AREAS OF COLLABORATION While there are many areas of collaboration between infection preventionists and industrial hygienists, we will highlight three where we have experienced synergy and success that would not have been possible if we were operating in a siloed environment: disinfectant selection, water safety and Legionella, and infection control risk in construction.

Disinfectant and Disinfection Technology Selection The healthcare environment is a recognized reservoir of infectious agents that may contribute to disease transmission. Selecting appropriate cleaners, disinfectants, and disinfection methods requires balancing multiple factors, including disinfectant efficacy and worker exposure. Disinfectant formulations include alcohols, aldehydes, chlorine dioxide, hypochlorites, hydrogen peroxide, iodophors, peroxyacetic acid, phenolics, and quaternary ammonium compounds. Designed to inactivate microbes, disinfectants also pose a health hazard to patients and workers.

Healthcare institutions are challenged with mitigating infections including multidrug-resistant organisms and Clostridium difficile. Clostridium difficile infection is one of the most common healthcare-associated infections leading to patient morbidity and mortality. The economic burden of Clostridium difficile infections is billions of dollars per year. As a spore-forming bacteria, Clostridium difficile is persistent in the environment and difficult to inactivate. Commercially available sporicidal disinfectants with Clostridium difficile indications include sodium hypochlorite and hydrogen peroxide/peroxyacetic acid mixtures. The Association of Occupational and Environmental Clinics lists sodium hypochlorite and hydrogen peroxide/peroxyacetic acid mixtures as potential asthmagens. When selecting sporicidal disinfectants, close collaboration between infection prevention and industrial hygiene is critical to prevent both patient infection and occupational diseases such as asthma.

Infection preventionists and industrial hygienists are the best professionals to identify feasible and effective solutions to the formidable task of protecting patients from infectious microbes in the environment and protecting healthcare workers from disinfectant exposure. Each profession has complementary backgrounds and skills for selecting safe and effective disinfectants. The selection of disinfectants is largely a matter of professional judgment with consideration of worker safety, regulations, and instructions on product labels. Industrial hygienists are accustomed to working with the regulatory frameworks for worker safety and environmental protection under OSHA and EPA. In the U.S., the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), administered by EPA, governs the registration, distribution, sale, and use of surface disinfectants used in healthcare.

Infection preventionists and industrial hygienists working together should evaluate disinfectant considerations including: • efficacy • EPA registration and indication • contact time • master label and instructions for use • hazard communication for chemical safety • PPE selection including gloves, eye protection, and respiratory protection • sustainability and environmental considerations • hazardous waste considerations • training

Novel means for surface disinfection including ultraviolet light, electrostatic spray, fogging, and vaporization have received increased attention since the COVID-19 pandemic. Spraying, fogging, and vaporizing disinfectants also pose novel occupational risk due to increased inhalation exposure potential. Similarly, the use of ultraviolet germicidal irradiation (UVGI) for sanitization of surfaces is becoming more common. Ultraviolet-C radiation (UV-C) is a recognized carcinogen and poses an acute eye hazard that can result in photokeratitis. Some UVGI sanitization devices operate at wavelengths that can produce ozone. Infection preventionists and industrial hygienists should critically review novel disinfection strategies for efficacy and to ensure worker protections are in place prior to implementation.

Within our own organization, it was determined that a standard UV product should be selected as a complement to cleaning and disinfection of rooms once a patient is discharged or moved. A selection committee was created that included the industrial hygiene, infection prevention, housekeeping, and supply chain departments. Working together, the team evaluated several UV room sanitization devices in controlled settings. Industrial hygiene staff evaluated UV exposure, ozone emissions, and product safety features. We found that if a person were to enter a room with an active UV-C sanitization tower, the UV Threshold Limit Value (TLV) could be exceeded in a matter of seconds. While we were evaluating one UV device, a caregiver unaware of what was happening opened the door and attempted to walk into the room when the UV light was active. Those present stopped the individual from entering the room, preventing harm. Highlighting the importance of hazard recognition, engineering controls, and administrative controls, the incident influenced the evaluation process and demonstrated the importance of safety in selecting UV sanitization devices.

In the final evaluation, safety was the team’s first consideration. Infection prevention staff evaluated devices based on efficacy of bioburden deactivation, and industrial hygiene staff reviewed the devices to ensure worker safety. Together, we selected a product that met everyone’s needs.

