If you were to ask a room full of Environmental Service (EVS) professionals to raise a hand if they felt they had enough time to fulfill their job duties, you probably wouldn’t see many fingers in the air. For those working in healthcare, time is usually in short supply. Getting patient rooms and surgical suites cleaned, disinfected and turned over for the next case is a demanding job. When time is limited, mastering efficiency is crucial.
Adopting strategies that combine best practices with effective products and services that are well-matched to the task at hand, conducting continuous education and training, and monitoring compliance are the essential ingredients for reducing healthcare-acquired infections (HAIs). Getting solid support and cooperation from other departments are also vital to success.
Lessons learned — an EVS success story
“Our HCAHPS scores were poor at best — we were at 29 percent,” said Vickie Schelvan, EVS Director, Memorial Medical Center, WI. Schelvan and Infection Preventionist Sarah Waby shared their story last year in a Learning Lab during the annual AHE Exchange in Pittsburgh. They said they uncovered various problems in the EVS department that not only kept staff from achieving their goals but also had a direct, negative effect on the patient experience.
Today, Memorial Medical Center patient satisfaction scores average 98 percent but getting there took some sleuthing to find out why, followed by a concerted effort to make several changes and stick with them.
“I had to start with education. They had no idea what HCAHPS were,” Schelvan explained. “I started sharing that info with them. We created employee surveys — what works, what doesn’t? We studied staff dynamics. We started meeting with staff regularly. We changed work slips, gave them more autonomy. We assigned unit champions.
“We also discovered personal preference, instead of best practice, dictated product choice,” she added. “Using AHE and APIC [recommendations] we began to implement changes, emphasizing how important the science was behind best practices. We also standardized our orientations and training.”
For example, Waby said they developed a protocol for addressing blood spills and made sure everyone understood and followed the same procedure. “We demonstrated how to wear PPE and clean it up,” Waby said. “They created a bucket of what they would need.”
Cleaning cards were also developed and distributed which Waby says made a big difference in getting staff to follow best practices. “They said it would be nice if you could write it down on a card,” Waby recalled. Now the team has laminated cards, housed on a key ring for easy access, that provide visuals and reader-friendly instructions for completing various tasks.
They also developed courtesy cards for patients to fill out, which Schelvan says has been very successful. “The feedback has been amazing. Not only do patients fill these out but they leave great comments. I can’t say enough about these courtesy cards. When you see patients commenting in such a positive manner you’ve got to feel good about what you do.”
Larinda Becker, Healthcare Marketing, Diversey Care, says some EVS teams are struggling to get the support they need to succeed. “Unfortunately, we still continue to see some organizations cut environmental services budgets, ignoring the fact that these teams provide the first and sometimes the last line of defense against infection,” she said. “Cleanliness delivered by pleasant EVS staff can help foster satisfaction and differentiate the hospital from its competition. EVS staff can improve a hospital’s reputation by interacting pleasantly with patients, explaining what they are doing and why it is important, and using effective cleaning practices to create a safer environment of care.”
Diversey offers a cleaning and disinfection portfolio that includes Oxivir 1-Minute disinfectant cleaners powered by AHP technology, MoonBeam3 UVC disinfectant systems, and TASKI machines and tools. “These solutions address the cost, quality, and, most importantly, the outcomes and results that providers are seeking, while being more responsible and pleasant to use around patients, visitors and staff,” said Becker.
Included on the list of ECRI’s “Top 10 Health Technology Hazards for 2017” is device failures caused by cleaning products and practices. The report states: “Repeated use of incompatible cleaning agents can damage equipment surfaces and degrade plastics, often resulting in device breakage—possibly with no visible warning signs; the use of improper cleaning practices can damage seals, degrade lubricants, and cause fluid intrusion. This can result in damage to electronics, power supplies, and motors. Because there is no single cleaner or cleaning process that will work with all devices, hospitals must stock and use multiple cleaning products and familiarize staff with device-specific cleaning methods—tasks that pose a significant burden. Nevertheless, failure to do so can lead to ineffective cleaning (a potentially deadly circumstance), as well as excessive component breakage and premature equipment failures (which can affect patient care and be a significant financial burden).”
Ellen Turner, Global Market Development Manager, specialty plastics in medical devices at Eastman Chemical Company, the battle against HAIs has prompted healthcare facilities to adopt new protocols, including use of more aggressive chemistries that contain isopropyl alcohol (IPA), IPA plus chlorhexidine, bleach, and other chemical disinfectants.
