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No-Touch Modalities for Disinfection of Hospital/Acute Care Settings: A Rapid Evidence Review

Research Protocol

On July 15, 2020, June 29, 2020, May 15, 2020, and April 29, 2020, amendments were made to this protocol (go to Table 2 for a summary of amendments).

Question

  1. What data exist for the effectiveness of no touch modalities for disinfecting patient rooms in hospital or acute care settings for:
    1. Respiratory viral pathogens
    2. Other pathogens with potential relevance to assessing efficacy vs COVID-19 (specifically Clostridioides (formerly Clostridium) difficile infection [CDI])

Condition or Domain Being Studied

The COVID-19 pandemic has caused nearly 870,000 infections and 50,000 deaths in the United States. Many COVID-19 patients have required prolonged hospitalizations for respiratory symptoms along with cardiac, hematologic, neurologic and other medical complications. Providing high quality care for patients while protecting healthcare staff from infection is challenging due to lack of knowledge regarding the safest and most effective methods and technologies for environmental cleaning of patient rooms. Thus, identifying evidence for cleaning/disinfection modalities for SARS CoV2 eradication in patient rooms is a high priority.

Terminal cleaning of patient rooms (i.e., cleaning and disinfection of surfaces and the environment after the patient has vacated the room) is typically performed by trained Environmental Services/Housekeeping staff that manually clean and disinfect surfaces using wipes/cloths/sponges moistened with chemical solution. No-touch modalities may also be used during terminal cleaning after manual processes. These modalities include ultraviolet (UV) disinfection systems, hydrogen peroxide vapor, ozone, and chlorine dioxide vapor. As no studies directly assessing no touch modalities for SARS CoV 2 are likely to exist yet, we undertook a rapid review of no touch modalities for disinfection of respiratory viral pathogens in patient rooms in hospital/acute care settings. We will also include studies reporting the impact of these modalities on Clostridiodes (formerly Clostridium) difficile (CDI) spores and infection, as a hospital acquired infection that is easily transmitted to surfaces and difficult to eradicate, as  a cleaning modality that is effective against CDI is likely to also be effective against CoV2.

Table 1. Proposed PICOS Elements

PICOS Element   Potential Strategies To Address Sparse Data
Population -----  
Intervention/Exposure No touch modalities for cleaning/disinfection:
  • Ultraviolet (UV) light disinfection systems
  • Gaseous systems (hydrogen peroxide vapor, ozone, chlorine dioxide)
  • Steam heat 
  • Antimicrobial copper surfaces
We may consider additional no touch modalities for cleaning/disinfection
Comparator/Control Any comparator, no comparator (e.g. control) -----
Outcomes
  • Surface contamination or
  • Patient infection rates (incidence) of respiratory viral pathogens, specifically: Adenovirus, coronaviruses, influenza, middle Eastern respiratory syndrome (MERS), respiratory syncytial virus (RSV), rhinovirus*, severe acute respiratory syndrome (SARS) or Clostridiodes difficile
We may consider including studies that used test cards on the viruses of interest in hospital settings and studies that created artificial contamination by inoculating surfaces in hospital rooms.
Setting Patient Rooms in Hospital or Acute Care Setting  

*Assays cannot distinguish between rhinoviruses and respiratory enteroviruses

Searches

We will search for systematic reviews and primary studies that address the research questions. We will search Pubmed and Embase from 2010 onwards. For searches of cleaning/disinfection of Severe Acute Respiratory Syndrome (SARS), we will search from 2000 onwards. Searches will focus on primary studies, but we will use systematic reviews to identify additional primary studies.

Our gray literature search will include links to manufacturers of no-touch technologies, relevant clinical practice guidelines, and safety information. We will also search Clinicaltrials.gov for ongoing studies.

Inclusion/Exclusion Criteria

We will assess primary studies to see if these meet our inclusion criteria. If we encounter sparse data, we may revise inclusion criteria (see Table 1, Column 3).

Inclusion Criteria

  • English language published full-full length studies
  • All empiric study types: including randomized controlled trials, quasi-randomized controlled trials, cohort studies, other observational studies, pre/post studies 
  • Studies assessing no-touch intervention(s) of interest for cleaning or disinfection of patient rooms in hospital/acute care settings 
  • Studies reporting outcomes of surface contamination or patient infection rates for respiratory viruses, specifically: Adenovirus, coronaviruses, influenza, middle Eastern respiratory syndrome (MERS), respiratory syncytial virus (RSV), rhinovirus, severe acute respiratory syndrome (SARS)

Exclusion Criteria:

  • Laboratory studies
  • Studies performed in the ambulatory settings
  • Conference abstracts, editorials, case studies

Data Extraction (Selection and Coding)

Abstract and title review, full text review, and abstraction will be performed by two analysts with experience in performing rapid reviews and topic expertise. Areas of disagreement will be resolved by discussion.

Data extraction will be performed by a single analyst. Categories will include author, year, country, study design, interventions, comparators, results, and authors' conclusions.

Risk of Bias (Quality) Assessment

Study quality will not be formally assessed. However, a description and summary of study limitations including key aspects of study design and conduct will be provided.

Strategy for Data Synthesis

Data will be compiled into evidence tables with a high level narrative synthesis (including evidence for efficacy) and discussion of limitations in the evidence base. No formal grading of strength of evidence will be performed.

External Peer Review: we will have at least two experts review the draft report.

Table 2. Summary of Protocol Amendments

Date

Section

Original Protocol

Revised Protocol

Rationale

7/15/20 Inclusion/exclusion criteria VHP VHP and aerosolized hydrogen peroxide Studies of AHP may also be of interest.
6/29/20 Throughout report "Efficacy" "Effectiveness" Request by CDC reviewer.
5/15/20 Methods

The protocol originally listed potential strategies to address sparse data including:

"We may consider additional no touch modalities for cleaning/disinfection"

"We may consider including studies that used test cards on the viruses of interest in hospital settings and studies that created artificial contamination by inoculating surfaces in hospital rooms."

N/A

We did not have time to add additional modalities or include studies that artificially inoculated surfaces.

5/15/20

Searches

"We will search for systematic reviews and primary studies that address the research questions. We will search Pubmed and Embase from 2010 onwards" Added clinicaltrials.gov We added clinicaltrials.gov provide information about ongoing relevant trials.
4/29/20 Searches "Our gray literature search will include links to manufacturers of no-touch technologies, relevant clinical practice guidelines, and safety information." Gray literature search was not necessary. This additional information was not considered necessary for AHRQ rapid review format and was not performed.
4/29/20 Inclusion/Exclusion Criteria "All empiric study types: including randomized controlled trials, quasi-randomized controlled trials, cohort studies, other observational studies, pre/post studies" "All relevant systematic reviews/meta-analyses, randomized controlled trials, quasi-randomized controlled trials, cohort studies, other observational studies, pre/post studies" The original wording did not explicitly state that we would use relevant systematic reviews as evidence along with primary studies to improve efficiency given the report's timeline. We had always intended to use  systematic reviews in this way, but added this language to clarify that.
4/29/20 Inclusion/Exclusion Criteria "Antimicrobial copper surfaces" "Solid copper surfaces" The intent was to capture only antimicrobial solid copper surfaces, but this was not explicitly clarified in the original protocol.
4/29/20 Inclusion/Exclusion Criteria

 

Added to exclusion criteria "Case series < 10)" Inadvertently left out of the original protocol.

Abbreviation: VHP=Vaporous Hydrogen Peroxide.