February 13, 2019

THEY SAID IT … we report it … and you evaluate the results and source credibility.  [The full text of research studies/papers articles are made part of this HOT TOPICS and are found at the end.]

WHERE ARE WE?  AQUAOX generators produce/supply hypochlorous acid that is electrostatically sprayed in hospitals to SAFELY assure efficacy of HOCL in killing pathogens and dispels any concern that HOCL could be related to allergenic/asthmatic reactions.  The modern-day protocol of the AQUAOX Infection Control System lowers worker injuries/claims and elevates staff productivity to improve (hospital) patient satisfaction off the charts.

While not additionally claimed (on Aquaox’s AX-525 containers), C.diff is indisputably managed as evidenced by anecdotal success from thousands of in-hospital applications.  So, while Aquaox is nicely managing reality . . .


Where does your organization sit when it comes to ‘healthy’ and proactive reduction of chemical use?

Here comes a little nudge from the good fairy sitting on your shoulder:  Simply follow the MORAL IMPERATIVE and, where applicable, the LEGAL OBLIGATION that EVERY facility gets their job done effectively while providing the safest working conditions possible.

OSHA’s guiding principle – “Don’t use hazardous chemicals if a less hazardous one is available.”  In other words, if there is a safer way to perform a job, choose the safer way.

The cost of killing MRSA, E.coli and other bacteria and viruses with chemicals also comes at great cost and often requires undesirable chemicals, chlorine or bleach – all bad.  Besides, the long contact time required of chemicals evaporates (toxic) fumes into the air we breathe … in addition to leaving on surfaces residue that can irritate skin, eyes and respiratory.

In hospital applications, think first of long-term health consequences to staff and patients due to chemical absorption into the body.  And always keep sight of the higher hard and soft costs of using chemicals, as opposed to doing the right thing with a more-potent, safe HOCL solution dispensed by electrostatic sprayer and ultra-high quality microfiber cloths and mopheads.


From Green Seal Study.pdf

3.4 Cleaner Use

The most important impacts associated with the use of cleaners include health and safety concerns for the workers and building occupants and environmental releases of the cleaners. In addition to reduction of environmental impacts though product selections, purchasers and users of cleaning chemicals should consider dispensing systems that limit worker exposure to cleaning concentrates. These are described in Section 2.4. This section describes relevant health, safety, and environmental impacts and then discusses various ingredients and their impacts.

Appendix B contains health and environmental data by ingredient.

3.4.1 Health and Safety

Worker Exposure to Cleaning Chemicals. Workers are commonly exposed to cleaning chemicals through their skin and their lungs, although oral exposure is also possible. In their review of janitorial injuries in the state of Washington, Barron and Sutherland (1999) reported that 76% of janitorial injuries from chemical exposure involve skin and eye irritation or burns and 12% involve worker inhalation of chemical fumes. Barron et al. (1999) estimates that medical expenses and lost time for chemical injuries to janitors in the United States cost approximately $75 million annually. Therefore, Green Seal wants to encourage the selection of products that are not toxic, corrosive, skin or eye irritants, or sensitizers.

Toxics. Although cleaning chemicals are not generally the most significant source of VOCs in an indoor environment, they are a significant source of VOCs to the workers who use them. This makes the inhalation toxicity of volatile cleaning chemicals an important consideration. Due to concern over worker exposure to some volatile compounds, OSHA has set permissible exposure limits (PELs) and the American Conference of Governmental Industrial Hygienists (ACGIH) has set threshold limit values for a number of solvents. Cleaning chemicals can also be absorbed through the skin, particularly some glycol ethers. Dermal toxicity of cleaning chemicals is also an important consideration. The potential for skin absorption can be greatly reduced by wearing gloves, as manufacturers generally recommend. The Consumer Product Safety Commission (CPSC) defines a toxic material as (16 CFR Part 1500.3)

LD50 < 5 g/kg (oral)

LC50 < 20,000 ppm (inhalation)

LD50 < 2 g/kg (skin)

It is important to note that health effects occur at levels below those defined as toxic.

Corrosivity and Skin and Eye Irritation. A chemical with a pH outside the neutral range may cause injury to the skin and eyes. Although products with a pH greater than 11 or less than 2.5 pose the greatest risk for skin and eye injury (Grant 1974), pH is not the only measure of a chemical’s potential for skin and eye injury.

Sensitizers. A sensitizer is a chemical that causes a substantial proportion of exposed people or animals to develop an allergic reaction in normal tissue after repeated exposure to the chemical. Sensitizers should be reported on MSDSs. A person can become sensitized to a cleaning chemical by inhaling it or from dermal exposure. Some of the responses to sensitizers include contact dermatitis and inflammation of the mucus membranes. According to the US Bureau of Labor Statistics, occupational skin diseases (mostly in the form of contact dermatitis) are the second most common type of occupational disease, accounting for 14% of all occupational diseases (BLS 1999b).

Flammability. The flammability of some solvents and propellants is an important safety issue. Flammable and combustible substances must be handled with extreme caution. The CPSC defines a flammable substance as one with a flashpoint between 20 and 100 °F and a combustible substance as one with a flashpoint between 100 and 150 °F (16 CFR Part 1500.3(c)(6)). OSHA defines several classes of combustible liquids. The Department of Transportation allows liquids to be tested to determine if the liquid can sustain a flame instead of relying on flashpoint. It is important to consider the combustibility of a product as a whole. For example, a dilute solution of ethanol in water would not be flammable or combustible. However, a cleaner containing high concentrations of pine oil, d-limonene, or other solvents could easily be flammable or combustible.

Indoor Air Quality. Americans on average spend 90% of their time indoors; therefore, good indoor air quality is essential to the health of building occupants (Berry 1994). Common complaints resulting from poor indoor air quality include headache, fatigue, and sluggishness and irritation of the skin, eyes, nose, throat, and lungs (Berry 1994; Bardana and Montanaro 1997).

In general, the main causes of poor indoor air quality are poor ventilation, pollutants emitted outside, biological contamination due to poor moisture control, building materials, inadequate cleaning, and tobacco smoke (Berry 1994; Godish 1995; Bardana and Montanaro 1997).

Cleaning and the use of cleaners promote good indoor air quality by minimizing the amount of dust, dirt, and odors that can cause a negative response in building occupants. Research Triangle Institute (RTI) (1994) assessed the effects of cleaning of indoor air quality and found that improved cleaning methods reduce the levels of biological, chemical, and particulate pollutants in the indoor environment. Additionally, cleaning removes sources of food for microorganisms and pests such as cockroaches and rodents. This reduces the potential for these organisms to cause poor indoor air quality.

On the other hand, many cleaners contain volatile ingredients, which evaporate during their use, and these VOCs cause sensory and central nervous system irritation. RTI (1994) found that cleaning chemicals containing lower concentrations of VOCs reduce the building levels of VOCs. Individuals exposed to 5 to 25 mg/m3 of a mixture of VOCs report an adverse response (Berry 1994; Kjaergaard 1991). In buildings, the major sources of VOCs include tobacco smoke, pesticides, and building materials such as insulation, wall and floor coverings, adhesives, and paint. Although cleaning chemicals are cited as a less significant source of VOCs, the use of VOCs in cleaners should be kept to a minimum to help maintain good indoor air quality.

LIFE magazine reveals that the public is mostly unaware that HOCl actually cleans their water.

Chlorine is currently employed by over 98 percent of all U.S. water utilities that disinfect drinking water. It has proved to be a powerful barrier in restricting pathogens from reaching your faucet and making you ill.

Chlorine effectively kills a large variety of microbial waterborne pathogens, including those that can cause typhoid fever, dysentery, cholera and Legionnaires’ disease. Chlorine is widely credited with virtually eliminating outbreaks of waterborne disease in the United States and other developed countries. And Life magazine recently cited the filtration of drinking water and use of chlorine as “probably the most significant public health advance of the millennium.”

Sonoma Pharmaceuticals Announces Publication of Consensus Report Describing Celacyn’s (Hypochlorous Acid) Impact on Post-Procedure Treatment and Scar Prevention … June 28, 2017 04:05 ET Source: Sonoma Pharmaceuticals, Inc.  For the abstract of this report:

I am excited about the potential of HOCl to efficaciously and safely treat wounds and scars.

This consensus concluded that hypochlorous acid has been shown to be an efficacious and safe therapy in pre- and post-procedure management, hypertrophic and keloid scar prevention and treatment. Through its potent broad-spectrum antimicrobial activity and anti-biofilm effects, HOCl solution has been associated with a lower risk of wound infection than other available treatments including Hibiclens, betadine and povidone-iodine. It increases oxygenation at wound sites, which may improve healing time. The safety of HOCl solution has demonstrated to be comparable to that of standard local antiseptics.