“Plastic materials unable to withstand exposure to these chemicals typically become cracked, crazed, or discolored; this can lead to a piece of equipment breaking down, which is costly to repair and replace resulting in a shorter equipment life cycle,” said Turner. “Even if equipment is not damaged per se, if the surface is sticky or becomes discolored, it can degrade the overall perception of the facility. Patients and users of the equipment may feel that the equipment is old or worn out.”
There are no industry standards for evaluating surface compatibility with the disinfectants used in healthcare facilities, although some manufacturers are taking on the task themselves. “It is not top-of-mind for biomedical engineers and designers to consider surface compatibility when designing equipment, but as cleaning protocols become stricter to reduce HAIs, this needs to figure in much more prominently into design considerations,” suggested Turner.
Clorox Healthcare is one supplier now working with Eastman to establish evaluation standards. Earlier this year Eastman rolled out a four-step testing protocol for plastics that enables equipment manufacturers and healthcare facilities to reliability assess the integrity of a device or surface after repeated cleaning and disinfection. Clorox’s Fuzion Cleaner Disinfectant is one product that passes the test.
“Eastman is working with Clorox Healthcare to raise awareness of this issue and is open to working with other disinfectant manufacturers,” said Turner. “While Eastman is raising awareness among biomedical engineers and designers, it is important for healthcare professionals to be aware of the testing protocol so that they can encourage their equipment suppliers to implement the test. Manufacturers can—and should—be choosing plastic materials that withstand the necessary disinfectant protocols required in today’s healthcare settings. We can ensure patient safety without sacrificing equipment performance, and healthcare professionals have an important voice in this regard.”
Wipe it away
Courtney Goodwin, Director of Marketing, Environment of Care, PDI, touted the efficacy and safety of the company’s Sani-Cloth Germicidal Disposable Wipes portfolio which includes different sizes and formats for use throughout the facility.
“PDI has conducted in-house testing of our Sani-Cloth brand germicidal disposable wipes on common surface materials found within the healthcare environment to ensure compatibility,” Goodwin said. “We also partner with leading device and material manufacturers to help build compatibility into the products from the onset. Finally, we offer our Sani-Tag Equipment Identification System to help indicate if a particular product should be used on a specific piece of equipment.”
Although EVS staff should know that following the disinfectant’s prescribed contact or wet time is crucial to its efficacy, sometimes there’s confusion. “Most manufacturers state that the surface must be wet for the duration of the contact time; there are some flaws in this recommendation,” Goodwin asserted. It goes back to a lack of time. EVS professionals must work fast and may feel that they have no option to wait. “Temperature, humidity, air flow, and the surface material itself all play a role in how quickly a disinfectant (or any liquid) will dry — in some situations the surface may dry faster than the manufacturer recommended contact time. What then, should the EVS professional continue to keep the surface wet?
“To clarify the situation we recommend that EVS professionals wipe the surface and allow it to be treated and remain undisturbed for the stated contact time (i.e., 2, 3, 4 minutes). As long as the surface is wiped and remains undisturbed, efficacy can be assured — as this process aligns with the required EPA testing methodology/registration.”
Research in the August 2017 issue of the American Journal of Infection Control showed that when accelerated hydrogen peroxide, quaternary ammonium compounds and sodium hypochlorite were each tested on stainless steel surfaces at 77 degrees Fahrenheit using EPA procedure MB-25-02, that the disinfectants were significantly less bactericidal at lower than label use contact times and concentrations. Specifically, all disinfectants were significantly less bactericidal against staphylococcus aureus when applied for times shorter than label contact times and significantly less bactericidal against S. aureus at lower than label concentrations, while the bactericidal efficacy of the sodium hypochlorite disinfectant was most tolerant to decreases in concentration and contact time.
During this year’s APIC conference, DebMed rolled out Coverage TB Plus Disinfectant wipes, a new accompaniment to its spray disinfectant. “The substrate friendly, two-minute efficacy disinfectant in Coverage Spray TB Plus has been used for over a decade to help disinfect hospital surfaces. By now offering this proven disinfectant chemistry in both a spray and a wipe, staff can be trained on the use of just one chemistry thereby simplifying their job,” said Charlie Kilfoyle, Senior Marketing Manager. “The spray-wipe combination simplifies training and the EVS worker’s job by making it easier for them to use spray and wipe format throughout the facility.”
