1. Infection Control
& Clinical Quality
January 2015 • Vol. 2015 No. 1
INDEX
Table of Contents
p. 4
Patient Safety
p. 5
Executive Briefing:
UV Light Disinfection
p. 10
Hand Hygiene &
Preventing HAIs
p. 17
The 5 Most-
Reduced Patient
Harm Events
Instances of 10 HACs dropped
17 percent from 2010 to 2013,
but which patient harm events
saw the greatest reduction? p. 6
721 Hospitals
Penalized by
Medicare for
High HAC Rates
15 things to know about the
HAC Reduction Program and
the hospitals receiving
penalties, p. 8
Hand Dryers vs.
Paper Towels
New study ends debate, p. 18
The 5 States
Most Prepared for
Infectious Disease
Outbreaks
See which states are in the best
shape, p. 20
Employee Rights vs.
Patient Safety: Balancing
Mandatory Flu Shots
By Akanksha Jayanthi
It’s January — the middle of flu season. Have you gotten
your flu shot?
Increasingly, healthcare organizations are requiring their
employees to do so.
Last flu season (2013-14), 75.2 percent of healthcare person-
nel, both clinical and non-clinical, reported receiving a flu
shot, up from 63.5 percent the season prior, according to the
Centers for Disease Control and Prevention.
Taking Hand Hygiene
High-Tech
By Heather Punke
For healthcare providers, following hand hygiene
protocol is one of the simplest actions they can take
to reduce the instance of healthcare-associated infec-
tions. Indeed, the World Health Organization calls
hand hygiene a “simple, low-cost action to prevent
the spread of many of the microbes that cause health-
care-associated infections.”
“Hand hygiene is definitely the most important thing we
can do to prevent infection,” said Clare Nash, RN, pro-
gram manager at The RoyalWolverhampton NHS Trust
Hospitals are charged with the dual
task of keeping patients well while
also keeping patients safe. The two
are inextricably linked, as patient
safety concerns often tie directly into
patient health concerns — hand hy-
giene, transitions of care and medi-
cation errors are a few such concerns
that come to mind.
Retrospectively, 2014 provided some
lessons in patient safety issues. The
Ebola outbreak shed light on the
country’s unpreparedness for han-
dling infection outbreaks after two
nurses contracted the virus while
caring for an infected patient, and
meaningful use guidelines are ramp-
ing up requirements for patient in-
volvement in their care.
Looking prospectively, these con-
cerns, and many others, will flow
into the next calendar year. Some
of the patient safety issues are long
established, and will remain in the
forefront of healthcare’s mind for
years to come. Here, in no particular
order, are 10 important patient safety
issues for providers to consider in the
upcoming year.
Healthcare-associated infec-
tions. HAIs have long plagued
healthcare facilities, both clinically
and financially. Protocol including
continued on page 17
continued on page 5
continued on page 14
10 Top Patient Safety Issues for 2015
By Akanksha Jayanthi
SAVE THE DATE!
Becker’s Hospital Review
Annual Meeting
May 7-9, 2015
Swissôtel - Chicago, Illinois
153 Great Health System Executives Speaking
119 Sessions - 212 Speakers
To learn more visit www.BeckersHospitalReview.com
To register, visit
www.regonline.com/hospitalreview6thannualmeeting

2. 10 Executive Briefing: UV Light Disinfection
Sponsored by:
10.875”
R
ecently, there has been an in-
creased focus in many healthcare
facilities on preventing the spread
of emerging pathogens, especially those
that are resistant to antimicrobial drugs.
These emerging infection risks have also
made it more and more important for fa-
cilities to develop and implement emer-
gency preparedness plans to both iso-
late and treat symptomatic patients while
safeguarding the hospital staff and larger
community. However, for those health-
care facilities that wish to adopt a more
comprehensive approach to environmen-
tal infection control, there is little guid-
ance on how to incorporate a bundled
approach of manual disinfectants and
ultraviolet treatment.
The Centers for Disease Control and Pre-
vention and U.S. Environmental Protec-
tion Agency developed a recommended
approach to help bridge the gap between
disinfectant efficacy claims for common
healthcare-associated pathogens and
emerging pathogens.1,2,3
The aim of this
approach is to help healthcare profession-
als choose appropriate manual disinfec-
tants for use against emerging pathogens
when no disinfectants with EPA-registered
claims are available. This article will out-
line the CDC and EPA approach and how
it can be extended to provide guidance for
the use of supplemental UV devices in an
environmental protection strategy against
emerging pathogens.