Evaluation of sprayed hypochlorous acid solutions for their virucidal activity against avian influenza virus through in vitroexperiments

The best way to combat with the [avian influenza (AI)] plague is to enhance biosecurity

Inactivation of AIV on the surfaces of objects or in the air at poultry farms would significantly reduce and or limit the chance for its circulation and outbreaks. Discovery of an effective aerosol disinfectant with applicability at farms that raise animals is a very important need to reduce bioaerosol.

Hypochlorous acid (HOCl) solution is one of the chlorine byproducts obtained by dissolving chlorine in water. The virucidal ability of solutions containing a high amount of HOCl is better than those containing HCl, because the virucidal ability of HOCl is 120 times higher than that of HCl. Furthermore, the level of free available chlorine in chlorine-based compounds (often called HOCl) is highest in pH 5 solutions.

DISCUSSION:  Hypochlorites are powerful oxidizing agents with bactericidal, fungicidal and sporicidal activity, and hypochlorous acid is their active moiety. There is less information available concerning the mechanism of action of hypochlorous acid solution, but in general, it affects structural proteins, such as the capsid or surface compounds, lipid envelop (if present) and nucleic acids (DNA or RNA) of viruses.

Hypochlorous acid solution is one of the chlorine compounds with good disinfection ability. In the present study, the aqueous phase of the original solution containing a free available chlorine concentration of 50 ppm could reduce the titer of an ordinary AIV (H7N1) from 107.7 TCID50/ml to lower than the detectable limit within 5 sec., which is faster than in previous reports, and its harvested solution after spraying from a distance of 1 cm had the same ability, but it lost its efficacy after spraying from a distance of 30 cm.

Installation and application of an appropriate spray system at the entrance (like an airlock entrance) and inside of animal farms at an appropriate distance and use of an ideal disinfectant, such as slightly acidic hypochlorous water, with a proper concentration would potentially reduce the chance of transmission of infections and diseases outbreaks.

Expert Recommendations for the Use of Hypochlorous Solution: Science and Clinical Application.

More advanced hypochlorous acid (HOCl) solutions, based on electrochemistry, have emerged as safe and viable wound-cleansing agents and infection treatment adjunct therapies.

Based on in vitro studies, the antimicrobial activity of HOCl appears to be comparable to other antiseptics but without cytotoxicity; there is more clinical evidence about its safety and effectiveness.

With regard to the resolution of infection and improvement in wound healing by adjunct HOCl use, strong evidence was found for use in diabetic foot wounds; moderate evidence for use in septic surgical wounds; low evidence for venous leg ulcers, wounds of mixed etiology, or chronic wounds; and no evidence for burn wounds.

The panel recommended HOCl should be used in addition to tissue management, infection, moisture imbalance, edge of the wound (the TIME algorithm) and aggressive debridement.

The panel also recommended intralesional use of HOCl or other methods that ensure the wound is covered with the solution for 15 minutes after debridement.

Effects of a low concentration hypochlorous Acid nasal irrigation solution on bacteria, fungi, and virus

CONCLUSIONS:  A low concentration HOCl solution can be used as an effective nasal irrigation solution

Direct Electric Current Treatment under Physiologic Saline Conditions Kills Staphylococcus epidermidis Biofilms via Electrolytic Generation of Hypochlorous Acid

CONCLUSIONS:  Our results are consistent with electrolytic generation of hypochlorous acid, a potent disinfectant, at the anode leading to biofilm killing.


Use of HOCl by the Human Body…. THE HUMAN BODY CONNECTION

February 11, 2019

Born to Fight Infection
Micro-organisms are found in the air we breathe and on the food we eat. As soon as a baby is born, innate defense mechanisms immediately protect the body and prevent infection by invading pathogens, microorganisms that are capable of causing diseases. The first line of defense is an external mechanical resistance that blocks entry into the human body. The skin, acts as a wall that keeps pathogens out of the body.  This nearly impermeable barrier is reinforced with chemical weapons such as lysozyme in the mouth which destroys bacterial cell walls and the acid pH of the stomach which inhibits microbial growth. Internal surfaces of the body secrete a sticky substance called mucus, which lines the surfaces of the respiratory, digestive, excretory and reproductive systems. This barrier coats and traps invading pathogens, which can then be can be swept away by cilia or destroyed by stomach acid.

Protection Against Unwanted Invaders
The second line of defense is the inflammatory response. White blood cells such as neutrophils respond to any tissue invasion by migrating to the site of infection.  Neutrophils, seek out pathogens such as bacteria or viruses, surround and destroy them using hypochlorous acid (HOCl). This process is known as phagocytosis (1). In the 1880s, the Russian microbiologist Metchnikoff  first reported the process of Phagocytosis. Metchnikoff observed that mobile white blood cells responded to the site of an infection and engulfed and destroyed the invading bacteria (2). The Nobel Prize winning microbiologist Metchnikoff called these hunting cells phagocytes, Greek for “eating cells,” and published his findings in 1883. The most common type of Phagocyte is the neutrophil, with 50 to 70 percent of the White Blood Cells in the body consist of neutrophils. The human body senses damage to tissue and, as part of the inflammation response sends out biochemical messengers called histamines in response to microbial invasion. These messengers act as warning signals to the body, increasing blood flow at the site of infection, causing the capillaries to become porous allowing neutrophil white blood cells to leave the capillaries and migrate to the site of infection (1).

Seeking Out and Engaging the Enemy
The neutrophils hunt down the ‘bad guys’ following the chemical trails left by invading micro-organisms through the process of chemotaxis. Once the neutrophils have  identified their target they bind to outer surfaces and devour them. The process of Phagocytosis

Finishing off the Bad Guy
Once engulfed inside the neutrophil cell the pathogen is encapsulated by a phagosome. The phagosome generates HOCL as the final step of the Oxidative Burst pathway, the centerpiece of the phagocytic killing mechanism. Large quantities of HOCl are released into the phagocytic vesicle to destroy the invading pathogen HOCl .

Chemistry of Neutrophil HOCL Production
During the oxidative burst pathway, neutrophils utilize the NADP oxidase enzyme complex which catalyzes the conversion of oxygen into superoxide anion (O2-). Superoxide dismutase then converts superoxide and water dismutase to form hydrogen peroxide (H2O2) and hydroxyl (OH) radicals. In the case of neutrophils the hydrogen peroxide then combines with chloride (Cl2-) ions by the action of the enzyme myeloperoxidase (MPO) to form hypochlorous acid (HOCL) (4).

The Beauty of HOCL
Simply take salt, water, and electricity and make HOCL. HOCL is produced when required to kill harmful microorganisms at the same concentration and at the same pH range as HOCl produced by the human body. HOCL is made on site on demand and replaces harmful and dangerous chemical. HOCl is many times more effective at killing harmful pathogens than hypochlorite, the major constituent of bleach (5). The  electrochemical process generates HOCl at near neutral pH using patented technology which generates the solution at the optimum pH to generate the maximum levels of hypochlorous acid.

Historical Use of Chlorine and HOCl
The laws of electrolysis were discovered by the English chemist Michael Faraday in 1832. Electrolysis is the passing of an electrical current through a salt electrolyte, which then breaks up into a positive and negatively charged solution (6). By the latter part of the 19th century chlorine and hypochlorite were being produced by the electrolysis of aqueous sodium chloride solutions.

The antimicrobial activity of HOCl was demonstrated over 120 years ago by Koch (7), it has found application in the treatment of recreational and industrial water systems, sanitary applications and surface disinfection in the food industry and the disposal of hospital waste (8,9) Granum & Magnussen, 1987; Tsai & Lin, 1999). Heuter first used HOCl as a wound disinfectant in 1831 and Semmelweis utilised its bactericidal properties as a hand wash in 1847, this form of uncombined chlorine has been widely used for the control of microbial activity.

HOCl First World War Life Saver
During The First World War many allied soldiers lives were saved by a wound treatment process developed by Alexis Carrel, a Nobel Prize winning French surgeon and Drysdale Dakin a British biochemist. The treatment involved a combination of removal of dead cells known as debridement, using specialized surgical technique and continuous irrigation with HOCl antiseptic fluid (10). As HOCl is not stable, the fluid was produced by adding boric acid to hypochlorite and delivered using a complex system of rubber tubing delivered HOCl known as Dakin solution to nearly every inner surface of the wound. Patients who received the Carrel treatment typically recovered in less than half the time of patients treated by other methods and was widely adopted the middle of 1915, saving lives and reduced the suffering of millions of allied soldiers.