Kilfoyle says they are a good investment as well. “When comparing the cost of a surface wipe to a ready to use spray or concentrate disinfectant, it is important to compare the ancillary costs associated with using the disinfectant,” he said. “Coverage TB Plus Disinfectant Wipes are ready to use and do not require the use of microfiber cloths, rags, or paper towels. When comparing the costs, the costs of the microfiber cloths, rags or towels — as well as any laundering costs if applicable — should be included in the total cost calculation for sprays and concentrates.”
“Subconsciously, many view the restroom as a microcosm of an entire facility,” said Jimy Baynum, Director of Market Development, North America, Essity Professional Hygiene Business, TORK. “If your restroom is unclean, then people will assume your facility is too.”
To free up EVS staff time and improve efficiencies, the Tork EasyCube intelligent facility cleaning system uses sensor technology, cleaning management software and data analysis to track supplies and cleanliness and assist in smart purchasing. “A crucial step to improving the quality of in-patient stays — and subsequent ratings — is ensuring that patient hygiene needs are met through fully-stocked, clean hospital rooms and general areas,” Baynum said.
Sensors are placed on restroom entrances to monitor foot traffic, and use of towel, tissue, soap and sanitizer dispensers, wirelessly transmitting the status in real time to a cloud-based data collection system.”Real-time data collection allows staff to be proactive and do exactly what’s needed when and where,” Baynum said. “Cleaning Management Software aggregates this data and displays it to facility managers, supervisors and Environmental Services staff through two, user-friendly web-enabled applications: The Facility Manager Web Application delivers an intuitive dashboard, analytics, charts and reports while the Cleaner Web Application digitizes cleaning routes to support more informed and automated task planning and cleaning schedules.”
Not only will staff replace supplies exactly when needed but the system is also a valuable tool that can be used to determine usage accuracy for better purchasing, including a potential for just-in-time buying.
What’s that smell?
There are also times when bathrooms may appear clean and well-stocked but something is amiss — the air. If it stinks, satisfaction scores can sink.
“Where we’ve seen very interesting attention to hygiene, is in the area of odor,” said Chris Ward, Air Care Category Manager, GP Pro (Georgia Pacific LLC). “GP Pro looked into the major causes of dissatisfaction in public restrooms and it turns out that behind seat hygiene, odor is the number two complaint. We found that if an area is clean, and even sanitized, if it smells bad, then it degrades the perception of clean.”
Launched in 2015, GP Pro’s ActiveAire line of air care products have helped hospitals tackle tough odors and increase HCAHPS scores.
Jamestown Regional Medical Center (JRMC) in Jamestown, NV is one example. Visitors were complaining about bathroom odors as the facility searched for a solution. Aerosol cans proved ineffective and expensive since they were over-utilized and EVS staff had to replace them continuously. JRMC installed 60 motion-activated ActiveAire Freshener Dispensers, which sit atop the toilet paper dispenser in individual stalls. Select exam rooms were also outfitted with whole-room air fresheners to fight odor during wound irrigation.
“After implementing this change, Jamestown Regional’s complaints regarding odor stopped and the dispensers received a lot of compliments,” Ward said. “Shortly after that, they saw HCAHPS scores rise. While it can require additional investment to add odor control to a restroom or facility cleaning regimen, if hospitals can do it while simultaneously increasing EVS efficiencies and raising HCAHPS scores, it reflects well on the hospital’s reputation and helps set them up to maximize Medicare payments from CMS based on HCAHPS scoring.”
Steve Ellis, Vice President, SE & Associates Inc., Digital Housekeeper, shares a similar sentiment, noting that while investing in technology is slow-going in some facilities, it’s worth doing. “We see managers embracing technologies more than in the past. But as in the past they still are finding it difficult to get the dollars for their capital budget for software, automated floor machines, riding floor machines, UV technology, etc.,” Ellis said.
Digital Housekeeper is a data driven system that tracks EVS staff accountability and improves efficiencies. Ellis explains: “Utilizing space inventory and assigning tasks and frequencies, we establish staffing needs based upon industry or benchmarking standards,” he said. “We develop written employee work assignments and follow up with fully customizable inspection templates. This improves the departments efficiencies and helps develop consistency of cleaning while keeping staffing in check. Census adjustments are made daily to ensure balanced workloads. If staffing reductions are necessary, DH can help determine where to make cuts based on frequencies and time standards. Knowing what actual staffing needs are, based on real numbers and not ‘gut feelings’ helps the user keep labor costs down.
