet Infect Dis. 2018 Aug;18(8):845–53. 10.1016/S1473-3099(18)30278-0. PMID: 29880301. [PMC free article: PMC6487496] [PubMed: 29880301] [CrossRef]
22.
Anderson DJ, Chen LF, Weber DJ, et al. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet. 2017 Feb 25;389(10071):805–14. 10.1016/S0140-6736(16)31588-4. PMID: 28104287. [PMC free article: PMC5935446] [PubMed: 28104287] [CrossRef]
23.
Grady D, Redberg RF, O’Malley PG. Quality improvement for quality improvement studies. JAMA Intern Med. 2018 Feb 1;178(2):187. 10.1001/jamainternmed.2017.6875. PMID: 29181495. [PubMed: 29181495] [CrossRef]
24.
Sampathkumar P, Folkert C, Barth JE, et al. A trial of pulsed xenon ultraviolet disinfection to reduce Clostridioides difficile infection. Am J Infect Control. 2019 Apr;47(4):406–8. 10.1016/j.ajic.2018.09.018. PMID: 30502111. [PubMed: 30502111] [CrossRef]

Acknowledgements

The authors gratefully acknowledge the following individuals for their contributions to this project: Elisabeth Kato, M.D., Amanda Sivek, Ph.D., Jonathan R. Treadwell, Ph.D., Timothy Wilt, M.D., M.P.H., Diane Robertson, Helen Dunn, Jennifer Maslin, and Michael Phillips.

Afterword

Recognized for excellence in conducting comprehensive systematic reviews, the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) program is developing a range of rapid evidence products to assist end-users in making specific decisions in a limited timeframe.

To shorten timelines, reviewers make strategic choices about which review processes to abridge. However, the adaptations made for expediency may limit the certainty and generalizability of the findings from the review, particularly in areas with a large literature base. Transparent reporting of the methods used and the resulting limitations of the evidence synthesis are extremely important.

AHRQ expects that these rapid evidence products will be helpful to health plans, providers, purchasers, government programs, and the health care system as a whole. Transparency and stakeholder input are essential to the Effective Health Care Program.

If you have comments on this report, they may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD 20857, or by email to vog.shh.qrha@cpe.

  • Gopal Khanna, M.B.A
    Director
    Agency for Healthcare Research and Quality
  • Stephanie Chang, M.D., M.P.H.
    Director
    Evidence-based Practice Center Program
    Center for Evidence and Practice Improvement
    Agency for Healthcare Research and Quality
  • Christine S. Chang, M.D., M.P.H
    Associate Director
    Evidence-based Practice Center Program
    Center for Evidence and Practice Improvement
    Agency for Healthcare Research and Quality
  • Arlene Bierman, M.D., M.S.
    Director
    Center for Evidence and Practice Improvement
    Agency for Healthcare Research and Quality
  • Elisabeth Kato, M.D.
    Task Order Officer
    Evidence-based Practice Center Program
    Center for Evidence and Practice Improvement
    Agency for Healthcare Research and Quality

Appendix A. Methods

We searched PubMed and EMBASE from January 1, 2000, through April 22, 2020.

PubMed. Bethesda (MD): National Library of Medicine [searched January 1, 2000, through April 22, 2020] Available from: http://www.pubmed.gov.

Search Strategy:

– #1.

cross infection[mh] OR hospital infection*[tiab] OR health care acquired infection*[tiab] OR health care associated infection*[tiab] OR hospital acquired infection*[tiab] OR hospital associated infection*[tiab] OR (infect*[ti] AND (nosocomial[ti] OR viral[ti] OR virus[ti] OR viruses[ti])) OR (HAI[ti] OR HAIs[ti])

– #2.