Mimicking the Human Body
Simple elements salt and water generates HOCl, a natural biocide made by the human body’s white blood cells to fight infection.

1. Mark B. Hampton, Anthony J. Kettle, and Christine C. Winterbourn . Inside the
Neutrophil Phagosome: Oxidants, Myeloperoxidase, and Bacterial Killing. Blood,
Vol. 92 No. 9 (November 1), 1998: pp. 3007-3017
2. Metchnikoff E: Immunity in Infective Diseases. New York, NY, Johnson Reprint
Corp , 1968
3. Klebanoff SJ: Myeloperoxidase-halide-hydrogen peroxide antibacterial system.
Bacteriol. 95:2131, 1968
4. Mark B. Hampton, Anthony J. Kettle, and Christine C. Winterbourn. Involvement
of Superoxide and Myeloperoxidase in Oxygen Dependant Killing og
Staphylococcus aureus by Neutriphils. Infection an dImmunity, Sept 1996, pp.
5. Morris J.C. (1966) Future of chlorination. J. Am. Water Works Assoc. 58: 1475-
6. Kraft A., Stadelmann M., Blaschke M., Kreysig D., Sandt B., Schroder F. and
Rennau J. (1999) Electrochemical water disinfection Part I: Hypochlorite
production from very dilute chloride solutions J. Appl. Electrochemistry. 29: 861-
7. Wallhauber K.H. (1988) Praxis der Sterilisation-Disinfektion-Konservierung-
Keimidentifizierung-Betriebshygiene. Georg Thieme Verlag, Stuttgart.
8. Granum P.E. and Magnussen J. (1987) The effect of pH on hypochlorite as
disinfectant, Int. J. Food Micro. 4: 183-186
9. Tsai C.T. and Lin S.T. (1999) Disinfection of hospital waste sludge using
hypochlorite and chlorine dioxide. J. Appl. Microbiol. 86: 827-833
10. Carrel, H. D. Dakin, Daufresne, Dehelly, Dumas:
Traitement de l’infection des plaies. Bulletin de l’Académie de médecin, Paris,
1915, 3rd series;74:361-368.
11. Gordon and Bubnis. Products of Salt Brine Electrolysis December (1999).

Identifying and eradicating biofilm (with HOCL)

November 12, 2018

Steps to eliminate an age-old hazard from the health care environment

June 6, 2018

John Scherberger, FAHE, CHESP

Biofilms serve as protective coatings for microbes to shield them from unfavorable environments.

Biofilms are complex colonies of microorganisms that serve as protective coatings for microbes to shield them from unfavorable environments such as heat, ultraviolet light, cold, disinfectant chemicals and antibacterial drugs used in health care.

The components of biofilm greatly heighten bacteria’s resistance to antibiotics, thus enhancing the longevity and potential harm caused by bacteria.


It often appears as slime and discoloring that can be seen in sink and floor drains, buildup around leaking faucets and faucet sprayers, unused toilets and floor mop sinks, hoppers found in soiled utility rooms in hospitals and janitors’ closets in commercial buildings. But biofilm is not always easily seen because it is found in many out-of-the-way locations such as air handlers, air conditioning evaporation trays, water cooling towers, and water coolers, features and fountains.

When biofilm is seen and (most often) not seen, bacteria are present and must be treated and approached with caution and concern.

Biofilm and health

Biofilm has existed as long as bacteria have been on the planet. But it wasn’t until the early 1970s that scientists began to understand the major impact biofilm had on human health; and scientists only began to understand the complexity of biofilms in the 1980s and 1990s.

It is not just an annoyance or another nuisance to be casually addressed by environmental services (ES) or facilities departments. It is an ever-present threat to health and the environment.


For instance, recent studies and investigations have shown that biofilm has been a major contributing factor in harm caused by improper or incomplete processing of medical devices and implants such as catheters, prosthetic joints and heart valves. Despite standardized processes thought to be effective at sterilizing medical instruments, biofilm is so pervasive and robust that numerous serious patient outcomes have resulted.

Failure to properly reprocess medical instruments to eradicate and remove biofilm during reprocessing of instruments like endoscopes prior to surgical procedures has resulted in infections such as carbapenem-resistant Enterobacteriaceae (CRE) being transferred to patients. As a result, the Centers for Disease Control and Prevention (CDC) established new procedures to ensure biofilm eradication is addressed when endoscopes are processed.

A hospital must be addressed in a universal manner because one area can have an impact upon another — even on other floors or nonintegrated departments. Too often, ES departments are not called upon to address issues found in nonclinical areas of hospitals.

For example, one area not typically addressed by the ES department in its constant pursuit of hygienic patient environments is food service facilities and locations. Biofilm is not only a constant concern as a source of food spoilage, but also food contact and preparation surface contact because, once food contact surfaces become contaminated with biofilm, it is much more difficult to eradicate the exopolysaccharides and bacterial cells of the bacteria.

Eradication and removal

Bacteria communicate and collaborate via chemical interactions for survival. To eradicate and remove bacteria and biofilm from the health care environment, a multidisciplinary and multimodal approach is essential. No one department can succeed and no one department has all the answers.

Biofilm is dangerous to immunocompromised patients. Therefore, removal and eradication must be concentrated and strategically approached.

Multidisciplinary teams must identify potential sites for targeting, which may include hot and cold water supply lines, idle faucets, drains, bathrooms, floors, moist/damp areas, soiled utility rooms, soiled laundry shafts, ice machine drains and dispensing chutes, water fountains, boiler rooms, air vents and many other areas.

Health facilities professionals who are responsible for the hospital environment must recognize that biofilm is not always seen by casual visual inspection and presents a real danger. These disciplines must also recognize that appropriate personal protective equipment (PPE) always should be used when addressing the removal of biofilm as the nature/virulence of a biofilm always must be considered suspect.

Facilities professionals tasked with locating, eradicating and removing biofilm also should be trained and educated regarding why they should look for it, what to look for and how to eradicate and remove biofilm once located.

Often, those responsible for carrying out biofilm removal are just told to “do it” or “get it done” without any specific directions or knowledge. Left to one’s own inventiveness or lack thereof, results are often minimal or even disastrous.

For example, thinking that pouring bleach or a bleach solution down a drain or on a surface will terminate the issue is shortsighted. Biofilm is produced to protect bacteria from harsh environments and disinfectants such as bleach, and antibiotics fall into the definition of a harsh environment.

ES professionals also should recognize that bleach does not clean; rather it is an oxidizer and disinfectant. Hypochlorous acid (HOCl) is an Environmental Protection Agency (EPA)-registered, hospital-grade disinfectant that is as effective as bleach (if not more) in the biofilm-abolition process and is much safer for the environment, metals, staff and PPE. The odor is not noxious and thus safer for all concerned, particularly if removing biofilm from a closed and fresh-air-deprived environment.

Additionally, hospitals are subject to EPA regulations regarding discharge of residual chlorine into wastewater. If an incorrect solution is applied, the possibility exists of exceeding the maximum residual chlorine level into the waste stream.

HOCl is considered a safe alternative to bleach for its disinfecting ability and is safer for personnel to use. However, ES professionals must have a complete understanding of both bleach and HOCl reactivity. With both solutions, there is still the potential for danger if ammonia is present. Both solutions, when mixed with ammonia, are hazardous. Neither HOCl nor sodium hypochlorite should ever be introduced directly into any drain without first flushing the drain with clean water. If ammonia in any form is present, doing so may result in chloramine gas being released, which may cause respiratory distress or death.

Disruption and eradication

Biofilm in the health care environment — as opposed to being present on implants or other implements introduced into a body — must be disrupted through mechanical or physical action.