Water Safety and Legionella Legionnaires’ disease is a disease of the built environment. Healthcare facilities pose a unique challenge as these buildings attract and house patients who are immunocompromised or who have other underlying health conditions that place them at increased risk of acquiring Legionella infection. Historically, the public health approach to Legionnaires’ disease prevention has been to identify disease clusters through surveillance and then investigate exposure sources. But despite these surveillance systems, the incidence rate for Legionnaires’ disease has continued to rise.

In 2017, CMS promulgated requirements for healthcare facilities to reduce Legionella risk and implement water safety management plans to prevent cases and outbreaks of Legionnaires’ disease. The industrial hygiene approach is one of disease prevention: anticipation, recognition, evaluation, and control of Legionella hazards to prevent infection. The industrial hygiene approach combined with epidemiologic surveillance is a robust tactic for Legionnaires’ disease prevention.

Legionella is not the only water-related organism of concern in the healthcare built environment. Nontuberculous mycobacteria (NTM), Pseudomonas, Burkholderia, Elizabethkingia, Serratia, and Stenotrophomonas species are other water-related, opportunistic pathogens of interest. Susceptible patients can be exposed to these pathogens through routes involving showers, sinks, toilets, and drains. Hospital wastewater plumbing, including sink drains, is a reservoir for multidrug-resistant organisms, including carbapenemase-producing Enterobacteriaceae (CPE). These pathogenic organisms harbored in drains can be aerosolized onto nearby surfaces or supplies and then transmitted to patients, causing healthcare-associated infections. Industrial hygienists are experts in conducting environmental assessments, including inventorying water systems, identifying amplification sources, performing environmental sampling, and identifying control strategies to mitigate these microbial hazards.

At our institution, we found that no one expertise can effectively tackle the complex issues of Legionnaires’ and other waterborne disease prevention in healthcare facilities. A multidisciplinary approach that encompasses infection prevention, industrial hygiene, and facilities maintenance is critical. Infection prevention brings an epidemiologic skillset and connection to clinical care. Industrial hygienists are perfectly suited to bridge the clinical aspects of infection control and the engineering and built-environment aspects of water systems.

Infection Control Risk in Construction Hospital-acquired infections have been associated with healthcare construction and renovation activity. For healthy individuals, environmental exposures to construction-related aerosols do not result in infection, but immunocompromised patients are susceptible to opportunistic bacterial and fungal infection, including aspergillosis. An infection control risk assessment (ICRA) is utilized to assess and reduce risk.

Industrial hygiene and infection prevention can work together to effectively mitigate construction infection risk. As construction activities generate dust with infectious particles, control of airflow and air pressure relationships is necessary to protect immunocompromised patients. Ensuring proper airflow, pressurization, filtration, and containment provides a safety net. Industrial hygienists have knowledge that can assist in airflow design and planning. These experts can guide architects, designers, engineers, and contractors in providing the correct containment needed for patient safety. Industrial hygienists are also involved in construction-related worker safety and health issues, including identification and control of asbestos, lead, and silica hazards. Preventing airborne spread of pathogens, dust, and other harmful construction products protects patients as well as those working in areas under construction. When a construction concern is escalated, the team can work together to find the best solution with the desired safety outcome.

With the implementation of the American Society of Health Care Engineers’ (ASHE) ICRA 2.0 framework, a multidisciplinary team was created at our institution to educate those involved. The industrial hygiene, infection prevention, facilities maintenance, design, and construction departments worked together to create educational materials as the new ICRA 2.0 expectations were implemented. At monthly touch-base meetings, different front-line teams asked questions of industrial hygiene and infection control and shared concerns about the new process. Working together, infection control and industrial hygiene provided the guidance needed to ensure best practices were utilized. Ensuring updated expectations for HEPA filter validation, exhaust design, and particle counting where necessary has required significant support from infection prevention and industrial hygiene. Industrial hygiene has been essential in the work needed to successfully implement updated ICRA practices. Together, the teams are making a difference in protecting patients and workers.

A POWERFUL VOICE Continued collaboration between infection preventionists and industrial hygienists will be essential to address emerging challenges and improve health outcomes. Multidisciplinary collaboration between the complementary but differing infection prevention and industrial hygiene points of view can result in more effective and efficient measures to prevent infection and disease in both patients and healthcare workers. This team-based approach results in trust between the professions. When infection prevention and industrial hygiene are not aligned, confusion can result, but when the professions speak in a unified manner, their combined voice is powerful. Together, we’re better, we’re stronger, and we’re safer.

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