“Based upon conversations and observations the EVS staff is following department practice and policies more than staff in other departments,” continued Ellis. “Some managers comment, ‘Everyone watches and critiques the EVS staff but not their own personnel.’ Appropriate staffing levels allow the cleaning staff to follow best practices. With proper training, adequate staffing and a good Quality Control program, it is much easier to follow and ensure best practices.” See product screenshot online at www.hpnonline.com/evs-formula-success/.
Fighting infection with walls and curtains
Quick-Change Privacy Curtains by Prime Medical make life easier for EVS staff and safer for patients.
“They are the only curtain panels that are made to be washed in EPA-reg. chlorine bleach, which kills pathogens and C. diff spores,” said Wendy Brady, Vice President, Marketing, Prime Medical. “The fabric will not fade in bleach and retains a shield of chlorine molecules with each wash as directed.”
The fabric binds chlorine for up to 120 days with each wash and staff can remove them quickly and easily for washing (no ladder required).
“Quick-Change Privacy Curtains were proven to show an 81 percent reduction in bioburden in an ICU, compared to untreated textiles,” Brady added.
Paint technology is also giving walls an antimicrobial boost. “Paint Shield is the first EPA-registered microbicidal paint that kills greater than 99.9 percent of Staph, MRSA, E. coli, VRE and Enterobacter aerogenes on painted surfaces within two hours of exposure,” said Steve Revnew, Senior Vice President of Product Innovation, Sherwin-Williams. “And continues to kill 90 percent of bacteria for up to four years when the integrity of the surface is maintained. Paint Shield microbicidal paint formula is patented in the U.S. and is EPA-registered. It has passed rigorous EPA test protocols conducted by third-party labs. Paint Shield underwent vigorous scrubbing tests and repeated exposure tests to make sure that when exposed to normal wear and tear, cleaning and scrubbing, it maintains its effectiveness.”
Don’t side-step those floors
The hospital floor, once overlooked as a source of infection, is now on everyone’s radar and for good reason according to studies. One published this year in the American Journal of Infection Control found that they are indeed harbingers of germs and should be reclassified as ‘critical’ areas requiring more thorough cleaning and disinfecting. In the study, researchers swabbed the floors of patients with and without C. diff. They also found evidence of MRSA and VRE. Rooms with C. diff patients were more likely to be contaminated with all three although C. diff was most common and found in 50 percent of the rooms. Additionally, in 41 percent of the rooms objects such as linens, medical devices, and towels were touching the floor, making transmission more likely. In fact, some of the staff handling the objects had those pathogens on their hands.
“You asked for our reaction and I guess the best answer is: hallelujah,” said Matt Morrison, Communications Director, Kaivac. “We have been suggesting to the professional cleaning industry, building managers, housekeepers, medical facility managers, and others for years that we need to pay much more attention to the fact that floors can harbor germs; those germs can spread from the floor to hands; and from the hands to people, causing disease. We are hopeful that with this study, and those conducted over the decades, medical facility managers and housekeepers will pay much more attention to effective floor care. It takes more time, we agree, but it saves lives and literally billions of dollars each year in added medical costs.”
Kaivac’s OmniFlex Crossover Cleaning system clean floors without a mop. “The system is walked over a spill or an entire floor area. Fresh cleaning solution and disinfectants are applied directly to the floor. As the machine is glided over the floor, the solution and debris are removed by the machine. Drying is nearly instant,” said Morrison. “This process may sound very familiar to readers. They are likely thinking this is an automatic scrubber. Its works like a scrubber but it’s not a scrubber nor does it cost anything near what an auto scrubber cost. Third party studies indicate it’s 30 to 60 times more effective at removing soils and contaminants than traditional floor cleaning methods, most specifically mops.Tests report it is up to four times faster than mopping a floor; this improves worker productivity and reduces costs. The battery powered system can clean 20,000 square feet in an hour. Repairs and servicing are rare. This translates into a very low cost of ownership for hospital administrators.”
Microfiber products are making their way into more healthcare facilities but often come with an adjustment period. Warwick Spencer, Critical Care Business Manager, Contec Inc., explains. “Change can come hard inside hospitals. New tools and new processes raise anxiety. Even when flawed, old familiar tools are tough to give up. In our experience, sharing the science of cleaning and disinfection through training and education helps overcome that fear factor. Our ‘quat binding’ and ATP testing data has proved this out. New, disposable microfiber simply cleans surfaces better than common, competing products that might come out of the laundry.”