coronavirus infections[mh] OR covid-19[supplementary concept] OR 2019 ncov[tiab] OR 2019ncov[tiab] OR 2019 novel coronavirus[tiab] OR coronavirinae[tiab] OR coronavirus[tiab] OR coronaviruses[tiab] OR corona virus[tiab] OR corona viruses[tiab] OR covid*[tiab] OR covid 19[tiab] OR covid19[tiab] OR covid2019[tiab] OR hcov 19[tiab] OR hcov 2019[tiab] OR hcov19[tiab] OR hcov2019[tiab] OR ncov*[tiab] OR ncov 2019[tiab] OR ncov2019[tiab] OR sars cov 2[tiab] OR sars cov2v[tiab] OR sarscov 2[tiab] OR sarscov2[tiab] OR severe acute respiratory syndrome coronavirus 2[tiab] OR severe acute respiratory syndrome corona virus 2[tiab]

– #3.

sars virus[mh] OR “severe acute respiratory syndrome”[tiab] OR sars[tiab]

– #4.

adenoviridae[mh] OR adenoviridae infections[mh] OR influenza a virus, h1n1 subtype[mh] OR influenza, human[mh] OR middle east respiratory syndrome coronavirus[mh] OR respiratory syncytial viruses[mh] OR respiratory syncytial virus infections[mh] OR rhinovirus[mh] OR adenovirus*[tiab] OR flu[tiab] OR h1n1[tiab] OR influenza*[tiab] OR mers[tiab] OR “mers cov” [tiab] OR merscov[tiab] OR middle east respiratory syndrome[tiab] OR respiratory syncytial virus[tiab] OR rhinovirus[tiab] OR viruses[mh] OR virus diseases[mh] OR virus shedding[mh]

– #5.

clostridium difficile[mh] OR clostridioides difficile[tiab] OR clostridium difficile[tiab] OR clostridium difficilis[tiab] OR c. difficile[tiab] OR c. diff[tiab] OR c.difficile[tiab] OR c.diff[tiab] OR peptoclostridium difficile[tiab]

– #6.

(epidemic*[ti] OR epidemics[mh] OR pandemic*[ti] OR pandemics[mh] OR contagion*[ti] OR crises[ti] OR crisis[ti] OR epidemic*[ti] OR outbreak*[ti] OR pandemic*[ti] OR scourge*[ti] OR plague*[ti]) AND (virus OR viruses OR viral)

– #7.

emergency service, hospital[mh] OR health facilities[mh] OR hospitals[mh] OR hospitals, isolation[mh] OR intensive care units[mh] OR operating rooms[mh] OR acute care[tiab] OR burn unit*[tiab] OR emergency room*[tiab] OR emergency department*[tiab] OR common area*[tiab] OR critical care[tiab] OR healthcare facilit*[tiab] OR health care facilit*[tiab] OR healthcare setting*[tiab] OR health care setting*[tiab] OR hospital*[tiab] OR hospitalis*[tiab] OR hospitaliz*[tiab] OR ICU[tiab] OR institution[tiab] OR institutions[tiab] OR intensive care[tiab] OR isolation room*[tiab] OR isolation unit*[tiab] OR medical facilit*[tiab] OR operating room*[tiab] OR patient care area*[tiab] OR patient* room*[tiab] OR ward[tiab] OR wards[tiab]

– #8.

equipment and supplies, hospital[mh] OR equipment contamination[mh] OR hospital bed* [tiab] OR (hospital*[tiab] AND (bar[tiab] OR bars[tiab] OR bathroom*[tiab] OR bed[tiab] OR beds[tiab] OR bed rail*[tiab] OR bedrail*[tiab] OR cart[tiab] OR carts[tiab] OR chair[tiab] OR chairs[tiab] OR commode*[tiab] OR door[tiab] OR door handle*[tiab] OR doors[tiab] OR equipment*[tiab] OR faucet*[tiab] OR floor[tiab] OR floors[tiab] OR flooring[tiab] OR handle[tiab] OR handles[tiab] OR light switch*[tiab] OR pole[tiab] OR poles[tiab] OR rail[tiab] OR railing*[tiab] OR rails[tiab] OR seat[tiab] OR seats[tiab] OR sink[tiab] OR sinks[tiab] OR table*[tiab] OR toilet* [tiab] OR wheelchair*[tiab]))

– #9.

