Assisted Living Network
Disinfectant Coating Surface Verification: A Case Study in Surface Control Disinfection and Observed Effects
This independent Case Study1 was designed to determine if a disinfectant coating technology and an accompanying measurement process could confirm an enduring continuous presence of the disinfectant agent on various hard surfaces after a single treatment in an Assisted Living environment. The confirmation of the surface disinfectant’s presence after a single application is intended to provide assistance to control unwanted microorganisms on surfaces, under conditions of normal use in a facility populated by regular site staff and residents.
Ridgestone and Great Lakes Senior Living, two related Wisconsin-based Assisted Living multi-site organizations, utilized Axenic’s Q Shield™ Professional Surface Protector, Hand Sanitizer, and real-time surface testing kits to detect and verify surface coating presence throughout a one-month Study. After a single surface treatment throughout the facilities, data from weekly tests confirmed the coating presence for a continuous period lasting up to a maximum of 27 days post-application (n=136) on a wide range of surfaces.
The study was conducted during the COVID-19 pandemic. An average of 14 days or more was confirmed on all Q Shield treated surface types. Site leadership declared “the [Axenic] program is helping us differentiate in three critical areas: resident safety and well-being, cost-effectiveness and employee satisfaction….and it is seen as one of our key tools to control the spread of COVID-19 in our facilities.”2
Confirmation verification that a protective coating on hard surfaces can last two weeks or more resets surface agent performance expectations.
“To know that we are using lab-tested technology that’s been proven effective gives us a huge amount of reassurance and invaluable peace of mind” – Scott Zimmerman, Great Lakes Executive Management and Investor
1. Axenic did not provide free products nor pay a sponsorship fee to the sites in this Case Study. All opinions are site managements or their employees.
2. Axenic has no direct evidence of the customer perceptions quoted and it is observational and anecdotal based on on-site experience during the Study.
Who is Axenic and what is Q Shield™?
Axenic Health Solutions Inc., headquartered in Plano, Texas, is transforming the standards of commercial and consumer hygiene by delivering its Q Shield™ branded hand sanitizers and a durable surface coating for use in enhancing general hygiene and cleaning practices by businesses, healthcare, education, hospitality, transportation and consumers around the world.
Through innovative and patented formulations, the Q Shield™ family of products offers disinfectant coatings as a defense against a broad spectrum of unwanted organisms – including the SARS- CoV-2 virus that causes COVID-19. (Q Shield Professional Surface Protector test destroys SARS- CoV-2 virus) Q Shield™ technology offers surface and hand products, along with surface test kits that can confirm the ongoing presence of a Q Shield coating. The surface test detection technology was utilized during the study by trained site staff.
The Study Setting
Ridgestone and Great Lakes Senior Living are Wisconsin-based Assisted Living companies with facilities that house 300 assisted living and memory care unit residents, supported by an employed team of 225 total staff in southeastern Wisconsin. Eight facilities participated in this study. All four Great Lakes facilities are accredited by the Wisconsin Assisted Living Association (WALA) and have achieved Diamond accreditation status.
Case Study Problem
From the outbreak of the COVID-19 pandemic, Assisted Living facilities across the country have been identified as “COVID-19 hotbeds” by governmental agencies and media outlets. Southeast Wisconsin was no exception. Local media reported that Assisted Living facilities in the southeast Wisconsin region had “outbreaks of COVID-19” and the trend intensified throughout 2020. With that said, the issue of higher-than-normal infection rates in the Assisted Living industry versus the public was already well established prior to the COVID-19 pandemic. Between 2013 and 2017, 82% of U.S. nursing home facilities were “cited for infection control issues… and about half (48%) had persistent problems and were cited across multiple years.”1 As a result, many facilities suffer CMS reimbursement penalties for high rates of infection.
Ridgestone and Great Lakes management and facility leadership made an early commitment to master fast-evolving pathogen control protocols to minimize and prevent COVID-19 facility spread. Resident and employee protection from the pandemic became the mission, as well as the need to protect the network’s reputation. Ridgestone and Great Lakes proactively adopted State of Wisconsin Department of Health Services (DHS) and U.S. Center for Disease Control and Prevention (CDC) guidelines before they were mandated.
In March 2020, Ridgestone and Great Lakes facilities elected to lock down sites, meaning non-essential visitors were prohibited from entry. Over time, leadership realized that the lockdown measures were becoming increasingly difficult for their residents and were not sustainable. Ridgestone and Great Lakes facility directors identified four key factors that created contagion risk that would contribute to an outbreak spread—which had already happened at multiple competing facilities:
- Vulnerable populations: Over the last decade, the average age of residents had increased from the mid-70s to the late 80s, and new residents were arriving with higher rates of multiple, chronic, high-maintenance conditions,
- Close living quarters: Residents consistently preferred social clustering and socializing in communal areas where family and friends visited,
- Difficult-to-clean surfaces: High use and shared surfaces became prime suspects for cross-contamination—such as high touch doorknobs, guard rails, chairs, tables, game boards, pianos, and shuffleboard sticks—demanding that they be cleaned more frequently and thoroughly. By implication this required that more time be diverted from the priority of resident oversight and care, and
- Difficult-to-monitor visitors: Visitors, EMTs and residents entering sites can unwittingly carry in germs on their hands or contaminated gifts, which meant that visitation standards required a diplomatic and compliance-friendly rethink.
