The Environmental Services (EVS) Department is as critical to a healthcare facility’s survival as rainfall is to the health of a forest. If the mission is to prevent infectious outbreaks, uphold patient safety, improve customer satisfaction, and keep reimbursements flowing, then smart providers know they need strong, capable EVS departments to help make it happen.
Yet, sometimes EVS staffs still struggle to do their jobs as effectively as they would like. Recruitment problems, poor training, failure to follow best practices, lack of time needed to complete tasks, and unresponsive leadership are some of the obstacles EVS departments encounter.
Sounds troubling but the flip side is that more healthcare leaders are starting to listen and respond in positive ways because they believe that taking a facility-wide approach to infection prevention should be the norm, not the exception.
Gaining ground with education
This year the Association for the Healthcare Environment (AHE) will debut the first-ever Certificate of Mastery in Infection Prevention (CMIP) for Environmental Services Professionals.1 during the AHE Exchange conference in Pittsburgh (Sept.25-28). The intensive 20-hour certificate of mastery program gives EVS leaders and other professionals the requisite knowledge they need to meet the Centers for Medicare & Medicaid’s Services (CMS) requirements for a “trained” professional. The course, which sold out months before the conference, is testament to the weight EVS holds in making the healthcare environment safer for everyone.
The Certified Healthcare Environmental Services Technician (CHEST) is another credentialing program launched by the AHE last year. The program, structured on the Train-the-Trainer model, has been a great success and draws consistent interest from EVS professionals across the country.
“Over the last few years, environmental services have petitioned for a best practice training program for supervisors and frontline staff in order to improve the patient environment,” said Laurie Rabens, Senior Product Manager, Clorox Healthcare, which underwrote the program. “Over the past year, every single session of the training has sold out, which we’ve taken as a clear sign of EVS teams’ enthusiasm for education and training opportunities and commitment to excellence in their field.”
J. Hudson Garrett Jr., PhD, MSN, MPH, CHESP and industry liaison for the National Board of Directors for AHE, helped develop and will co-facilitate the CMIP course. He says there’s strong evidence to support the idea that EVS staff can and will deliver excellent infection prevention outcomes and results — every time — if given the right tools and guidance and executive leadership support.
Whether it’s due to budgetary constraints, assembling the wrong size team, or some other reason, staff shortages have plagued EVS departments for years — and they are likely to be feeling it even more acutely today as patient load increases.
“When you look at staffing there’s not currently any scientific way to determine an ideal number of staff per square foot,” said Garrett. “Something that AHE is working on fairly aggressively right now is a staffing model that can be used by environmental services leaders.”
The second part of the equation is time. Technicians need more time to do the work they are assigned.
“Certain rooms, like the OR or ICU, are complex and house lots of equipment, requiring extended time to complete a thorough, detailed clean,” said Melanie Waddell, Senior Product Manager, PDI. “According to AHE, to follow all of the recommended practice steps, an occupied patient room clean will take approximately 25 to 30 minutes per room and a terminal clean takes 40 to 45 minutes at a minimum. We should attempt to address the root of the problem, perhaps asking ourselves if we’re empowering environmental services staff to follow evidence-based practices at every juncture.”
“Room turnover time is a huge issue because they’re measured on that,” Garrett added. “You’ve got patients down the hallway that are trying to get into the rooms and they can’t because environmental services are trying to do their cleaning and disinfection process in a high pressure environment. We must allot the proper amount of time to ensure safe room turnover each and every time.”
Incorporating lasting change also requires leadership accountability and ensuring that top-level decision makers are educated and involved with EVS activities. They should be familiar with job details and able to determine quickly if and when additional steps are necessary to correct mistakes or improve processes.
“I don’t really mean the environmental services director, I mean the C-Suite making sure that those departments have what they need, what’s necessary to do their jobs effectively,” said Garrett. “I think we’re seeing more [involvement] with the reporting that’s happening and the emphasis on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores and how they tie back into value-based purchasing but we still need more.”
If communication between departments isn’t flowing EVS might consider taking the initiative to spearhead collaboration.
“If we expect the C-Suite to pay attention to what we’re doing we need to share that with the C-Suite and get a seat at the table,” Garrett said. “I’m not saying the environmental services leader has to be at every single board meeting but they should be coming to board meetings, they should be presenting their data with confidence and talking about the great work they’re doing to maintain a clean and sanitary environment. So we’ve got to ask for those invitations.”
Garret said EVS folks are quite willing to apply new approaches if they have the right information and tools.
“I actually find most of the environmental services leaders are more open to change than other people in other roles in healthcare,” he said. “I really feel strongly that we’re on a very positive trajectory as a profession. And that can be a good intersection point with nursing and other key stakeholders.”
Products and services roundup
EVS product and service experts shared what facilities are using in their efforts to wipe out pathogens and stop the spread of infection in patient rooms, the OR, nurse’s stations and elsewhere.*
Rabens (Clorox) suggested that products must evolve to meet facility needs by offering improved efficacy and ease of use without causing damage to surfaces and equipment.