Once a multidisciplinary and multimodal team has been identified and trained, how the process is implemented is vital. The following actions may be used or adapted by ES professionals:

  • If possible, determine the type or identity of the biofilm to be removed to know the best process to implement.
  • Discuss what chemical/disinfectant is to be used and how it is to be applied.
  • The decision to manually scrub with a brush and a bucket of cleaner/disinfectant is usually one of the first to be considered and dismissed. But, just as in medicine, the guiding principle for removal and eradication of biofilm should be to use the most appropriate and efficient method without disrupting or causing harm to surrounding areas.
  • Scrubbing or high-pressure spraying is most often the choice, but must be appropriate to the environment and conditions personnel may encounter. Methods and chemicals will be dictated by accessibility, electrical considerations, the patient care environment and restricted areas such as pharmacies, intensive care units or research labs.
  • Steam is also one of the most useful multimodal interventions that can be used in combating biofilm. Two types of steam generators are normally available for health care ES: low-pressure/high temperature electric powered, usually with a self-contained steam chamber that uses manual effort in combination with mechanical action (brushes or microfiber cloths) designed for small spaces; and high-pressure/high-temperature generators that are fully electric or a combination of electric/gas units connected to water supply sources via hoses. These units rely on high-pressure water nozzles to disrupt and remove biofilm. The high temperature of both types of generators dislocates and kills the cells, and the manual or mechanical pressure physically removes the biofilm and most biofilm molecules from surfaces. Again, the environment in which the biofilm is located must be considered.
  • The physical removal of the biofilm must be followed by removing any remaining contaminated water from floor, metal or other surfaces lest any bacteria remaining be allowed to repopulate the contact surfaces.
  • The previous step should be followed by a clean-water rinse followed by an application of a properly diluted solution of a germicidal agent such as HOCl.

Proper and appropriate PPE must be used and documented. Implementation of the buddy system — especially in closed and potentially dangerous environments — must be followed.

ES professionals must use safe and effective cleaners and disinfectants for cleaning and disinfecting brushes, wipers, buckets, scrapers, mops, steam generators, wet vacuum cleaners and attachments, and clothing/footwear that may have been contaminated. Proper hand washing after completion of the assigned tasks must be followed as well.

Training required

Proper processing of clinical and aesthetic surfaces (cleaning and disinfecting with proper tools that trap and remove bacteria and unseen biofilm) is an essential step toward the goal of a healthy, hygienic patient care environment. Biofilm will never be completely eradicated from the health care environment, but every reasonable effort to prevent its presence and proliferation must be taken.

Formal training of ES and facilities staff regarding the virulence and ubiquitous nature of biofilm must be a priority.

The Association for the Healthcare Environment’s Certified Healthcare Environmental Services Professional, Certified Healthcare Environmental Services Technician and Certified Surgical Cleaning Technician programs are excellent first steps in addressing the importance of proper processes and techniques to address biofilm.

John Scherberger, FAHE, CHESP, is president and founder of Healthcare Risk Mitigation, Spartanburg, S.C. He can be contacted via email at

HOCL as an antimicrobial

November 11, 2018

Topical antimicrobials are frequently used in conjunction with treatment and surgery to prevent and reduce the likelihood of infection. Hypochlorous acid (HOCl) is naturally occurring and its benefits has been well documented. The use and safety of HOCl as an antimicrobial in healthcare settings is supported by available evidence.

In the human body, cells produce hypochlorous acid – which helps destroy bacteria – thus making HOCl a naturally occurring chemical. Hypochlorous acid (HOCl) is a weak acid consisting of reactive oxidizing molecules that include hypochlorous acid and peroxide. This evolutionary response of white blood cells has allowed them to combine hydrogen peroxide and an enzyme known as myeloperoxidase to produce HOCl which safely and effectively eradicates any known pathogen in nature.  HOCl has enabled our biology (i) to eradicate every pathogen by dissociating into different oxidative molecules each with a distinct mode of action and capability to eradicate pathogens (ii) while remaining safe to mammalian cells through the entire biological process and (iii) not promoting the emergence of newly resistant bacteria.

HOCl is a potent antimicrobial capable of eradicating bacteria including antibiotic-resistant strains, viruses, fungi, and spores. For more than 25 years the technology has been used worldwide primarily for the mechanical cleansing and debridement of wounds. “Chlorine-containing biocides are widely used for the decontamination of surfaces, usually in the form of hypochlorite (ClO−), being inexpensive to produce and having proven antimicrobial activity”. Applications of aqueous solutions containing approximately 30-2500 ppm (.003% to 0.25%) HOCl are in a variety of areas including (but not limited to) wound care4, as antimicrobial agents5, as anti-allergen agents6, dental care7 and there are also significant applications in water treatments8, food sanitization9, and hard surface disinfection10, oil drilling11 and cosmetics12

Mode of Action

When water and sodium hypochlorite interact, they produce Na+ and OCl− in an equilibrium with hypochlorous acid (HOCl). Th pH affects the predominance of HOCl or OCl− in solution. As [insert citation paper] states that chlorine exists primarily as hypochlorous acid between pH 4 and 7, as opposed to hypochlorite being the most prevalent above pH 9.

Hypochlorous acid is the active component responsible for bacterial disruption by chlorine-releasing agents (CRAs). It is understood that the OCl− ion has little effect compared to undissolved HOCl.

Hypochlorous acid indiscreetly targets bacteria by chemically linking (or attaching) chlorine atoms to  nucleotide bases that disrupt the function of bacterial DNA, impede metabolic pathways in which cells use enzymes to oxidize nutrients, and release energy, and other membrane-associated activities. At certain concentrations, HOCl eradicates spores and viruses. As a sporicide, HOCl causes the spore coat to detach from the cortex, where further degradation occurs.[e1] According to Springthorpe, “CRAs also possess virucidal activity”. HOCl is an effective virucidal when fogging a confined space. Park et al describes how  “Exposing virus-contaminated carriers of ceramic tile (porous) and stainless steel (nonporous) to 20 to 200 ppm of HOCl solution resulted in ≥99.9% (≥3 log10) reductions of both infectivity and RNA titers of tested viruses within 10 min of exposure time. HOCl fogged in a confined space reduced the infectivity and RNA titers of NV, murine NV, and MS2 on these carriers by at least 99.9% (3 log10), regardless of carrier location and orientation. We conclude that HOCl solution as a liquid or fog is likely to be effective in disinfecting common settings to reduce NV exposures and thereby control virus spread via fomites”


Toxicity, flammability and compatibility of materials should be considered in selecting an appropriate disinfectant. For environmental decontamination applications within habitable spaces, clearly certain biocides are too toxic (e.g., phenolics and glutaraldehyde) or flammable (e.g., alcohols) or have the potential to leave unwanted residues on surfaces (e.g., iodophors). Hypochlorous is not flammable and not known to release harsh chemicals. Hypochlorous acid should not be mixed with ammonia-based products, as chloramines can be released.

EPA Approved Marketing Claims

The Environmental Protection Agency approved marketing claims in 2017 for Lysol’s Daily Cleanser (owned by Reckitt Benckiser), a hypochlorous acid product with the following ingredients, water (99.813%), salt (0.17%), Hypochlorous acid (0.017%). Lysol’s approved marketing claims exhibit it’s product to be gentle with no harsh vapors, safe for babies and pets, and suitable for medical applications.

  1. Suitable (for use) as a (peroxide alternative)
  2. Breaks Down to Saline Solution
  3. (Breathe Easy:) (Fragrance Free) (No Harsh Fumes) (No Harsh Chemicals)
  4. Leaves no harsh (chemical) residue
  5. No harsh (chemical(s)) (residue) (left) (behind)
  6. A (gentle) (mild) way to clean
  7. No rinsing (necessary) (required)
  8. For use in (newborn) nurseries
  9. For use in neonatal nurseries
  10. No harm after pet contact with product
  11. Fragrance Free, won’t irritate your dog’s nose
  12. No harsh fumes to irritate (pet) (dog) noses
  13. (Gentle) (Mild) (enough) to use on any washable hard, non-porous surface

Acute Oral Toxicity

A 2-year study by the National Toxicology Program was initiated to determine the potential toxicity and carcinogenicity associated with extended, direct exposure to chlorinated water or indirect chemical exposure through the formation of by-products. This study is cited for its completeness. Water containing 0, 70, 140, or 275 ppm chlorine (based on available atomic chlorine) was given to both female and male rats and mice. Further, water containing 50, 100, or 200 ppm chloramine was administered to rats and mice of both sexes for 2 years as well. The study noted that survival among treated rats and mice was similar to controls. The Environmental Protection Agency used NTP study to develop an oral Reference Dose (RfD) for chlorine. In the EPA’s Rfd report, they clarify that “the term “free chlorine” (free available chlorine, free residual chlorine) refers to the concentrations of elemental chlorine, hypochlorous acid and hypochlorite ion that collectively occur in water.” A No Observed Adverse Effect Level (NOAEL) was identified by the EPA, which states “the NOAEL of 275 ppm (13.6 or 14.4 mg/kg-day for male and female rats, respectively)”. Another hypochlorous acid study was performed that exposed rats to 14 mg/kg-day for up to 12 months (Abdel-Rahman et al. 1984). A NOAEL of 14 mg/kg-day was identified for this study. No mortality was observed. Only minor systemic toxicity was found.