Contec’s PREMIRA synthetic microfiber is effective when using any type of chemistry. “It allows your chemical, whatever it is, to do whatever job it’s assigned,” Spencer said. “Reused mops and wipes just can’t be relied upon to deliver consistent, superior cleaning and disinfection. We hear supply chain professionals asking about simplicity, risk mitigation and value distinction. Laundry isn’t simple. It’s unpredictable and it exposes employees and patients to textiles that have turned into fomites. With Contec disposables, acquisition and distribution are simplified, moving through existing channels. And with that, compliance will improve at the macro (supply chain) and the micro (cleaning processes) levels.”
Also in the flooring segment is 3M’s next generation Stone Floor Protection System, which includes improvements to both the Scotchgard Stone Floor Protector and 3M Trizact Diamond Abrasive Pads. The improved abrasive pads are optimized to wear evenly and last two times longer, increasing value and lowering total cost of ownership. Polishing time is also reduced and they work more effectively on heavily damaged floors, produce a long-lasting, high-traction shine that resists scuffs, stains and scratches in fewer steps and removes the need to burnish between coats. Additionally, the comprehensive system — which can be used on marble, terrazzo, polished concrete and other porous stone floors — includes components for greener cleaning and reduces the need for stripping and deep scrubbing.
No room in a hospital is safe from pest invasion — and when they get in and aren’t dealt with immediately, they pose serious risk to patients and staff and they can also put a real dent in a facility’s reputation.
“Over the past couple of years, several hospitals have come under fire in the media for everything from rat infestations to cockroaches taking over kitchen and dining areas,” said Glen Ramsey, B.C.E., Technical Services Director, Orkin, LLC. “ Flies, cockroaches, ants, rats and bed bugs are the most common pests found in healthcare environments and some can spread disease, including salmonella and E.coli. Cockroaches shed their skins and leave droppings, which can aggravate allergies and even cause asthma attacks.”
Flies and cockroaches are commonly found in kitchen and dining areas and are often a symptom of a larger sanitation or maintenance issue. They reproduce rapidly, so it’s important to work with a pest management professional to identify the source of the problem.
Ants are very resilient pests because their diet preferences can change throughout the year and they have massive populations — some boasting as many as half a million in one colony. Once they find a food or water source in a building, ants will leave a chemical scent trail for others to follow.
Rats can burrow and live up to 100 yards away from your building, and they can get inside through holes as small as the size of a quarter. They can gather in foodservice areas or employee breakrooms where food is often left accessible. In addition to spreading disease, they can cause structural damage and will chew on almost anything, including electrical wires.
Bed bugs are not a sign of poor sanitation and can be brought into a healthcare facility by anyone, including staff and employees. In addition to irritating patients with their bites, bed bugs can pose a significant threat to a facility’s reputation.
“Facility managers should work with their pest management provider to host pest management training for EVS staff and incorporate pest management best practices into everyday responsibilities,” said Ramsey. “Most pest control professionals will provide that training as part of their monitoring, inspection and treatment service.
“Orkin’s Healthcare Precision Protection protocols are based on extensive research and designed to comply with proven practices recommended by healthcare thought leaders including the Association for the Healthcare Environment , Health Care Without Harm and Practice Greenhealth,” he continued. “The standard Healthcare Precision Protection program includes insect and rodent control. In addition, any treatment Orkin uses is in compliance with Environmental Protection Agency guidelines.”
At least that’s what the survey says according to Kimberly-Clark Professional (KCP). The company funded an Omnibus study a few years ago and found that 70 percent of hospital respondents (357 patients participated) valued efforts to make them feel more comfortable, including the use of brands names that they may recognize and/or use at home.
That’s just one component of KCP’s new Make a Healing Home program. “Make a Healing Home provides a team of specialists trained in the science of hygiene who work directly with hospitals to provide evidence-based recommendations that can help create more home-like healing,” said Sarah Happel, KCP’s Healthcare Segment Marketing Leader. “The on-site assessment goes beyond hygiene practices to look at the total environment that shapes the patient experience, including facility design, amenities and the interactions between patients and staff. The goal is to help EVS staff enhance their role as empathetic caregivers, improve hygiene practices and increase their efficiency, freeing up time to connect with patients.
“One common challenge is the need to properly clean rooms within a tight time frame while minimizing disruptions for the patient,” continued Happel. “KCP specialists will observe how staff prepare for cleaning rounds and how they clean the patient’s room. Based on these observations, the specialist can suggest improvements. The Healing Home program includes informational posters, white papers, staff recognition cards that help EVS directors raise staff awareness of their roles as caregivers, improve their efficiency, and create a more home like setting that improves patient satisfaction and recovery.”