Working with environmental services to improve infection control efforts

by David Collette

A recent Cintas Corporation study of infection prevention professionals during the 2010 APIC Conference revealed that the relationship between the infection control (IC) and environmental services (EVS) departments is good but can be better. Only 42 percent of respondents strongly agreed that they work closely with the EVS department to establish cleaning protocols and ensure compliance. And only 27 percent of respondents strongly agreed that they were involved in the selection of the cleaning products used within their facility.

In years past, the impact of the EVS department and cleaning to prevent the spread of potentially harmful bacteria was undervalued. As a result, very few guidelines and regulations existed mandating cleaning frequencies or overall environmental hygiene regulations. However, with the increasing spread of Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococcus (VRE) and Clostridium difficile (C. diff), more research has been conducted on the impact of cleaning in preventing potential outbreaks from occurring. As a result, recent rules mandated by the Centers for Medicare and Medicaid Services (CMS) require infection prevention programs with housekeeping actively monitoring protocol adherence to ensure that the hospital maintains a clean and sanitary environment.

For infection control programs to evolve and become more effective, IC and EVS must work closely together to ensure the proper resources are in place to equip, audit, train and recognize EVS staff. With a few simple steps, these two departments can work together to ensure cleaning processes are properly performed to a level that will limit the potential for cross contamination and costly hospital-acquired infections (HAIs).

Equip

The days of cleaning with cotton in healthcare facilities are quickly coming to an end. Many cleaning professionals, especially in healthcare environments, now use microfiber towels and mops to keep surfaces clean. Known for its enhanced cleaning properties and ability to physically remove more than 99.9 percent of bacteria from a surface, microfiber is a core component of an effective cleaning system. Its widespread adoption has been further accelerated by the fact that when used properly, microfiber reduces the amount of chemical and water required in the typical cleaning process, improving worker productivity.

In a study conducted at the University of California – Davis Medical Center,¹ the hospital made the switch from conventional loop mops to microfiber mops in patient-care areas because microfiber mops did a better job of penetrating surface pores and removing dust particles than conventional string mops and cotton cloths during testing. After a surface was cleaned with conventional tools, there was a 30 percent reduction in bacteria growth, while microfiber had a reduction of 99 percent. The study also found that because microfiber mops weigh significantly less than conventional mops, use of microfiber mops reduced workers’ compensation claims.

In the Cintas APIC study, more than 50 percent of the respondents indicated a preference for microfiber over cotton as an effective cleaning tool. However, when the participants were asked if microfiber demonstrated a positive contribution to their facility’s infection control efforts, there was no clear agreement. This ambiguity could be explained by the response to another question: Only 29 percent strongly agreed that their cleaning process was proactively and objectively measured. One potential reason for these results is the lack of a robust cleaning quality assessment and measuring system.

While microfiber is the preferred method for keeping surfaces clean, moving to a microfiber program may be considered cost prohibitive. To assist in equipping EVS with the right resources to clean and disinfect hard surfaces, IC must work closely with EVS when budgets are being allocated. EVS and IC can jointly explain and outline the requirement for any changes to the IC program. Key issues to be addressed include cotton or microfiber, rent or own, inventory management and processing guidelines for soiled cleaning material. All soiled material should be handled following OSHA rules and the recommended CDC guidelines for laundering healthcare textiles.

Audit

Oftentimes a discrepancy exists between IC’s expectations for cleaning and the actual cleaning performed. This can sometimes be attributed to staffing shortages or the budgetary limitations of environmental services. But in some cases, the cause is simply that proper cleaning protocols have not been established. In the aforementioned APIC survey, only 35 percent strongly agreed that their facility had established clear cleaning protocols. And even in circumstances where protocols have been created, they may not always be followed. Auditing is an important step to ensure that critical patient care areas are being properly cleaned and disinfected.

To properly conduct an audit, it is important for the IC representative to work together with the EVS team performing the cleaning. The cleaning process should be timed in order to get an accurate assessment of how rooms are cleaned on a daily basis. If patient rooms are not sized similarly throughout the facility, each room type and size should be audited with separate and specific measurements.

Once the audit is complete, infection control staff should continue to work together with the EVS department to make sure that cleaning times are realistic and up to date with current policies. Audits should also be conducted on an ongoing basis to ensure workers continuously improve their effectiveness.

Train

According to a recent survey of more than 2,000 members of the American Society of Healthcare Environmental Services (ASHES)², the most important concern for EVS directors is the hiring, retention, and management of quality staff. High turnover creates training challenges—a key focus for EVS departments looking to help reduce HAIs.