[Insert: HOCl is less that acute toxicity amount]

NTP, 1992. Chlorinated and Chloraminated Water, NTP TR 392

Respiratory and Inhalation Effects

A 2-year chlorine gas inhalation study with rats showed no evidence of carcinogenicity (CIIT 1993; Wolf et al. 1995).

According to the Environmental Protection Agency an Inhalation Reference concentration (RfC) for chlorite is not recommended at this time.

Pool chlorination has been associated with a risk of developing asthma. However results of pool chlorination causing respiratory symptoms or other health effects are not consistent. Font-Ribera et al suggests that swimming did not increase the risk of asthma or allergic symptoms in British children. However swimming was associated with increased lung function and lower risk of asthma symptoms, especially among children with preexisting respiratory conditions. Goodman et al conducted a meta-analysis that noted that asthma and swimming could only be confirmed in a study of only non-competitive swimmers. The study mentions that it’s too early to draw conclusions between swimming and asthma, since the association isn’t confirmed among non-competitive swimmers. The study also notes, “Asthmatics may be more likely to select swimming because of their condition”.

Jiang-Hua Li et al mentions that chlorination is the most popular method for disinfecting swimming pool water; however, although pathogens are being killed, many toxic compounds, called disinfection by-products (DBPs), are formed. The study, with a rat model concluded that direct irritation of the DBPs to the respiratory tract, eyes and skin because these organs were in direct contacted with the DBPs, the eyes and skin might be the organs that require greater attention for permanent damage, the liver is most likely the most possible target organ of DBPs. Also that training intensity, training frequency and water choking may be the primary factors for lung damage induced by swimming, instead of chlorination.

“Nevertheless, disinfection of swimming-pool water with chlorine is an example of how a very strong oxidant such as HOCl can be tolerated by humans if the concentration is accordingly low. As a result of feeding chlorine gas into the pool water, HOCl is formed (see equation 1) and maintained at a very low concentration equivalent to 0.5 to 1.5 mg Cl2/liter (7.1 to 21.2 μM).”

With enough free chlorine and adequate ventilation to blow away the breakdown products that gas off the pool, the chlorine will break down the ammonia products until nitrogen is all that is left, which gases off the pool.

Nitrogen trichloride is the cause of most of that “swimming pool” smell. It can be highly irritating and is the cause of the lung, eye and throat irritation people experience in poorly ventilated indoor pools.

Ae Dermal Toxicity


Few animal studies addressed no- or mild-effect levels at exposure times of 10 min to 8 h. No gross or microscopic lung changes occurred in rabbits following a 30-min exposure at 50 ppm (Barrow and Smith 1975). The highest 30-min values resulting in no deaths (LC0) for the rat and rabbit were 547 ppm (Zwart and Woutersen 1988) and 200 ppm (Barrow and Smith 1975), respectively. The 60-min concentrations resulting in no deaths in the rat and mouse were 322 (Zwart and Woutersen 1988) and 150 ppm (O’Neil 1991), respectively. No deaths, but moderate to severe lesions of the respiratory tract and peribronchiolitis, occurred in rats following a 6- h exposure at 9.1 ppm (Jiang et al. 1983).

Thirty-minute LC50 values ranged from 137 ppm in the mouse (Back et al. 1972) to 700 ppm in the rat (Zwart and Woutersen 1988). The 60-min LC50 and LC01 values for the rat were 455 ppm and 288 ppm (Zwart and Woutersen 1988).

Reproductive & Developmental Effects

Chlorine administered in the drinking water or by gavage to rats or mice did not cause reproductive or developmental problems (Druckrey 1968; Abdel-Rahman 1982; Meier et al. 1985; Carlton et al. 1986).


HOCL can be synthesized through electrolysis of a dilute brine solution:

In the electrolysis process, a brine solution (NaCl + H2O) provides the chloride ion (Cl-) that is reduced (by electricity) to form chlorine gas. This process is done in water, so the chlorine gas produced chemically reacts with water present to produce hypochlorous acid (HOCl), hydrogen ion (H+) and chloride ion (Cl-). The reaction is as follows:

2Cl-      Cl2                                 (electrolysis)
Cl2  +  H2O     HOCl  +  H+  +  Cl-            (hydrolysis)

This process utilizes an electrochemical chambered cell or group of cells that have electric current passed through the aqueous NaCl solution.
OCl-   +   H+       HOCl                       (lowering  pH)

To be continued……

Your HOCL caregiver,

Michel van Schaik,

For more information visit

Air Purification in Inhabited Rooms by Spraying or Atomizing Hypochlorites (HOCL).

November 10, 2018

Author(s) : MASTERMAN, A. T.

Journal article : Journal of Industrial Hygiene and Toxicology 1938 Vol.20 pp.278-88

Abstract : A sodium hypochlorite solution containing sodium chloride was atomized and the rate of progress of the vapour followed by means of a series of Bunsen burners placed at increasing distances from the atomizer. The yellow sodium flame indicated when the vapour reached the burner and also how long it persisted in the neighbourhood. The rates of travel varied in different experiments, but in one experiment quoted, in which the sprayer was worked at 4 1b. per sq. inch air pressure and in which a hypochlorite solution containing 0.05 per cent. available chlorine was used, the spray travelled 20 feet in under two minutes and persisted for over 20 minutes. Experiments were carried out by exposing Petri dishes containing nutrient agar at different parts of a room or factory in which numbers of people were working, and measuring the degree of air purification that occurred following a single spraying by the decrease in the number of colonies developing. In different experiments it was found that the plate count 1-5 hours after spraying might show a reduction of 90 per. cent. on the .initial count. The proportion of active chlorine needed was not determined precisely, though in one experiment a concentration of 0.14 mgm. of active chlorine per cu. ft. appeared to yield satisfactory results. Assuming that the chlorine was in the form of hypochlorous acid gas, this would represent a concentration by volume of one part in six millions. No discomfort was caused to any of the occupants of the room or factories. G. S. Wilson.

Record Number : 19382701336

Descriptor(s) : chlorine, factories, feet, occupational health, purification, sodium chloride, sodium hypochlorite, spraying

Identifier(s) : NaCl



November 9, 2018


Wound complications such as infection continue to inflict enormous financial and patient quality-of-life burdens. The traditional practice of using antiseptics and antibiotics to prevent and/or treat infections has been questioned with increasing concerns about the cytoxitity of antiseptics and proliferation of antibiotic resistant bacteria. Solutions of sodium hypochlorite (NaOCl), commonly known as Dakin’s solution, have been used in wound care for 100 years. In the last 15 years, more advanced hypochlorous acid (HOCl) solutions, based on electrochemistry, have emerged as safe and viable wound-cleansing agents and infection treatment adjunct therapies. After developing a literature-based summary of available evidence, a consensus panel of wound care researchers and practitioners met to review the evidence for 1) the antimicrobial effectiveness of HOCl based on in vitro studies, 2) the safety of HOCl solutions, and 3) the effectiveness of HOCl acid in treating different types of infected wounds in various settings and to develop recommendations for its use and application to prevent wound infection and treat infected wounds in the context of accepted wound care algorithms. Each participant gave a short presentation; this was followed by a moderated roundtable discussion with consensus-making regarding conclusions. Based on in vitro studies, the antimicrobial activity of HOCl appears to be comparable to other antiseptics but without cytotoxicity; there is more clinical evidence about its safety and effectiveness. With regard to the resolution of infection and improvement in wound healing by adjunct HOCl use, strong evidence was found for use in diabetic foot wounds; moderate evidence for use in septic surgical wounds; low evidence for venous leg ulcers, wounds of mixed etiology, or chronic wounds; and no evidence for burn wounds. The panel recommended HOCl should be used in addition to tissue management, infection, moisture imbalance, edge of the wound (the TIME algorithm) and aggressive debridement. The panel also recommended intralesional use of HOCl or other methods that ensure the wound is covered with the solution for 15 minutes after debridement.
More controlled clinical studies are needed to determine the safety and efficacy of HOCl in wound types with limited outcomes data and to evaluate outcomes of various application methods.

KEYWORDS: hypochlorous acid, review, anti-infective agents, wound, cleansing
INDEX: Armstrong D, Bohn G, Glat P, Kavros S, Kirsner R, Snyder R, Tettelbach W. Expert recommendations for the use of hypochlorous acid solution: science and clinical application. Ostomy Wound Manage. 2015;61(5 suppl): 4S–18S.


