The correlation between the clinical environment of care and HAIs

The contaminated clinical environment of care (CEOC) has been proven to play a role in the transmission of multidrug-resistant pathogens such as Methicillin Resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Environmental surfaces are routinely touched by the healthcare team, as well as the patient on a daily basis. These high-touch surfaces can become contaminated with a variety of bacteria, viruses, and pathogenic fungal organisms. Additional evidence has shown that patients admitted to hospital rooms after they were previously occupied by patients with multidrug-resistant organisms, such as MRSA, can be at increased risk for contracting a healthcare-associated infection (HAI). As such, the clinical environment of care must be closely monitored through a comprehensive environmental monitoring program to measure the effectiveness of cleaning and disinfection. With increasing evidence supporting the potential of HAIs resulting from environmental contamination, the collaboration of the Environmental Services Professional and Infection Preventionist is more important than ever.

Embracing responsibility

Much of the responsibility for the CEOC falls upon the Environmental Services (EVS) Team since the frontline care of the clinical environment is performed by the EVS technician. These EVS technicians not only help maintain a clean and sanitary environment, but equally important, they engage with patients and family members daily during their normal practices. To prevent HAIs, the entire healthcare team must actively engage the patient in the prevention of infection. This includes steps such as offering the patient and family members an opportunity to perform hand hygiene, talking to the patient about what the healthcare team is doing to reduce their risk for infection, advising the patient about their role in speaking up and holding the healthcare provider team accountable for basic interventions such as hand hygiene, and asking questions when they don’t know why a particular treatment or medicine is being administered.

To successfully and sustainably reduce the risk for HAIs, all healthcare stakeholders and the patient must be engaged in prevention efforts. Environmental contamination can come from the bacterial contamination of a bedside table with MRSA, Clostridium difficile bacteria on a bedside toilet, or a blood spill from a patient with Hepatitis B virus. Each of these situations creates risk for the patient, the healthcare provider, EVS technician, and the clinical environment itself. To mitigate risk, a standardized approach to environmental cleaning and disinfection must be carefully followed including adherence to the evidence-based practice guidance available from the Centers for Disease Control and Prevention (CDC) and the Association for the Healthcare Environment.,

Particular concerns within the healthcare CEOC

In today’s healthcare settings, the risk for the presence of multidrug-resistant microorganisms is ever-present. Typical pathogens found in healthcare can include the following:

• Gram-negative and Gram-positive bacteria
• Enveloped and nonenveloped viruses
• Bloodborne pathogens
• Pathogenic fungal organisms
• Bacterial spores

Most of the microorganisms can be successfully removed from the CEOC by adherence to hand hygiene and isolation precaution guidelines and proper cleaning and disinfection practices using an EPA-registered, hospital-grade disinfectant (low or intermediate level disinfectant). Some more resilient microorganisms, such as Clostridium difficile and Norovirus, may require the use of specialty disinfectants that can inactive certain bacterial spores which have the capability of forming endospores.3

No-touch environmental disinfection

Multiple no-touch technologies are commercially available for the purpose of environmental disinfection in healthcare settings. Examples of these technologies include ultraviolet light, fogging systems, self-disinfecting surfaces, and environmental-monitoring tools. Each of these adjunctive disinfection technologies can be valuable when properly used according to the manufacturer’s instructions for use and after implementation of all evidence-based practices relative to environmental cleaning and disinfection. While these technologies can automate many disinfection practices, they do not eliminate the need for traditional cleaning and disinfection practices.

It is important that when advanced technologies are utilized and deployed in a facility, that the staff with responsibility for operating this equipment also receives special training in its operation and safety. Environmental monitoring programs should account for the use of these tools and compliance should be closely monitored by the Environmental Services leadership. New technologies can be helpful in many circumstances, but they should be properly evaluated, trialed, and then implemented according to best practice. Sometimes, going back to the basics in respect to cleaning, disinfection, hand hygiene, and isolation precautions can rapidly drive down HAI rates and reduce costs of care delivery.

Going forward

The role of the clinical environment of care will continue to be further understood as additional clinical research is performed, but what is already clear is the impact of an integrated Environmental Services and Infection Prevention program in the fight to reduce and eliminate HAIs. We know for sure that many multidrug-resistant bacteria and other pathogens can readily inhabit and thereby contaminate the clinical environment of care, but they can be effectively removed and the associated risks of infection reduced with a comprehensive environmental services program. It is also important to highlight the importance of removing these multidrug-resistant microorganisms from the environment before they have an opportunity to contaminate the patient and cause potential issues with antibiotic resistance.

The Association for the Healthcare Environment (AHE) has developed evidence-based resources in the form of certification programs (Certified Healthcare Environmental Services Technician and Certified Healthcare Environmental Services Professional) and evidence-based Practice Guidance (Practice Guidance for Environmental Cleaning) to assist Environmental Services Technicians and Professionals in hard wiring evidence-based practices for infection prevention in their programs. Additionally, the CDC has funded clinical research grants through its EPICENTER program to evaluate the role of the healthcare clinical environment of care in transmission and also identify best practices to reduce the risks of transmission.

Together, Environmental Services and Infection Prevention and Control work collaboratively to reduce HAIs, improve clinical outcomes and healthcare quality metrics, and improve the overall patient experience. Infection Prevention and Control is a moving target, and requires constant vigilance, collaboration, and transparent communication, but these efforts protect the most valuable component of our healthcare delivery systems: the patient. hpn

Additional Resources for HAI Reduction:

• Association for the Healthcare Environment Certificate of Mastery in Infection Prevention and Control for Environmental Services, http://www.ahe.org/ahe/lead/CMIP/index.shtml.
• Association for the Healthcare Environment Practice Guidance for Environmental Cleaning, https://ams.aha.org/EWEB/DynamicPage.aspx?WebCode=ProdDetailAdd&ivd_prc_prd_key=529ab0ff-718f-401d-8433-175d01bef546.
• Centers for Disease Control and Prevention Healthcare Infection Prevention Toolkits, http://www.cdc.gov/hai/prevent/prevention_tools.html.

References

1. Weinstein RA. Epidemiology and control of nosocomial infections in adult intensive care units. Am J Med 1991; 91 (suppl 3B): 179S-184S.
2. Practice Guidance for Environmental Cleaning, Association for the Healthcare Environment, 2012.
3. Guideline for Disinfection and Sterilization in Healthcare Facilities, Healthcare Infection Control Practices Advisory Committee, U.S. Centers for Disease Control and Prevention (2008).