fomites[mh] OR counter[tiab] OR counters[tiab] OR countertop*[tiab] OR counter top*[tiab] OR surface*[tiab] OR (surface*[tiab] AND (contamina*[tiab] OR environmental[tiab] OR hard[tiab] OR high contact[tiab] OR high touch[tiab] OR hospital*[tiab] OR hygiene[tiab] OR nonporous[tiab] OR non porous[tiab]))

– #10.

disinfection system*[tiab] OR ((automat*[tiab] OR “no touch”[tiab] OR “non touch”[tiab] OR robot*[tiab] OR touchless[tiab]) AND (aerosol*[tiab] OR air[tiab] OR airborne[tiab] OR clean*[tiab] OR chlorine[tiab] OR disinfect*[tiab] OR decontaminat*[tiab] OR fog*[tiab] OR fumigat* [tiab] OR gas[tiab] OR gaseous[tiab] OR gasses[tiab] OR mist*[tiab] OR purif*[tiab] OR sanitis*[tiab] OR sanitiz*[tiab] OR steam*[tiab] OR sterilis*[tiab] OR steriliz*[tiab] OR vapor*[tiab] OR vapour*[tiab]))

– #11.

ultraviolet rays[mh] OR “pulsed xenon”[tiab[ OR “ultra violet”[tiab] OR ultraviolet[tiab] OR uv[tiab] OR “uv c”[tiab] OR uvc[tiab] OR uvgi[tiab] OR vuv[tiqab] OR xenon[tiab]

– #12.

lightstrike OR “germ zapping robot*” OR “optimum uv” OR pathogon OR “rapid disinfector” OR “rd uvc” OR smartuvc OR “steriliz r d” OR “steriliz rd” OR surfacide OR “tru d” OR “uvc cleaning system*”

– #13.

hydrogen peroxide[mh] OR hydrogen peroxide[tiab] OR H2O2[tiab] OR “H2 O2”[tiab]

– #14.

bioquell* OR haloc50* OR halofogger* OR halohpc* OR halosil* OR halomist* OR ‘HC 80TT*’ OR steramist* OR sterilucent OR tomi

– #15.

copper[mh] OR copper[tiab]

– #16.

chlorine dioxide[tiab] OR chlorine dioxide[supplementary concept] OR ozone[mh] OR ozone[tiab] OR steam[mh] OR steam*[tiab] OR water vapor[tiab] OR water vapour[tiab]

– #17.

(#1 OR #2 OR #3 OR #4 OR #5 OR #6) AND (#7 OR #8 OR #9) AND (#10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16)

EMBASE. Amsterdam (The Netherlands): Elsevier B.V. [searched January 1, 2000, through April 22, 2020]. Available from: www.embase.com. Subscription required.

Search Strategy:

– #1.

‘hospital infection’/de OR nosocomial*:ti OR ((‘health care acquired’ OR ‘health care associated’ OR ‘hospital acquired’ OR ‘hospital associated’) NEXT/1 (infect* OR nosocomial OR pathogen* OR viral OR virus*)):ab,ti,kw OR (HAI OR HAIs):ti

– #2.

‘coronavirinae’/exp OR ‘2019 ncov’:ab,ti,kw OR 2019ncov:ab,ti,kw OR ‘2019 novel coronavirus’:ab,ti,kw OR ‘corona virus’:ab,ti,kw OR ‘corona viruses’:ab,ti,kw OR coronavirus:ab,ti,kw OR coronaviruses:ab,ti,kw OR covid*:ab,ti,kw OR ‘covid 19’:ab,ti,kw OR covid19:ab,ti,kw OR covid2019:ab,ti,kw OR ‘hcov 19’:ab,ti,kw OR ‘hcov 2019’:ab,ti,kw OR hcov19:ab,ti,kw OR hcov2019:ab,ti,kw OR ncov*:ab,ti,kw OR ‘ncov 2019’:ab,ti,kw OR ncov2019:ab,ti,kw OR ‘sars cov 2’:ab,ti,kw OR ‘sars cov2’:ab,ti,kw OR ‘sarscov 2’:ab,ti,kw OR sarscov2:ab,ti,kw OR ‘severe acute respiratory syndrome coronavirus 2’:ab,ti,kw OR ‘severe acute respiratory syndrome corona virus 2’:ab,ti,kw OR (((asia* OR china OR chinese OR epidemic OR new OR novel OR pandemic OR wuhan) NEAR/5 (coronavirus OR coronaviruses OR ‘corona virus’ OR ‘corona viruses’ OR covid* OR hcov)):ab,ti,kw)

– #3.