DAVID G. ARMSTRONG, DPM, MD, PHD, has disclosed he has received honorarium for participating in an Innovacyn scientific advisory board.
GREGORY BOHN, MD, FACS, ABPM/UHM, FACHM has disclosed he has received speaker honoraria and served as a consultant or paid advisory board member for Innovacyn. Dr. Bohn is also a member of the Speakers’ Bureau for Steadmed Poster Support.
PAUL GLAT, MD, FACS, has disclosed he has received speaker honoraria and served as a consultant or paid advisory board member for Innovacyn. Dr. Glat is also a member of the Speakers’ Bureau for Integra LifeSciences and Smith and Nephew.
STEVEN J. KAVROS, DPM, FACCWS, CWS, is the Medical Director of Innovacyn, Inc.
ROBERT KIRSNER, MD, PHD, has disclosed he has received speaker honoraria and served as a consultant or paid advisory board member for Innovacyn. Dr. Kirsner is a scientific advisor for Innovacyn, Mölnlycke, Kerecis, and Cardinal Healthcare. Dr. Kirsner is also a consultant for Kerecis.
ROBERT SNYDER, DPM, MSC, CWS, has disclosed he has received speaker honoraria and served as a consultant or paid advisory board member for Innovacyn. Dr. Snyder is also a consultant for Macrocure, MiMedx, and Acelity.
WILLIAM TETTELBACH, MD, FACP, CWS, has disclosed he has received speaker  honoraria and served as a consultant or paid advisory board member for Innovacyn. He is a member of the speakers’ bureau for Spiracur and MiMedx.



November 8, 2018

Some of the truths about to be stated may be hard to admit.  Nevertheless, let our blunt approach be a wake-up call that empowers you to make real conversion to HOCL & NaOH SOLUTIONS.

The characteristics of HOCL & NaOH should be of interest to Environmental Services (EVS)and Infection Preventionists (IP), but few are joining the knowledge parade or paying serious attention.

The good news is that other actively-engaged professionals are now recognizing that HOCL & NaOH are ready-to-use, low-cost SOLUTIONS that render healthcare facilities really safe and hygienic.  And, these SOLUTIONS are safe when discharged into the environment.

Over the years, EVS and IP resistance has centered around 1) wanting to avoid being first, and 2) wanting to speak to “someone in a local hospital” rather than accept that a number of nationally-recognized hospitals have made successful HOCL & NaOH conversion.


EVS & IP are reluctant to drop using their chemical distributor in spite of their awareness that on-site generated HOCL & NaOH SOLUTIONS are less expensive and more-effective cleaners and disinfectants.

Insisting that only EPA registered disinfectants can be used, EVS & IP fail to grasp that the HOCL SOLUTION generated is an EPA registered hospital-grade disinfectant … while the Aquaox on-site generator itself is not.

Aquaox Infection Control Systems include two EPA registered disinfectants.  Rather than accepting HOCL efficacy data and combined label claims, IP looks for off-label microorganisms (not found on chemical labels, either).  So, what is enabling big companies to continue providing chemicals unsound for humans, facilities and the environment?


Failure to share, cooperate and collaborate leads to the dysfunction of departments and disciplines responsible for ensuring hygienic equipment and outcomes.

Until EVS leaders take responsibility to become more educated and aware of issues historically outside their wheelhouse, they cannot be effective centers of influence in their hospitals.

Support for using HOCL and NaOH solutions must come from the board of directors and facility manager.

The most effective approach is TOP-DOWN directive from the Board and/or C-level executive(s) that the EVS (contract cleaners) use only on-site generated HOCL & NaOH SOLUTIONS and that their company is subject to dismissal should they bring on property any unapproved (specialty) chemicals or attempt to push other disinfection methods.

When top management is truly ready to make a change for the better – they can have improvements in hygiene cleanliness and really effective discharge-room outcomes that result in reduced infection rates and bring higher patient satisfaction ratings.

Lip service does not bring back lives lost due to failure to reduce HAI rates.

The real fear ought to be what happens when not making the conversion.

Again, let our blunt approach be a wake-up call that empowers you to make a clean conversion with HOCL & NaOH SOLUTIONS.

Aquaox’ years of onsite experience validates that disinfectants do not effectively remove debris. Keeping surfaces clean requires effective, periodical cleaning using a detergent. Then, spray disinfectant and let air-dry.

For more information, contact Michel van Schaik at 800.790.7520.

Hospitals focus on antibiotic overuse as CMS prepares new mandate

December 30, 2014
Antibiotic resistance is a threat to national security.

That’s how President Barack Obama described the rapid growth of such resistance when he issued an executive order in September instructing HHS and the Defense and Agriculture departments to take aggressive action on the issue.

The president cited federal data showing that at least 2 million Americans are infected with drug-resistant bacteria each year and 23,000 die as a result. He emphasized the critical need for improved antibiotic stewardship—coordinated practices promoting the appropriate use of antibiotics—in healthcare facilities. Federal officials say such programs are among the most effective ways to curb resistance and reduce the number of hard- or impossible-to-treat infections.

A growing number of hospitals are instituting stewardship programs, which experts say not only improve patient outcomes, but also reduce costs and lengths of stay and lower antibiotic-resistance rates within hospitals. Those efforts have been bolstered by looming federal action that would make the inclusion of a stewardship program a requirement to participate in Medicare.

But many hospitals—especially smaller, community facilities—face tough challenges, often related to inadequate staffing and resources. Increasingly, however, those hospitals are using telemedicine, local partnerships and other creative strategies to push stewardship forward.

Intermountain Healthcare is conducting a 15-hospital study on running stewardship programs in smaller hospitals. Kenmore Mercy Hospital, a 155-bed facility in Buffalo, N.Y., is collaborating with independent physicians in its accountable care organization to educate its staff on antibiotic best practices. Other smaller hospitals in California and Minnesota have contracted with infectious-disease, or ID, specialists to lead their programs.

“We can’t control how fast bacteria develop resistance or how fast we develop new drugs, but antibiotic stewardship is 100% under our control,” said Dr. Arjun Srinivasan, associate director for healthcare-associated infection prevention programs at the Centers for Disease Control and Prevention. “I would go so far as to say antibiotic stewardship is one of the most important things we can do.”

Stewardship initiatives vary widely. But in a March report, the CDC listed the core elements for such programs, which include a commitment from senior leadership, tracking and reporting of antibiotic prescribing patterns and resistance, clinician education and the appointment of a single person to lead the effort.

Benefits of stewardship programs

Stewardship programs, the CDC recommended, should implement at least one intervention, such as prior authorization for certain restricted antibiotics, antibiotic dose optimization, or prospective audit and feedback. The last involves someone outside the treating team reviewing antibiotic orders and cultures and advising clinicians on recommended changes.

In addition to improving patient outcomes, stewardship programs save money, in most cases more than paying for themselves, Srinivasan said. According to data cited by the CDC and the Infectious Diseases Society of America, a comprehensive antibiotic stewardship program can reduce antibiotic use by 22% to 36%, with annual savings of $200,000 to $900,000. “It’s a win across the board,” Srinivasan said.

Officials estimate that roughly half of the nation’s hospitals have some kind of antibiotic stewardship program. But little is known about how robust those programs are and their interventions. “We need better data,” Srinivasan said. The CDC is planning in 2015 to add several questions about stewardship to its annual survey, distributed to the more than 4,000 hospitals that report healthcare-associated infection data to the CDC’s National Healthcare Safety Network.

He predicted that in the coming year, hospitals will look more seriously at implementing stewardship programs or beefing up the ones they already have. That’s at least partly because CMS officials have said the agency plans to add antibiotic stewardship to its hospital conditions of participation, a move Srinivasan said would have “a transformative effect.”

Dr. Shari Ling, deputy chief medical officer in the CMS’ Center for Clinical Standards and Quality, confirmed that the agency plans to propose a condition of participation for antibiotic stewardship in 2015, with an implementation window in 2017. Currently, California is the only state that mandates that hospitals have stewardship programs.

The challenge for the CMS, Ling said, will be ensuring that the new rules allow for differences in hospital size and resources. “The condition of participation has to permit flexibility so that all facilities can engage in a way that’s meaningful for them,” she said.

Large academic medical centers, for instance, usually have specialized infectious-disease doctors and pharmacists who can guide stewardship programs, while smaller hospitals rarely do. And smaller hospitals often lack the money and IT infrastructure that larger facilities can use to boost their efforts.

Srinivasan said the CDC tried to address that variation in its March report. “We tried to boil it down to program functions instead of employee titles so that it was useful to all hospitals,” he said. “Our goal was to say, ‘Here are the things you need to do, but who does them will depend on who you have available in your facility.’”