In a 2009 interview,³ Philip Carling, MD, director of Infectious Diseases and Epidemiology at Caritas Carney Hospital in Boston and a professor at Boston University School of Medicine, said, “On the basis of my discussion with dozens of Infection Preventionists … it appears that the primary reasons for suboptimal performance in terminal room cleaning relate to shortcomings in the education of environmental services staff with regard to their understanding of specific, clinically relevant cleaning expectations, and their critical role in patient safety through the prevention of hospital-associated pathogen (HAP) transmission from near-patient environmental surfaces.”

Before proper training can occur, the right cleaning protocols must be in place. In the APIC survey only 35 percent of respondents strongly agreed their facilities had established clear cleaning protocol for in-patient room cleaning. Since it is imperative that IC and EVS partner to continually review and improve in-patient room cleaning, there is significant work to be done to optimize outcomes in many U.S. hospitals.

A team of researchers from the University of North Carolina – Chapel Hill, recently identified five key high-touch surfaces in patient rooms that may contribute to HAI transmission:⁴ bed rails, bed surfaces, supply carts, over-bed tables and intravenous pumps. While some cleaning protocols may focus on other areas that can transmit disease between people, such as door handles, it is particularly important that surfaces near the patient are a primary focus for the environmental services staff.

EVS staff must first receive product and process training before being allowed to clean a patient room and then be provided follow-up training to ensure continuous improvement. Infection preventionists must also work in partnership with EVS managers to ensure that training materials are up to date, that the resources are in place to provide inservice training as needed, and that specialists are available to help staff understand the importance of their role in limiting the spread of infection.

In addition to knowing the proper way to clean and disinfect the room, EVS staff should also be trained on how to communicate with patients. A worker who introduces him/herself to the patient and is able to articulate what they are doing in the room helps relax the patient, improving their experience. Another key benefit from having the EVS staff interact with patients is that the cleaning activity is acknowledged by patients and can be used to reinforce the message that the facility is working diligently to provide a clean and safe healthcare experience.

Vendors are great resources to tap for training assistance. Supplier representatives can often provide training upon implementation of a new product or program, as well as ongoing training to make sure the product is being used correctly. Vendors should be equipped to provide documentation of all training completed for surveys by the Joint Commission or Occupational Safety and Health Administration (OSHA) audits. Vendors are also continuing to innovate healthcare cleaning systems via new chemicals, processes, tools and textiles, and EVS and IC can enhance their value by leveraging vendor partnerships for information and education.

Recognize

“Well-trained, conscientious EVS workers who have a clear understanding of their role in decreasing [cross contamination] are motivated to perform their surface cleaning activities more thoroughly,” said Carling. “Having a system which provides ongoing objective and timely performance feedback to EVS staff has also been shown to improve the thoroughness of disinfection cleaning.”

In order to improve cleanliness levels and reduce opportunities for cross-contamination, infection preventionists must work with the EVS department to empower cleaning staff by offering feedback and recognizing them for work performed well.

By implementing a process for continual evaluation and feedback, employees will have a better understanding of the quality of their work. It is important to note that “quality” workers are not likely to be the “fastest” workers. Technology such as ATP testing meters can be used to provide objective measurements for auditing and performance feedback.

In addition to evaluating work and providing recognition for a job well done, national events such as “International Housekeepers Week” (International Executive Housekeepers Association) or “Environmental Services Week” (ASHES) are also ways for the entire hospital to show appreciation for the work performed by their cleaning staff. This positive reinforcement gives staff members a better understanding of the importance of their work, encouraging them to continue in their dedication to the overall hospital mission.

Conclusion

Communication and coordination between EVS and infection control does exist but there is still work to be done. HAIs are still an issue that costs hospitals from $28.4 billion to $33.8 billion annually(5), and improving the partnership between the two departments can aid in reducing the threat of infection and overall costs to the hospital.

The formula is relatively simple—a close partnership between IC and EVS, equipping the cleaning staff with the right tools and process, providing the proper training so they know how to clean, conducting audits to ensure compliance and provide feedback for continuous improvement, and reinforcing good performance by staff recognition. These important efforts will ensure IC and EVS deliver the optimal cleaning experience for their healthcare facility.

References

1. http://www.ucdmc.ucdavis.edu/newsroom/releases/archives/other/2006/mop6-2006.html
2. http://www.infectioncontroltoday.com/news/2010/06/staffing-tops-concerns-for-environmental-services.aspx
3. http://www.infectioncontroltoday.com/articles/2009/11/proper-environmental-cleaning-relies-on-education.aspx
4. http://boards.medscape.com/forums/?128@guest@.2a0146d6!comment=1
5. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf

David Collette is director of New Business Development for Cintas Corporation. For more information on Cintas’ solutions for healthcare, go to www.cintashealthcare.com.