Andrew Streifel – Hospital Environment Specialist – University of Minnesota – Environmental Infection Control

Air Date: 7-28-2017|Episode 470                                                                                Listen|Download

This week on IAQ Radio we welcome Andrew Streifel.  Andrew J. Streifel is a Hospital Environment Specialist with the Department of Environmental Health & Safety at the University of Minnesota. Whenever there is a high profile hospital acquired infection one of the first names that comes to mind is Andy Streifel.

 

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This week on IAQ Radio we welcome Andrew Streifel. Andrew J. Streifel is a Hospital Environment Specialist with the Department of Environmental Health & Safety at the University of Minnesota. Whenever there is a high profile hospital acquired infection one of the first names that comes to mind is Andy Streifel. Mr. Streifel has been involved in the investigation of over 80 clusters of infection related to hospital air quality. He has served as a consultant in over 400 hospitals worldwide on a variety of indoor air quality issues, water microbial contamination and has investigated clusters of bacterial infections due to unsanitary clinical practice. His current research interests involve energy management impact on infection prevention and validation of the air and water safety in healthcare facilities.

Andy is a registered Environmental Health Specialist in Minnesota. He currently serves as an invited nonvoting member on the Maintenance Committee for the SSPC 170: ASHRAE Standard for Ventilation of Health Care Facilities 2008 – present. Mr. Streifel is also serving on the revision committee for the 2014 edition of the FGI Guidelines for Design and Construction of Health Care Facilities. He has served on this committee since 1994 and has participated in the development of the 1996, 2001, and 2006, 2010, 2014 & 2018 editions. In addition Mr. Streifel has served on the Special Project committee that authored the HVAC Design Manual for Hospitals and Clinics. He was an author on ASHRAE published articles on Ventilation for the Protection of Immune Compromised Patients-1988, Construction Impact on Indoor Air Quality-1995 and Air Leakage Analysis of Special Ventilation Hospital Rooms-2008. Mr. Streifel has assisted University of Minnesota Institute of Technology & School of Public Health as technical advisor on filtration, patient room airflow studies and particle management projects. He also serves on the National Air Duct Cleaners Association Standards Committee. In addition, he is an author in over 50 articles, published in the academic and professional journals, related to ventilation and water quality in health care.

Z-mans Blog:
“Hospitals Go to Guy”  
Hospital Environment Specialist, Andrew Streifel was this week’s guest on IAQradio. When hospitals need help with resolving problems with hospital acquired infections Andy often gets the call. He has consulted with over 400 hospitals worldwide on issues such as: IAQ issues, water microbial contamination, clusters of infection, etc.When he entered the healthcare field, Andy was a dialysis technician. He looked at the patient’s chart for the Problem page. It would inevitably list renal failure as number one, the eventual cause of death would be an infection.
Nuggets mined form today’s episode:
2-3 million people contract healthcare related infections occur yearly of which 70,000 will die. The fatality rate has dropped significantly.
Centers for Medicare & Medicaid Services (www.cms.gov) has standardized the former term “nosocomial infection” to “Healthcare Acquired Infection”(HAI).
The most imposing organism in hospitals today is Clostridium difficile (C diff).
30% of patients who stay in room in which the prior resident had a C diff infection will also develop a C diff.
As C diff is acquired by surface contact, deeper and better surface cleaning including handling of dirty linens lowers C diff risks.
The good news today is that heroic modern medicine can save or prolong the lives of more and more very sick people, liver failure, leukemia, etc. The severity of the illness and intrusiveness of the surgery/treatment impacts infection rates. 50% of pancreas transplant patients develop an HAI. Burn patients are also highly susceptible to infection. Acquired infection risks are based upon the types of patients the hospital chooses to serve.
There reemergence of tuberculosis (TB). TB is a bacterial infection that is spread airborne.
CMS decision not to pay for treatment of some types of HAIs has resulted in hospitals having the monetary incentive to lower HAI rates.
Endoscopes can transit disease from the process water supply to patients.
Pulmonary spread of infection is an issue that may indicate a defect in the HVAC systems such as improperly fitting filters.
Contact spread is a much greater risk than pulmonary spread.
The public is unaware of the seriousness of the real HAI problem as most publicity about these problems is purposely suppressed. Lawyers are the true legislators.
 