Manual environmental
cleaning & disinfection
approach for emerging
pathogens
For emerging pathogens or pathogens that
are hard to isolate or handle safely in the
laboratory, such as the Ebola virus, there
often is no regulatory pathway to obtain an
EPA-registered sanitization or disinfection
claim. In this case, a new microbiological
analysis protocol must be developed fol-
lowing EPA guidelines.4
However this is a
time-consuming process that sometimes
involves using a surrogate organism to
represent the target pathogen to reduce
safety risks and deliver an organism for
test purposes.5
This waiting period can
leave hospital infection control teams at a
loss when trying to determine appropriate
disinfectants for use in the interim.
When an emerging pathogen poses a sig-
nificant public health risk, the CDC and
EPA guidance is intended to bridge the
gap by identifying disinfectant products
that may be used while effective test pro-
tocols are being developed. The approach
draws on well-established pathogen hi-
erarchy and efficacy data, in addition to
peer-reviewed studies. Table I shows the
EPA-recognized pathogen hierarchy for
the selection of disinfectants to be used
against emerging pathogens. This hierar-
chy ranks classes of microorganisms by
order of their relative susceptibility to hard
surface disinfectants,6
with the hardest
pathogens to kill (bacterial endospores) at
the top of the list and the organisms most
susceptible to disinfectants at the bottom.
Using this pathogen hierarchy and the
wealth of micro-efficacy testing data for
EPA-registered disinfectants, the CDC de-
veloped recommendations specifically for
the Ebola virus.8
Though the Ebola virus is
an enveloped virus, the CDC recommends
the use of EPA-registered hospital disin-
fectants with kill claims against harder-to-
kill non-enveloped viruses in order to dis-
infect rooms of patients with suspected or
confirmed Ebola virus disease. The same
approach can be applied to develop rec-
ommendations for other emerging patho-
gens as well.
Applying the “bridge the
gap” approach to UV
devices
It is well documented that UV-C light, a
high energy form of ultraviolet light, is a
highly effective germicide9,10
– so well, in
fact, that Kowalski’s UV handbook states
that “given sufficient exposure time, any
exposed pathogen can be inactivated.”11
Bridging the Gap: Establishing UV
Claims for Emerging Pathogens
By Sarah S. Snow, PhD, Senior Scientist, Clorox Professional Products Company
Table I
Pathogen Hierarchy7
Descending order of resistance to germicidal chemicals
Bacterial Spores
(Bacillus subtilis, Clostridium sporogenes)
Mycobacteria
(Mycobacterium tuberculosis var. bovis, Nontuberculous mycobacteria)
Nonlipid, Non-enveloped, or Small Viruses
(Poliovirus, Coxsackievirus, Rhinovirus)
Fungi
(Trichophyton, Cryptococcus, Candida spp.)
Vegetative Bacteria
(P. aeruginosa, S. aureus, S. choleraesuis, Enterococci)
Lipid, Enveloped, or Medium-sized Viruses
(Herpes simplex, Cytomegalovirus, RSV, Hepatitis B, Hepatitis C, HIV,
Hantavirus, Ebola virus)

3. ABOVE
AND
BEYOND
New heights in the fight against HAIs
Add advanced UV technology
to proven disinfectants.
All from Clorox Healthcare®
.
UV System: 4-log reduction of C. difficile
spores in 5 minutes at 8 feet.
Bleach Germicidal Wipes & Cleaners: kill
C. difficile spores in as fast as 3 minutes*.
Hydrogen Peroxide Wipes & Cleaners: kill
most bacteria and viruses in 30–60 seconds.
Learn more at cloroxhealthcare.com/UV
*3 minutes (wipes), 5 minutes (spray)
© 2014 Clorox Professional Products Company. Use products as directed.
NI-27527

4. 12 Executive Briefing: UV Light Disinfection
Thus, similar to the CDC’s pathogen hierarchy for manual disin-
fectants, examining the UV pathogen hierarchy is a good starting
point when determining if a specific device has the potential to
support a claim against emerging pathogens.
The generalized UV pathogen hierarchy adapted from the “Ultra-
violet Germicidal Irradiation Handbook: UVGI for Air and Surface
Disinfection” (shown in Table II), provides guidance on the micro-
bial susceptibility to UV-C light among various organism species.
The hierarchy of susceptibility to UV-C light is notably different
than that referenced for chemical manual disinfectants. In general
with UV-C, vegetative bacteria are easier to inactivate, and fungi
require the highest UV-C dosage for inactivation. Interestingly,
bacterial spores such as Clostridium difficile, which are known
for their environmental persistence, are intermediate on the UV
Dose Hierarchy.
Beyond this hierarchy, there is a wealth of data available on the
UV dosage required for inactivation of specific pathogens. How-
ever, unlike manual surface disinfectants, the EPA does not cur-
rently provide a route for obtaining EPA-registered kill claims us-
ing UV germicidal irradiation.