‘severe acute respiratory syndrome’/de OR sars:ab,ti,kw OR ‘severe acute respiratory syndrome’:ab,ti,kw

– #4.

‘adenoviridae’/de OR ‘influenza a virus (h1n1)’/de OR ‘influenza virus’/de OR ‘middle east respiratory syndrome coronavirus’/de OR ‘human respiratory syncytial virus’/de OR ‘rhinovirus’/de OR ‘rhinovirus infection’/de OR ‘viral respiratory tract infection’/de OR (adenovirus* OR flu OR h1n1 OR influenza* OR mers OR ‘mers cov’ OR merscov OR ‘middle east respiratory syndrome’ OR ‘respiratory syncytial virus’ OR rhinovirus):ab,ti,kw

– #5.

‘clostridioides difficile’/de OR ‘clostridium difficile infection’/de OR (‘clostridioides difficile’ OR ‘clostridium difficile’ OR ‘clostridium difficilis’ OR ‘c. difficile’ OR ‘c. diff’ OR ‘c.difficile’ OR ‘c.diff’ OR ‘peptoclostridium difficile’):ab,ti,kw

– #6.

(‘epidemic’/de OR ‘pandemic’/de OR ‘pandemic influenza’/de OR contagion*:ti OR crises:ti OR crisis:ti OR epidemic*:ti OR outbreak*:ti OR pandemic*:ti OR scourge*:ti OR plague*:ti) AND (‘viral contamination’/de OR ‘virus’/exp OR ‘virus infection’/exp OR ‘virus shedding’/de OR ‘virus transmission’/de OR virus/de OR ‘viral contamination’/de OR viral:ti OR viruses:ti OR viral:ti)

– #7.

‘emergency care’/de OR ‘health care facility’/de OR hospital/de OR ‘isolation facility’/de OR (‘acute care’ OR‘burn unit*’ OR ‘emergency room*’ OR ‘emergency department*’ OR ‘common area*’ OR ‘critical care’ OR ‘healthcare facilit*’ OR ‘health care facilit*’ OR ‘healthcare setting*’ OR ‘health care setting*’ OR hospital* OR hospitalis* OR hospitaliz* OR ICU OR institution OR institutions OR ‘intensive care’ OR ‘isolation room*’ OR ‘isolation unit*’ OR ‘medical facilit*’ OR ‘patient care area*’ OR ‘patient* room*’ OR ward OR wards):ab,ti,kw

– #8.

‘hospital equipment’/de OR ‘hospital bed*’:ab,ti,kw OR (hospital* AND (bar OR bars OR bathroom* OR bed OR beds OR ‘bed rail*’ OR bedrail* OR cart OR carts OR chair OR chairs OR commode* OR door OR ‘door handle*’ OR doors OR equipment* OR faucet* OR floor OR floors OR flooring OR handle OR handles OR ‘light switch*’ OR pole OR poles OR rail OR railing* OR rails OR seat OR seats OR sink OR sinks OR table* OR toilet* OR vent:ti,ab OR ventilation:ti,ab OR vents:ti,ab OR wheelchair*)):ab,ti,kw

– #9.

fomite*:ab,ti,kw OR fomite/de OR ‘surface area’/de OR (counter OR counters OR countertop* OR ‘counter top*’ OR surface*):ti OR (surface* NEAR/2 (clinical OR contamina* OR environmental OR hard OR ‘high contact’ OR ‘high touch’ OR hospital* OR hygiene OR nonporous OR ‘non porous’)):ab,ti,kw

– #10.