“The new Clorox Healthcare Fuzion Cleaner Disinfectant provides a sporicidal solution with broad surface compatibility, superior aesthetics and an innovative formulation that minimizes residue and eliminates the need for a rinsing step,” she said. “Additionally, Clorox Healthcare actively partners with customers to train their staff and implement new products and protocols and provide ongoing technical support in order to ensure the highest level of efficacy.”
Larinda Becker, Healthcare Marketing, Sealed Air Diversey Care, said her company is also focused on providing cleaning solutions that integrate products, processes, training and measurement systems to improve results, reduce risk and lower overall cost.
“Our cleaning and disinfection platform includes Oxivir disinfectant cleaners powered by AHP technology, and TASKI machines and tools to enable fast, effective, responsible and sustainable results. These solutions address the cost, quality, and, most importantly, the outcomes/results that providers are seeking, while being more responsible and pleasant to use around patients, visitors and staff.”
Waddell (PDI) said at St. John’s Medical Center the equipment was not disinfected every time becasue staff didn’t have adequate access to surface disinfectant products. “PDI implemented a 360-degree approach for surface disinfection, which included new surface disinfecting wipes, staff education, canister brackets attached to walls and equipment and countertop caddies with contact time reminders,” she said. “I think environmental services staff want to do the right thing by the patients and follow evidence-based practices every single time they clean; however, the external factors sometimes don’t allow them to do so.”
Karl Soderquist, President, the HUBSCRUB Company, said “Environmental cleaning products and protocols are definitely moving in a positive direction that includes safety for the user, minimal impact to our environment and technology for better cleaning. Examples include the updating of information required in the SDS Safety Data Sheet previously known as MSDS. Perhaps most important the customer base is asking for these types of products in greater numbers.”
The HUBSCRUB automated system cleans and disinfects items such as wheelchairs, commodes and other patient-care equipment efficiently. “Antimicrobial products include liquid disinfectants and our unique ultra-violet (UV) for high-level disinfection such as C.diff. CRE, MRSA. Independent Research testing5 demonstrated that the HUBSCRUB three-minute wash and rinse followed by a three-minute UV application completely removed C.diff and CRE,” Soderquist said.
Textiles are another paradise for pathogens as noted in many studies including the 2012 study “Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria.” The research, published in the American Journal of Infection Control, shows how rapidly and frequently curtain bacteria travels to patients by way of healthcare worker’s (HCW’s) hands. The authors said hand hygiene, often practiced prior to touching curtains and before patient care, is often forgotten about in between.
“Being that soft surfaces cover 90 percent of the patient contact environment, a patient’s stay in a healthcare facility makes it almost impossible not to come in contact with these surfaces,” said Bill Kadi, Business Unit Manager, Construction Specialties Inc. “The product from our selection that has been proving time and time again as being the most valuable to healthcare networks has been On The Right Track, which essentially resolves the issue of the infamous ‘Cubicle Curtain Crisis.’ Traditional cubicle curtain hooks make the curtain replacement process extremely difficult, dangerous and time consuming. On average, it takes 20 minutes to replace a cubicle curtain, and ladders pose too much risk and liability.”
On The Right Track’s patented split ring technology and The Grabber tool allow HCW’s to change curtains in 60 seconds or less without a ladder. Also, the curtain panels snap together vertically, allowing for the replacement of one contaminated panel at a time. “A case study based on a five- year projection study compiled by a New Jersey hospital using On The Right Track 100 percent recyclable disposable curtains in their emergency department shows that the facility will be able to save at least $36,650 over five years,” 2 said Kadi.
Adam Estelle, Project Engineer, Copper Development Association Inc., said installing uncoated copper and related metals, which have inherent antimicrobial properties that kill bacteria continuously, is an excellent supplement to standard infection control practices. He said an estimated 150 healthcare facilities in 35 states are using copper-based sinks and faucets in public restrooms, patient rooms and hallway basins, cabinet pulls, I.V. pole handles, handicapped-access buttons, patient tray tables, chair arms, grab bars, flush handles, switch plates, outlet covers, soap dispensers, keyboards and more.
“The Environmental Protection Agency granted a public health registration to copper alloys which permits products made from these materials to make antimicrobial effectiveness claims against six bacteria, including Methicillin-Resistant Staphylococcus aureus and Vancomycin-ResistantEnterococcus faecalis, killing greater than 99.9 percent within two hours of exposure,” Estelle said. “Additionally, two clinical trials have demonstrated that the strategic placement of antimicrobial copper surfaces can reduce HAIs.3,4
“From an investment standpoint, the direct cost of treating a single hospital acquired infection is approximately $43,000 (exclusive of the patient’s pain and suffering),” he continued. “In comparison, the incremental cost to outfit a patient room with a full suite of antimicrobial copper products is typically less than $5,000 based on current estimates from EPA-registered suppliers. This represents an attractive value proposition, particularly when considering the useful life of copper products.”