Management teams at all eight facilities observed increased time and labor intensity to maintain protocols for standard hygienic clean-up responses. The pandemic increased response frequency for simple events such as resident coughing and intensive cleaning for more significant interventions. Conventional disinfectant solutions were soon understood to be extremely short-acting.
Case Study Objective
Determine if a disinfectant technology, applied one time by a manual sprayer, exhibits sustained surface presence on a variety of surface types, using a surface verification test for confirmation of coating presence. Total time of sustained presence was the primary endpoint for the study. Unplanned secondary observational matters were mentioned around:
- staff impact from the disinfectant technology,
- the application process and effect on operations efficiency, and
- infection transmission occurrences and staff safety perceptions
The development of long-lasting single application products capable of demonstrating residual efficacy “for days, weeks and months” says EPA’s Andrew Wheeler, and led the U.S. Environmental Protection Agency (EPA) to designate a new “residual disinfection” product category in October, 2020. 2 This Case Study is intended to confirm the ability of the coating to remain present on treated surfaces for an extended period and to contribute to a facility’s carefully designed program to maintain hygiene and cleanliness in a real-world environment.
Q Shield™ Hand Implementation
Facility directors were instructed to close facility access to all but one facility entrance. Bottle dispensers of Q Shield Hand product were placed at this point of entry with the application required to create a protective perimeter. This was integrated within a new three-step visitor entry procedure which required all staff, vendors, and visitors to receive:
- a health screening interview,
- a temperature check, and
- a single treatment dose of Q Shield™ Hand Sanitizer per person per day for every site entry
Q Shield™ Professional Surface Protector Implementation
A virtual training session was conducted by Axenic in early November with Ridgestone and Great Lakes leadership and coordinators. The training to apply Q Shield™ and verify with surface tests “was fast, easy and took only 10 minutes”, as stated by a facility director.
Q Shield™ Professional Surface Protector was applied by Housekeeping staff the week of November 16, 2020. Surfaces treated included high-touch areas in common areas such as door handles, light switches, lamps, touchpads, buttons, remote devices, tables, armchairs, railings, desks, bathroom fixtures, and services areas. Surface materials included metals, plastics, wood, stone, and glass.
“Residents were never concerned about Q Shield application because it was applied when they were not present, and they never noticed any odors or equipment” – Great Lakes Facility Director
Surface Testing for Disinfectant Presence
After treatment and sufficient dry time, surface verification tests were immediately conducted to confirm the product was applied properly, with results recorded. Weekly tests on treated surfaces were conducted to verify continued Q Shield presence. Routine cleaning by housekeeping continued with protocols adjusted to avoid the use of abrasive scrubbers such as steel wool, synthetic rough cloth, and stiff plastic bristle brushes. Measurements of surfaces were integrated into routine staff housekeeping processes with a disciplined recording of results. The speed of test result visualization provided housekeeping coordinators real-time confirmation of continued Q Shield presence or the need to re-treat due to wear and tear. Facility leaders stated that their Housekeeping staff “felt empowered, took ownership and actually enjoyed the [product detection] testing.”
Surface – Ridgestone and Great Lakes Housekeeping staff tested key surface areas over a weekly cycle using a SiQuat verification detection test to determine the ongoing presence of the Q Shield coating. Pathogens can survive for significant time periods on surfaces for hours to weeks, depending upon the pathogen type and environmental conditions. 4. Surfaces also receive highly variable rates of touch and abrasion daily, which has an effect upon how long the product will last on surfaces.
The verification tests for the Q-Shield Professional Surface Protector product being present on treated surfaces were confirmed for up to 27 consecutive days, post-application (27 days post-application was the number of days data was collected).
The average period of detection was confirmed at more than 14 consecutive days post-application across all surface types.
Hand – Hand Sanitizer user compliance rate of 98% for staff and visitor hand utilization was achieved per site. Staff acceptance was aided by Q Shield™ Hand Sanitizer’s independent test results confirming the destruction of SARS-CoV-2 [COVID-19] on surrogate skin. (Q Shield Hand destroyed SARS-CoV-2 virus release) Access to test information accelerated trust in the incremental hand treatment as a mainstay for facility staff members to help fight COVID-19 spread by hand. An observational peripheral benefit was reported stating that users enjoyed a soft skin feeling rather than dry and cracking skin.