UV dosages for non-enveloped viral pathogens such as adenovi-
rus, norovirus, poliovirus, and rotavirus range from 18,000-84,000
μw-sec/cm² for a 2-log kill.13
,14
In comparison, the UV dosage re-
quired to inactivate enveloped Ebola virus is significantly less –
200015
-530016
μw-sec/cm² for a 2-log kill. Historically, UV doses
have been listed by either their D90 (90 percent inactivation) or
D99 values (2-log reduction). In order to address the more strin-
gent needs for healthcare applications, 3-4 log reductions (99.9
percent to 99.99 percent microbial kill) or greater are typically ob-
tained for target microorganisms and validated via laboratory test-
ing. Comparisons of known and predicted pathogen doses can be
used to determine the effectiveness of a UV-C device at a given
exposure time and distance.
Current limitations for UV microorganism
efficacy testing
Since there are no EPA-approved protocols to validate micro-effi-
cacy claims for UV devices, the industry faces a lack of standard-
ized test methods and oversight on the claims made by device
manufacturers. Thus manufacturers generate data using different
test methods, making it difficult to compare efficacy claims from
one device to another for pathogens.
Device manufacturers that generate micro-efficacy data should
show full transparency about the test conditions used, such as the
irradiation time, distance, substrate, carrier load, and density as
well as for the log reductions obtained.
Building the case for a comprehensive
bundled approach: Manual disinfection
supplemented by UV-C devices
In light of the dangers posed by emerging pathogens, many hos-
pitals are interested in emerging technologies such as UV-C tech-
nology to reduce transmission to patients and protect their staff.
UV devices can add an extra layer of assurance when it comes to
terminal cleaning; reaching areas of the healthcare environment
that may otherwise be missed or insufficiently addressed due to
human error. However manual disinfection is still essential for re-
moving soils and killing pathogens on environmental surfaces and
plays an important role in infection prevention protocols.
A key finding of the 2011 study by Sagripanti and Lytle in the
Archives of Virology17
and work by Bausch published in The
Journal of Infectious Diseases18
is that environmental conditions
can impact the effectiveness of pathogen inactivation via UV de-
vices. The presence of organic matter, such as dried blood, can
shield the pathogen from the UV-C light and reduce the treat-
ment’s effectiveness. In addition, studies have shown that only
50 percent of high-risk surfaces in healthcare settings are prop-
erly cleaned19
. These studies further illustrate the need for the
use of appropriate manual disinfection prior to UV-C treatment.
UV-C room treatment serves to supplement, not replace, stan-
dard cleaning and disinfection protocols20
and provides another
weapon in the battle against pathogens that cause healthcare-
associated infections (HAIs).
As healthcare facilities strive to identify novel solutions to meet
the infection control challenges posed by emerging pathogens,
it is important to remember how to “bridge the gap” to determine
which disinfectants and UV devices can be used based on EPA-
registered efficacy claims. This can be done by consulting known
Table II
Generalized UV-C Dose Hierarchy12
Listed by Decreasing Inactivation
Difficulty
Fungal Spores
Fungal Cells/Yeast
Bacterial Spores
Viruses
Vegetative Bacteria
Since there are no EPA-approved
protocols to validate micro-efficiency
claims for UV devices, the industry
faces a lack of standardized test
methods and oversight on the claims
made by device manufacturers.
When an emerging pathogen poses
a significant public health risk, the
CDC and EPA guidance is intended
to bridge the gap by identifying
disinfectant products that may be
used while effective test protocols
are being developed.

5. 13Executive Briefing: UV Light Disinfection
Building on a century-long legacy in cleaning and disinfecting, Clorox Healthcare offers a wide range of products to help stop the
spread of infection in healthcare facilities. From comprehensive surface disinfection, including advanced ultraviolet technology, to skin
antisepsis, we are committed to providing efficacious solutions to the healthcare community.
pathogen hierarchies, micro-efficacy data and peer-reviewed
studies, and by applying principles set by the CDC and EPA to
understand how to address dangerous emerging pathogens.
For information about Clorox Healthcare™ Optimum-UV™ Sys-
tem, a comprehensive bundled approach for environmental infec-
tion control, as well as information about emerging pathogens and
HAIs, visit www.CloroxHealthcare.com/UV. n
(Endnotes)
1 Centers for Disease Control and Prevention. “Interim Guidance for Environ-
mental Infection Control in Hospitals for Ebolavirus.” 1 August 2014. http://
www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html.
2 US Environmental Protection Agency. “Implementation of the Emerging
Pathogens and Disinfection Hierarchy for Antimicrobial Products.” 3 April 2008.
http://www.epa.gov/oppad001/disinfection_hier.htm.