Checklists and reminders
Research shows, said Cali Sartor, Director of Marketing, Spartan Chemical Company Inc., that healthcare associated infection (HAI) rates drop significantly when staff are trained to clean and disinfect patient areas the right way. However, there may be a caveat.
“Those studies also show that training in health care facilities starts to diminish after 90 days, and people go back to their old habits,” said Sartor. “To address this issue, we have taken our highly successful CleanCheck program and added a health care module that addresses the short and long-term training needs of healthcare facilities while providing exam-supported training certification.”
Spartan’s HealthCheck uses a three-pronged approach — training, validation and documentation — via a web-based platform. Portable CleanCheck procedure cards reinforce the training program and facilitate compliance while the CompuClean mobile app quality inspection tool helps EVS managers with training, assessments, and tracking to aid in identifying success as well as areas of concern.
Brian Herriot, President, ReadyList Inc., points out that most facilities are quick to implement best cleaning protocols. However, when focusing on certain pathogens that may be harder to eradicate, such as C.difficile, other areas can suffer from a lack of attention or thoroughness.
“At UCSF Medical Center, C.difficile cleaning protocols were quickly identified and rolled out to EVS technicians. As the spotlight shines on C.diff rates, EVS departments are right to focus on cleaning and sanitizing certain high-risk rooms,” said Herriot. “However, this could be at the expense of other room cleans. Most often, additional cleaning to eradicate the C.diff microorganism is handled on top of existing staffing and departmental processes, with no staff augmentation or workflow improvements. Therefore, something has to give. There is an opportunity to improve consistency of evidence-based cleaning across every clean.”
He says ReadyList for EVS can help achieve that end with its easy-to-use software platform which guides EVS technicians through step-by-step cleaning protocols at the point-of-service. It offers real-time progress monitoring, quick-click electronic inspections and detailed management reports for delivering transparent data that can help drive accountability and influence use of best practices.
Let’s assume best practices and products are practiced religiously and everybody’s on board, every time. Now what? No matter how hi-tech or effective a product claims to be, or how well of a job the EVS team thinks it did, if results can’t be measured, it’s hard to really know for sure.
“When a new disinfection technology is introduced there is a tendency to believe that the work of cleaning can therefore be less rigorous when in fact the opposite is true. Meticulous cleaning is an absolute required first step in any disinfection process,” said Grace Thornhill, PhD, Technical Services Specialist, 3M Infection Prevention Division. “There is a growing body of evidence that supports the implementation of comprehensive, daily monitoring program as a key strategy that results in the improvement in the efficacy of cleaning. The monitoring program should provide objective, numerical data that can be tracked, trended, thus providing actionable results leading to cleaning process improvements.
“In 30 seconds, the 3M Clean-Trace ATP Monitoring System is able to quantify the cleanliness of a surface using Adenosine triphosphate (ATP) bioluminescence, based on established pass/fail thresholds,” she explained. “With the integrated software, you can set up testing protocols and generate reports to monitor the effectiveness of your cleaning processes, enabling you to re-clean when necessary, identify lapses in protocol, and determine whether additional training is needed.”
Barbara Connell, MS, MT (ASCP) SH, Vice President, Clinical Services, Medline, recalled an impression she had while shadowing some hospital EVS housekeepers. “I was taken aback by all the surfaces, equipment, fixtures and furnishings that needed to be cleaned and all within 30 minutes,” she said. “Many healthcare facilities are implementing technology to not only decontaminate rooms better, but also monitor staff effectiveness in this area. ATP is an enzyme present in all living cells; Medline ATP Sanitation Monitoring Systems can detect the amount of organic matter remaining after cleaning an environmental surface, medical device or surgical instrument.”
Lauren Roady, Marketing Manager, Hygiena, added that the ATP systems are affordable, easy to use and can provide a good amount of actionable data. “Infection Preventionists and EVS Directors love data and reports from which to make decisions and objectively investigate problems,” she said. “Putting managers behind the steering wheel of user-friendly data analysis and reporting tools is empowering and satisfies that need for on-demand data analysis. That’s why Hygiena has designed the newest version of SureTrend data analysis software to be 100 percent customizable and flexible to output any report, graph, or table as needed. For example, EVS and IP managers can tell which areas in patient rooms need more cleaning and which individual staff members need more training, so measurable improvement can be made. The only group that loves these reports more than managers is accrediting organization surveyors.”
Garrett said ATP seems to be the tool of choice to verify whether staff is cleaning and disinfecting thoroughly but he also suggests that the devices may not be 100 percent infallible.
“I think ATP is probably the biggest one right now but I think it’s a poorly understood area — no one really knows what that magical number is other than zero so that’s something to think about,” he said. “But I do think there is some value in using it as a process-monitoring tool.”
*For information on no-touch room decontamination, read “No room for Bugs.”
- Research on file with vendor.
- Salgado et al, Infect Control Hosp Epidemiol, Vol. 34, No. 5, May 2013.
- Von Dessauer et al, Am J Infect Control, June 2016, in-press.
- Research on file with vendor.