“Staff and visitors routinely commented that Q Shield feels nice on their hands and, unlike alcohol-based products, did not dry or hurt their hands in the dry Wisconsin winter” –Scott Zimmerman, Great Lakes Executive Management
Key learnings – After Q Shield™ treatment, it was recognized that treated surfaces should be cleaned with a non-abrasive cleaning tool (using conventional surfactants and detergents) for removal of basic dirt, dust, grease, fats, and other soilage, avoiding the use of an abrasive cleaning tool or product. Avoidance of highly abrasive scrubbing tools resulted in the average time of Q Shield performance increasing by more than 8 days, as compared to when stiff bristle brushes or other highly abrasive materials were inappropriately used. Testing was quick, easy, and built-up confidence measures in staff and residents across their environment.
Impact and Outcomes
Ridgestone and Great Lakes staff and residents had not received a COVID-19 vaccine prior to or during the study, resulting in no vaccine impact upon any of the direct or indirect results.
Site staff’s utilization of Q Shield’s verification of presence testing, as well as access to independent lab test data, was reportedly helpful in supporting staff confidence in the protection extended to them and their residents by the new agent. A culture of stewardship and custodial responsibility for the maintenance of a powerful, protective shield energized housekeeping and instilled a sense of heightened responsibility. Spot surface measurement with real-time results drove pride in maintaining results, communication of excellence, and confidence across the workforce and management.
Management stated that the Q Shield™ Professional Surface Protector protocol was easy to train employees for application and to conduct periodic verification testing. The longevity of surface presence convinced management that the facility budget could find room for surface products that had an extended life on surfaces. “One bottle really goes a long way– we’ve been using this one for almost 2 months!” declared a Facility Director.
Key Observational Outcome
Since March 2020, unaffiliated peer facilities in SE Wisconsin recorded “multiple occurrences of COVID-19” in Assisted Living and Memory Care sites. Each time there was spread within such facilities, resulting in numerous hospitalizations across their resident and staff populations5. Observationally, during the period of the Study, if a resident or staff member was diagnosed with COVID-19, there was no further spread of the virus reported within the sites. It is not known nor is it confirmed if Q Shield was a contributing factor to the suppression of transmission in these cases. As of the conclusion of this study, (January 22, 2021) the network remains without a positive COVID-19 resident.
“Q Shield™ is one of our key tools [used] to control the spread of COVID-19 in our facility.” – Great Lakes Facility Director
High touch surfaces—like doorknobs, cabinet knobs, safety rails, chairs, game boards, and piano keyboards—are likely to require Q Shield™ Professional Surface Protector application more frequently but should be measured for specific confirmation of the need and frequency. Less frequently touched surface types—such as walls, floors, countertops, bulletin boards, and piano keys—received only one treatment throughout the study and demonstrated the presence of Q Shield, thereby requiring application on a comparatively less frequent basis than high touch surfaces.
Observationally, the study established a net positive benefit due to infrequent application, long-lasting presence, and low maintenance as compared to higher frequency deep cleans. It was observed that there was an improved custodianship by Housekeeping staff for surface maintenance through active monitoring. Management reported there was enhanced confidence across facility staff as they perceived a heightened sense of protection from surface-sponsored transmission potential. Lastly, there was a reported improvement in the perception of facility safety and protection for residents by visiting family and friends. Anecdotally, after several positive COVID-19 diagnoses of an infected resident, the rate of spread that was historically experienced across Assisted Living facilities was not experienced by Ridgestone and Great Lakes facilities6.
The presence by a novel surface treatment has been confirmed across a wide range of surface materials, object types, and lengths of time. The indirect benefits provide opportunity for improved operations efficiency, a heightened operating culture of cleanliness, greater staff confidence in their environment, and easier maintenance associated with a high-performing clean environment.
At a time when families and caregivers across the country are hesitant to place their loved ones in assisted living facilities, Ridgestone and Great Lakes facilities continue community outreach and are currently intaking new residents. Ridgestone and Great Lakes are committed to differentiating from competitors by providing superior safety and generating higher levels of trust. Zimmerman says that “Axenic is helping [them] achieve those business goals.”
1. GAO Analysis for Centers for Medicare and Medicaid Services (CMS) report, GAO-20- 576R, 2020. https://www.gao.gov/products/gao-20-576r
2. https://www.epa.gov/newsreleases/epa-administrator-andrew-wheeler-announces- expedited-pathway-companies-claim-long
3. https://www.researchgate.net/publication/6873698_How_Long_do_Nosocomial_Pathoge ns_Persist_on_Inanimate_Surfaces_A_Systematic_Review; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1564025/; https://www.biorxiv.org/content/10.1101/2020.06.15.152983v1.full; https://www.cdc.gov/mrsa/community/environment/index.html;