‘disinfection system’/exp OR ‘disinfection system*’:ab,ti OR ((automat* OR ‘no touch’ OR ‘non touch’ OR robot* OR touchless) NEAR/2 (aerosol* OR air OR airborne OR chlorine OR clean* OR disinfect* OR decontaminat* OR fog* OR fumigat* OR gas OR gaseous OR gasses OR mist* OR ozone OR purif* OR sanitis* OR sanitiz* OR steam* OR sterilis* OR steriliz* OR vapor* OR vapour*)):ab,ti

– #11.

‘ultraviolet irradiation’/de OR ‘ultraviolet radiation’/de OR (‘pulsed xenon’ OR ‘ultra violet’ OR ultraviolet OR uv OR ‘uv c’ OR uvc OR uvgi OR vuv OR xenon):ab,ti,kw

– #12.

(lightstrike OR ‘germ zapping robot*’ OR ‘optimum uv’ OR pathogon OR ‘rapid disinfector’ OR ‘rd uvc’ OR smartuvc OR ‘steriliz r d’ OR ‘steriliz rd’ OR surfacide OR ‘tru d’ OR ‘uvc cleaning system*’):ab,ti,kw,dn,df

– #13.

‘hydrogen peroxide’/de OR (‘hydrogen peroxide’ OR H2O2 OR ‘H2 O2’):ab,ti,kw

– #14.

(bioquell* OR halo OR haloc50* OR halofogger* OR halohpc* OR halosil* OR halomist* OR ‘HC 80TT*’ OR steramist* OR sterilucent OR tomi):ab,ti,kw,dn,df

– #15.

copper/de OR copper*:ti OR (copper NEAR/2 (antimicrobial* OR coated OR coating* OR impregnated OR surface*)):ab,ti,kw

– #16.

‘chlorine dioxide’/de OR ozone/de OR ‘water vapor’/de OR (‘chlorine dioxide’ OR ozone OR steam* OR ‘water vapor’ OR ‘water vapour’):ab,ti,kw

– #17.

(#1 OR #2 OR #3 OR #4 OR #5 OR #6) AND (#7 OR #8 OR #9) AND (#10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16)

Appendix E. Flow Diagram

Appendix E is an image of the literature flow diagram for the rapid review. The image shows several boxes, each of which depicts either the number of citations screened at a step or the number of citations excluded, along with reasons for exclusion. The first box describes the total number of citations (1,378) identified by searches. Two arrows extend from this box: one arrow extends rightward to another box describing the number of studies excluded at the Title screening level (n = 1,037) for being off-topic. The other arrow leads from the first box straight down to another box describing the number of articles reviewed at the abstract or full text level (n=341). Two arrows also extend from this box describing 341 citations screened at the abstract and full text level. One arrow extends rightward to another box describing reasons for exclusion of 330 studies. These reasons include not a pathogen of interest, not an intervention of interest, review/opinion article, not acute care setting, not related to SARS and publication date <2010, did not report outcome of interest, artificial inoculation study, duplicate or patients already included in the systematic review, conference abstract, or other (such as study included less than 10 patients or non-English study). A second arrow extends downward from the box to another box describing total number of included studies: 11 studies were included consisting of 1 systematic review, 9 unique studies, and 1 secondary analysis. One arrow extends downward from this box of included studies to 4 separate horizontally aligned boxes describing 4 different intervention types for which studies were identified. The four boxes (from left to right) are as follows: Ultraviolet light (with 1 systematic review including 12 studies), 6 studies, 1 secondary analysis; Vaporous Hydrogen Peroxide (with 1 systematic review including 6 studies), Aerosolized hydrogen peroxide plus silver ions (with 1 study), and Copper Surfaces (with 2 studies).

Suggested citation:

Tsou AY, Pavlides S, Koepfler L, Drummond C. No-Touch Modalities for Disinfecting Patient Rooms in Acute Care Settings. Rapid Evidence Product. (Prepared by the ECRI Evidence-based Practice Center under Contract No. 290-2015-00005-I). AHRQ Publication No. 20(21)-EHC021. Rockville, MD: Agency for Healthcare Research and Quality. October 2020. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCCOVIDNOTOUCH.

Disclaimers: This report is based on research conducted by ECRI under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00005-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

The information in this report is intended to help health care decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report is made available to the public under the terms of a licensing agreement between the authors and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.

AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.

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