Fungal infections can be spread by contact: Phycomyces, Mucor& Rhizopus. Aspergillus fumigatis and other organisms that grow at body temperature pose a risk.
Bone marrow patients who must stay in hospital for 40 days are at great risk.
Fomites are objects or materials that are likely to carry infection, such as clothing, utensils, and furniture. Physician’s phones, ties, stethoscopes are fomites. He once identified filthy curtains in the hospital room of a multi-drug resistant patient as being the problem.
While hand cleansing remains the most important infection control practice, we need to develop & standardize other best infection control practices.
It’s thought that we can only culture and identify 10% of what is present in the environment.
Key steps to a hospital inspection:  What is the organism? Was the patient confined to the building or were they permitted to go outside? When aspergillosis is the problem, rule in or rule out the HVAC system.
Inspection tools:  A particle counter is used to check the condition of the HVAC system. He uses a sensitive pressure gauge. He uses both an air sampler and surface sampling with Rodac plates. Incubating the Rodac plates at body temperature.
Rodac plates (RODAC = Replicate Organism Detection And Counting) can be used for microbiological control of many surfaces. Contact-plate sampling. Method for making the bacterial load on surfaces visible. A nutrient Agar surface is pressed against the test surface for a short moment. Thus, part of the bacteria colonizing the surface is transferred to the agar surface and incubated.<25 colonies is satisfactory, 50 > is unsatisfactory. He has used Rodac plates to solve many problems including microbial cross contamination from a lab refrigerator to tissue cultures.
The ATP test is a process of rapidly measuring actively growing microorganisms or proteins through detection of adenosine triphosphate, or ATP. ATP is used to monitor cleanliness of surfaces in patient rooms. <250 is considered satisfactory. ATP sampling cannot be done on air.
CASE STUDY:  When 21 people were infected in a prominent hospital in Baltimore they called upon Andy to investigate. Using his particle counter, he found particle counts of 1,000,000 > .5 microns in the building. The particle count at an HVAC diffuser was 1,000. The count outdoors was 2,000,000. The problem was pressure differential. He determined that the hospital was sucking air in from an underground utility chase. It’s important to manage pressures, have efficient and properly sized air filters, be observant of water damages.
CASE STUDY: He used PCR (polymerase chain reaction) to save time on a mold remediation project in Hawaiian hospital. By using PCR he circumvented the need for waiting 5 days for culture samples to be analyzed. When PCR determined contamination was only in the air the cleaning crew could move on, when PCR determined contamination was on a surface recleaning was required. PCR (polymerase chain reaction) is a technique in molecular genetics that permits the analysis of any short sequence of DNA (or RNA) even in samples containing only minute quantities of DNA or RNA. PCR is used to reproduce (amplify) selected sections of DNA or RNA for analysis. By first identifying the profile of the environment and determining.
Some commonly overlooked sources for environmental infection: pressure imbalances, hidden mold colonies above suspended ceilings, condensation above ceilings and on, in or around refrigeration equipment, under sinks. The importance of quality construction and installation. The potential health risks of deferring maintenance. Personal belongings in patient rooms is very important: has found dolls stuffed with straw, eagle feathers, Christmas trees in patient rooms. Has studied what is brought in our visitors clothing. Has studied fungal isolates on people 20 years old and older and 20 years old and younger and found much higher numbers on the younger population which he attributes to: cuddling, where the house cat sat, kids burying their noses in parents clothing.
When bringing an immune compromised mouse into the colony the whole colony must improve, also applies to people. When a hospital does bone marrow transplants and teats people with leukemia the whole hospital must improve.
Private patient rooms are better, less opportunity for cross contamination more opportunity for plumbing problems.
The awareness of building science in hospital design? He has been involved in construction planning in 10 hospitals. In the USA the driving factors are cost per square foot and fire code. He has seen significant improvement in utilization of clean to dirty airflows and keeping sheetrock off floor slabs to prevent water wicking behind coving.
Infection risks aren’t always equal:  the risks are the greatest during discovery and demolition and lesser during construction.
Hospitals are using germicidal UV light for infection control which seems to be working, he’s not sure about C diff? Vaporized hydrogen peroxide is also a tool. According to Andy, the best thing is bleach available in wipes because it improves contact time. He isn’t a fan of the use of aerosolized chemicals in hospitals for infection control. There is no one step decontamination process that eliminates the need for precleaning. Need to ensure that decon procedure doesn’t deteriorate/corrode electronics.
Infection control in Blood Systems Laboratories, where unknown/emerging diseases such as Ebola are handled and studied.
Legionella is a risk; there are a myriad of other organisms we should be concerned about such as pseudomonas aeruginosa. The best practice for preventing legionella is to keep the water continuously moving. Legionella can be a problem during facility construction when sinks and plumbing sit for months without being used during which time biofilm develops which is difficult to remove.
Immune compromised patients are the most vulnerable populations. Neutropenic patients have a low level of neutrophils. Neutrophils are a type of white blood cells that help the body fight infection. Steroids change the immune system.
Very useful document on building containment titled:  Airborne Infection Disease Management, methods for temporary negative pressure isolation.
 http://www.health.state.mn.us/oep/training/bhpp/airbornenegative.pdf
Useful information during construction, remediation and in the event of a pandemic.
Crystal Ball Prediction:  Water quality will be the most important issue. CMS will exert financial pressure on hospitals. ASHRAE standard 188 https://www.ashrae.org/resources–publications/bookstore/ansi-ashrae-standard-188-2015-legionellosis-risk-management-for-building-water-systems
Andy Streifel’s email:  strei001@umn.edu
Z-Man signing off
Trivia Question:
Name the father of modern bactertiology and a winner of a Nobel prize.

Answer:
Robert Koch

 

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