MH Takeaways

Smaller hospitals look to telemedicine and partnerships with infectious- disease experts to establish best practices on appropriate use of antibiotics.

The needs of smaller hospitals

Another challenge is that there are few studies—and no randomized controlled trials—that provide evidence-based guidance on how to implement antibiotic stewardship in smaller hospitals, said Dr. Eddie Stenehjem, medical director of antimicrobial stewardship at 21-hospital Intermountain Healthcare, headquartered in Salt Lake City. “Most of our data comes from large urban hospitals,” he said. “We have no idea what really works in a smaller hospital.”

Stenehjem and his colleagues are trying to find out. They are in the midst of a 15-month randomized trial, launched in March 2014, that includes 15 Intermountain community hospitals, some with fewer than 20 beds. Each hospital was assigned to one of three groups, receiving a high-, medium- or low-level antibiotic stewardship program.

The low-level group received a set of stewardship best practices, antibiotic usage data and training for the hospitals’ pharmacists. In contrast, hospitals in the high-level group received best practices and usage data, a more robust curriculum, monitoring of antibiotic restrictions by an off-site infectious-disease pharmacist and review of each culture by an off-site infectious-disease physician. Stenehjem said he hopes the study, scheduled to end in June, will shed light on the needs of smaller hospitals and which stewardship initiatives work best for them.

Riverton (Utah) Hospital, a 92-bed facility, is in the high-level group in Stenehjem’s study. The hospital had no formal stewardship program before the study, said Jennie Barlow, a clinical pharmacist. But 10 months in, the hospital’s pharmacists and physicians now rely on support from Stenehjem and his colleagues. “I hope the study shows that the high-level approach is the one that works best, because it’s great to have the extra help,” she said.

That support from an ID specialist is especially valuable when advising a physician about appropriate use, said Karla Snow, Riverton Hospital’s pharmacy director. “If a physician ordered a restricted antibiotic before, we didn’t always feel comfortable pushing back,” she said. “Now our physicians know we have ID physicians on board.”

Hospitals that don’t have outside help, though, still can make progress, Snow said. She advised starting small with “low-hanging fruit,” such as intravenous-to-oral conversions, when IV antibiotics are switched to their oral version. That’s a change that reduces the risk of infection, improves patients’ mobility and lowers costs. Antibiotic timeouts—when antibiotics are reviewed after 48 hours to assess whether they are being appropriately used and whether they are still necessary—are also relatively easy to implement, she said.

Creative solutions

Kenmore Mercy Hospital in Buffalo had several of those stewardship components in place but had never pulled them together into a formal program, said James Bartlett, the hospital’s lead clinical pharmacist. Then in 2012, its parent, Buffalo-based Catholic Health System, was recognized as an ACO under the Medicare Shared Savings Program, which provided financial incentives to collaborate and improve outcomes. “All of a sudden, we had all these different groups in our ACO that were looking for ways to optimize care,” Bartlett said.

Kenmore Mercy partnered with an independent physician group within its ACO to launch a stewardship program at the hospital. The physicians group provided the infectious disease support and helped to educate Kenmore Mercy’s physicians and pharmacists on antibiotic best practices. “We have a meeting every day where we review cases with an ID physician,” Bartlett said. “And every single one of our pharmacists rotates through the lead stewardship role so they can get used to it and learn from the ID physicians.”

During the first year, the program saved more than $145,000 on drug purchasing alone, he said. Pharmacist-initiated IV-to-oral conversions increased 688%, compared with the previous year. And physicians accepted the recommendations of infectious-disease physicians nearly three-quarters of the time.

Like Stenehjem, Bartlett noticed the dearth of research about antibiotic stewardship programs at community hospitals. He and a colleague wrote an article describing their experience designing an antimicrobial stewardship program, which was published in June in the American Journal of Health-System Pharmacy.

Bartlett acknowledged that Kenmore Mercy’s program would have been harder to implement without the help of its parent health system and the other members of its ACO. “Without that support, our program would not look the way it looks now,” he said.

One option for small, stand-alone hospitals looking to implement stewardship programs is telemedicine, said Dr. Javeed Siddiqui, founder and chief medical officer of TeleMed2U, a Roseville, Calif.-based company that offers a telemedicine-based antimicrobial stewardship program. His company provides stewardship services for three California hospitals, including 65-bed Sonoma (Calif.) Valley Hospital and 48-bed Ukiah (Calif.) Valley Medical Center. California hospitals are especially motivated to try telemedicine, he said, because state law requires that hospitals have antibiotic stewardship programs.

Siddiqui serves as the infectious-disease physician for all three hospitals, working with each facility’s pharmacists, hospitalists and microbiology staff. “Telemedicine is just the vehicle,” he said. “Those hospitals have an ID physician—me. I’m part of their medical staff.”

Since its program began, Sonoma Valley Hospital has seen its use of flouroquinolones and piperacillin/tazobactam—two categories of broad-spectrum antibiotics—drop by 80% and 70%, respectively, Siddiqui said. The hospital’s resistance rates also dropped.

Despite the evidence of the benefits of stewardship, Siddiqui has encountered pushback from a few physicians. “There are still some physicians at Sonoma who don’t want my input, but I think we have about 90% of them on board and I’ll take that any day,” he said.

The CDC’s Srinivasan pointed to another antibiotic stewardship model that might work for community hospitals. Dr. Gary Kravitz, an infectious-disease specialist with St. Paul (Minn.) Infectious Disease Associates, runs stewardship programs at five local hospitals, including 192-bed St. John’s Hospital and 232-bed St. Joseph’s Hospital, both in St. Paul, and 86-bed Woodwinds Health Campus, Woodbury, Minn. He started in 2002 by developing a stewardship program for 398-bed United Hospital in St. Paul, where he was on staff. “I think we were getting paid about $50,000 to do the program and the hospital saved that much just on pharmacy costs in the first year,” he said.

His results were so strong that over the next few years, he took the business proposition to other hospitals, negotiating renewable contracts to design and oversee stewardship programs.

With the right training, general pharmacists can lead antibiotic stewardship efforts as long as they have access to an infectious-disease specialist to review difficult cases, such as when they are unsure about which drug is appropriate, Kravitz said. “There’s a lot of ways to make this work, but you need people who are really interested in doing it.”

Srinivasan said 2015 promises to be a big year for advancing stewardship programs. “There is much more awareness of the problem now and stewardship efforts that have been underway for a long time seem to be coming to fruition,” he said. “I think we’re going to see a lot of good work that will carry us into the future.”

Follow Maureen McKinney on Twitter: @MHmmckinney

The Magic of Microfiber

December 30, 2014

microfibreHere’s the truth about why microfiber towels and mops work so well and it’s not magic (sorry about the headline).

If you took a microfiber towel, cut off one fiber, then cut that fiber into tiny pieces and looked at them under a really powerful microscope, they would look like an asterisk (*). Which means that each fiber has a ton of surface area to pick up soils that you can and can’t see. Conversely, cotton towel or paper towel fibers have much less surface area, and cannot pick up a large variety of soils.

Microfiber picks up watery and oily soils. That’s why new, clean microfiber towels stick to your hand. If you were to fold several of microfiber towels after washing (we have thousands) after about 5 minutes your hands would be so dry they might start cracking.

In our public health seminar we demonstrate the magic of microfiber with a little contest. We have a mirror smeared with butter. One person tries to clean it with water and a paper towel and the other person uses a microfiber towel. After about 7 seconds the microfiber side is clean and the paper towel side is a smudgy mess.

Recommended uses of microfiber

All general cleaning activities
Sometimes, microfiber will leave extra fibers on glass, if you don’t like how that looks I recommend using a squeegee for glass cleaning

Carpet, upholstery, and fabric spotting
Next time you have a spill or drip, try to transfer the soil from your fabric to a clean microfiber towel. Use a little water, if necessary. It won’t work every time, but it good to try this first before using any product that may do more harm than good.

Dry dusting
Using a microfiber towel or duster for dusting can eliminate more standard options that simply push the dust around or lift it back into the airspace to land on a different object or breathe in.

Vehicle interior and exterior cleaning
Many people keep microfiber towels in their car for drying water drops after a car wash or detailing the interior of their car. Use a dry microfiber towel to remove the haze from interior glass.