3 Centers for Disease Control and Prevention. “Severe Respiratory Illness As-
sociated with Enterovirus D68 – Multiple States, 2014.” Official CDC Health
Advisory. 12 September 2014. http://emergency.cdc.gov/han/han00369.asp.
4 The FEM Microbiology Action Team. “Method Validation of U.S. Environmen-
tal Protection Agency Microbiological Methods of Analysis.” The EPA Forum
on Environmental Measurements (FEM) . FEM Document Number 2009-01. 7
October 2009. http://www.epa.gov/fem/pdfs/final_microbiology_method_guid-
ance_110409.pdf.
5 Sinclair, R.G. et al. “Criteria for Selection of Surrogates Used to Study the Fate
and Control of Pathogens in the Environment.” Appl Environ Microbiol. 78.6
(2012): 1969-1977. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298155/
pdf/zam1969.pdf
6 US Environmental Protection Agency. “Implementation of the Emerging
Pathogens and Disinfection Hierarchy for Antimicrobial Products.” 3 April 2008.
http://www.epa.gov/oppad001/disinfection_hier.htm.
7a. As referenced by the EPA: Spaulding, E.H. “Chemical disinfection of medi-
cal and surgical materials.” Disinfection, Sterilization, & Preservation, 3rd Edi-
tion., Block, S. (Ed). Philadelphia: Lea & Febiger, 1968. 517-31.
7b. See also: Favero, M.S., Bond, W.W. “Chemical disinfection of medical
and surgical materials.” Disinfection, Sterilization, & Preservation, 5th Edition.
Block, S. (Ed). Philadelphia: Lippincott Williams & Wilkins, 2001. 888 (Table
43.2)..
8 Centers for Disease Control and Prevention. “Interim Guidance for Environ-
mental Infection Control in Hospitals for Ebolavirus.” 1 August 2014. http://
www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html.
9 Kowalski, W. Ultraviolet Germicidal Irradiation Handbook: UVGI for Air and
Surface Disinfection. Springer, 2009.
10 Bolton, J.R., C.A. Cotton. The Ultraviolet Disinfection Handbook. American
Water Works Association, 2008.
11 Kowalski, W. Ultraviolet Germicidal Irradiation Handbook: UVGI for Air and
Surface Disinfection. Springer, 2009. 467.
12 Adapted from W. Kowalski, Ultraviolet Germicidal Irradiation Handbook:
UVGI for Air and Surface Disinfection, Springer, 2009. 75.
13 For example: Kowalski, W. Ultraviolet Germicidal Irradiation Handbook:
UVGI for Air and Surface Disinfection. Springer, 2009. Appendices A, B, C.
14 The response to UV exposure is often described in terms of UV inactivation
dosage or UV rate constants. For example, the UV dose required to inactivate
99% of the organism (2 log kill) is referred to as the D99
dose. UV Doses are
typically listed by either their D90
(90% inactivation) or D99
values, and differ-
ent sources use different units (i.e., J/m2
, μW-sec/cm², or mw-sec/cm²) for the
dose, so care must be taken when comparing referenced dose values. In
general, the D99
value is approximately twice the value listed for D90
.
15 Sagripanti, J.L., Lytle, D.C. “Sensitivity to ultraviolet radiation of Lassa, vac-
cinia, and Ebolaviruses dried on surfaces.” Arch Virol 156 (2011): 489–494.
16 Kowalski, W.J. Internal UVDI/Clorox Communication.
17 Sagripanti, J.L., Lytle, D.C. “Sensitivity to ultraviolet radiation of Lassa, vac-
cinia, and Ebolaviruses dried on surfaces.” Arch Virol 156 (2011) : 489–494.
18 Bausch, D.G. et al. “Assessment of the Risk of Ebolavirus Transmission
from Bodily Fluids and Fomites.” J Infect Dis 196 (2007): S142–7.
19 Carling, P.C., Parry, M.M., Rupp, M.E., Po, J.L., Dick, B., Von Beheren,
S., Healthcare Environmental Hygiene Study Group. “Improving Cleaning of
the Environment Surrounding Patients in 36 Acute Care Hospitals.” Infection
Control and Hospital Epidemiology 29.11 (2008): 1035-41.
20 Memarzadeh, F. et al. “Applications of ultraviolet germicidal irradiation dis-
infection in health care facilities: Effective adjunct, but not stand-alone technol-
ogy.” Am J Infect Control 38 (2010): S13-24.http://www.ashe.org/resources/
tools/pdfs/ajic1006_memarzadeholmstedbartley_uvgi.pdf.
In light of the dangers posed
by emerging pathogens, many
hospitals are interested in emerging
technologies such as UV-C technology
to reduce transmission to patients
and their staff.