How to care for your microfiber towels

-Wash your microfiber towels and mops together and do not combine them with other fabrics. Lint from the other fabrics will stick to the microfiber

-Use half of the amount of detergent you would normally use. Microfiber will release the soils they are holding very easily in water and minimal detergent. When you use too much detergent you risk not rinsing all of it out and your microfiber towel will be streaky

-Do not use fabric softener or dryer sheets. The residue from these products will stay in the microfiber and will then streak on your surfaces

-Dry on low heat. Microfibers can melt under high heat and lose surface area.

With proper usage and care you microfiber towels and mops can last from 50 to 100 washings. When your microfiber towels stop sticking to your dry hands, you know they are losing their surface area and it’s time to retire them into the slop rag/really dirty cleaning pile.

This entry was posted in Cleaning & Disinfecting by Anthony Fors. Bookmark the permalink.

The Future Of Infection Control

February 16, 2014

Studies prove hand hygiene importance while monitoring technology improves program compliance.
By Phillip Lawless

Infection control — though the concept sounds simple enough, it is actually a serious cleaning industry issue that includes a multitude of responsibilities.
Through cleaning and prevention, education and action, facility managers and building service contractors use sound infection control practices to prevent illness outbreaks and treat “sick buildings.”
From surface disinfection and sanitization to restroom cleaning and hand hygiene programs, there are many important links in the chain of effective facility infection control.
This is especially true in hospitals and the healthcare market.
Various scientific studies have proven the importance of hand hygiene in this arena, and new ideas and technology stand ready to improve practices and strengthen the chain of infection control.
Unhealthy Hospitals?
While most people think of hospitals and other healthcare facilities as places to receive treatment and regain strength, cleaning quality and safe infection control can have a large impact on patients’ overall wellbeing.
In fact, around 2 million patients acquire hospital-related infections every year, according to the U.S. Centers for Disease Control (CDC), and almost 100,000 die from these infections.
Recognizing hand hygiene’s contribution to a strong healthcare infection control program, one group set out to study and improve hand hygiene compliance in this market.
Klaus Nether is center solutions development director with the Joint Commission Center for Transforming Healthcare.
“The Center for Transforming Healthcare is an entity under the Joint Commission Enterprise,” Nether says. “It was created in 2008 to address some of healthcare’s safety and quality issues.”
The center works with participating organizations — hospitals and healthcare organizations — to address important issues, Nether notes, and hand hygiene was the first program that the participating organizations identified to address.
Studying The Issue
Using a scientific approach, the group:
• Looks at what the issues are
• Measures these issues to gauge their severity
• Identifies contributing factors
• Targets solutions specifically to these factors
• Develops a control plan to sustain improvements over time.
Working with eight healthcare organizations across the United States, the commission developed a measurement system to monitor employee wash ins/wash outs in patient areas using the same parameters, Nether states.
A measurement system was created that used secret observers to collect data, and training modules taught them how to observe, how to fill out the forms and included a test for them to take.
According to Nether, employees who were expected to wash in/wash out at the facilities included laboratory workers, nutritionists, dieticians and environmental employees.
Using this system, baseline wash in/wash out compliance at the eight organizations was, as an aggregate, 47.5 percent, Nether explains.
Looking at the eight healthcare facility participants, different contributing factors were identified at each location.
Over 20 different hand hygiene contributing factors were found, including:
• Inoperable or empty soap dispensers
• Perception of excessive hand cleaning being required
• Broken sinks
• A lack of accountability
• Distractions and forgetfulness
• Issues with wearing gloves.
To address the specific issues at each location, targeted solutions were developed and a control plan was created to sustain hand hygiene improvements over time.
“One of the things that we learned is that best practices don’t always work,” Nether reveals. “Best practices were created to address specific contributing factors that were identified at that organization that developed those best practices. And sometimes, as you adopt those best practices, they may not work at your organization. Although we all had the similar problem with hand hygiene, the contributing factors were different from one organization to the next.”
Maintaining Improvement
According to Nether, the eight hospitals that started with an aggregate wash in/wash out compliance of 47.5 percent ended the study with an aggregate of 81 percent and sustained that performance for 11 months.
“There is a correlation with hand hygiene and health acquired infections, so one of the organizations that actually implemented the targeted solutions tool … they actually saw that as their hand hygiene compliance rates went up, their blood stream infections actually decreased by 66 percent,” Nether states.
While there is definitely a correlation between hand hygiene and infections, there are other factors that can affect the rate of health acquired infections (HAIs), Nether notes.
Using these findings, the commission created a Targeted Solutions Tool to help individual healthcare organizations decrease HAIs and increase hand hygiene compliance in approximately 12 weeks, according to Nether.
The next challenge is sustaining the improvement, Nether says.
To guarantee the hand hygiene program moving forward, organizations should continue measuring and develop a control plan to monitor the process.
If any dips are seen in the hygiene program measurements, an organization must react before it gets too bad, Nether concludes.
New Monitoring Technology
New technology has changed almost every facet of the cleaning industry, and now it stands ready to improve facility hand hygiene programs as well.
Jeff Hall, compliance program director, North America, with GOJO Industries Inc., says hand hygiene has become a subject of high importance in the cleaning and healthcare industries.
This is due to the huge impact that it can have on health and well-being — possibly even saving lives.
Hall notes it has been proven through multiple studies that hand hygiene is the number one way to prevent the spread of infection1 and that hand hygiene compliance rates in healthcare average less than 50 percent nationally.2
The bottom line is that HAIs are a chronic and costly problem that require quantitative data to demonstrate performance, Hall states.
That is the biggest reason newer electronic monitoring system technology is now necessary; it allows for measurement and accountability.
“In order to improve hand hygiene, we need to give hospitals the tools to measure it and the clinical education resources to interpret the data,” Hall explains. “One solution does not fit all hospitals; we work individually with each hospital to find a solution and technology that works for them.”
How It Works
Healthcare personnel function in an environment of heavy workloads, enormous responsibilities, multitasking and being constantly pressed to do more things in less time, according to Hall.
This challenges their time management, priority setting and efficiency of practice.
That is why Hall’s company was committed to providing hand hygiene solutions that make compliance easier.
Hand hygiene technology systems that became available earlier this year measure and improve hand hygiene compliance.
Hall states his type of technology can include:
• An activity monitoring systemthat measures compliance on a community level providing real-time actionable data by floor, unit or room.
• Technology that monitors and measures hand hygiene compliance at an individual level through Real-Time Locating System (RTLS)-enabled employee badges. (A system can integrate with existing third-party RTLS systems.)
• In addition, some companies provide a representative or employee who becomes part of the hospital’s infection prevention team and provides customized implementation, on-site audits, setup, baseline measurements and detailed improvement plans
• Finally, software can allow users to automatically upload, visualize and analyze data from a free application for portable devices used to electronically collect hand hygiene events.
Compliance Study
Hall’s company conducted an independent research study at the John Peter Smith Hospital in Fort Worth, Texas, to determine the impact on hand hygiene compliance rates when the hospital hand hygiene program included an electronic compliance activity monitoring system.
During the study, the system was installed to monitor all patient room entries and exits and all hand hygiene events from touch-free soap or hand sanitizer dispensers.
Compliance was measured as number of events in contrast to number of opportunities, and included the entire community, not only healthcare workers.
The study duration was three months during which a comprehensive hand hygiene program for healthcare workers, patient and visitors was implemented.
Additional education was established including the development of a hand hygiene improvement goal, leadership support and feedback opportunities for the staff.
Results of the study were presented at the APIC 2013 Conference.
The authors concluded that during the study period of June to September 2012, there was a 92 percent increase in hand hygiene compliance rates — from 16.5 percent at baseline to 31.7 percent — when an electronic monitoring system was included in a hand hygiene program.
During the post-study period the rate decreased to 25.8 percent, still significantly above baseline.
Through the study, it was found that the implementation of an electronic hand hygiene compliance monitoring system as part of a clinical hand hygiene program can significantly increase hand hygiene compliance.
“We also are aware that additional data is needed to better understand the impact of electronic compliance monitoring programs on clinical outcomes, such as infection rates,” Hall says.
Today, it is clear that safer facilities equal improved employee production, increased profitability and healthier communities.
Thankfully facility managers, service contractors and workers are not fighting this important battle alone.
New technologies, scientific studies and updated approaches offer the promise of safer, cleaner and healthier facilities in the future.

1 According to the CDC, “Hand Hygiene Project: Best Practices for Hospitals …” Joint Commission, Nov. 2010.
2 Herbert C. Weber SG. Common approaches to the control of multidrug-resistant organisms other than methicillin-resistant Staphylococcus aureus Mar:25(1): 181-200. Epub 2010 Dec. 17.