John Michael Weir – BBA, CHESP, REH

Don’t start itching, and then check underneath your bed! You see it seems that bedbugs, also known as Cimex Lectularius are showing up in many places.

The bloodsucking bugs were virtually eradicated in the United States in the 1950s. But they are now showing up practically everywhere, nursing homes, jails, apartment buildings, dormitories, even hospitals. There has been a 500% increase in the last few years!

Experts blame the resurgence on increased international travel, immigration, changes in pest-control practices, and the bugs’ growing resistance to insecticides.

Bedbugs can live for a year without a blood meal, but once they start biting their victims may be plagued with multiple bites each night.

The EPA has made some information available to the general population that should be of interest to healthcare professionals.

http://cfpub.epa.gov/oppref/bedbug/

http://www.epa.gov/bedbugs/

Here is a link to the CDC as well:

http://www.cdc.gov/nceh/ehs/Publications/Bed_Bugs_CDC-EPA_Statement.htm

I hope this is of benefit to all of you with problems or concerns.  Please pass this information along to your staff, your Infection Preventionist, Facilities department, and anyone that can be of assistance in addressing the infestations.

I am currently investigating a disposable curtain that does not require a ladder to change. We need a easy way to change curtains much more often then when they look soiled, or every six months. Studies have shown that bacteria can live without the source of a host for months at a time, depending on the bacteria.

What good is it to terminally clean a room including wiping down all of the People Contact Points/Touch Points to rid them of potential microbes that cause HAIs and yet leave curtains that have been touched countless times by contaminated hands?

Curtains should be changed at each and every terminal cleaning – period.  Is it done? No.  Is there documentation that curtains act as vectors for microbes? Yes. You can download the report below.

Infection Control and Hospital Epidemiology November 2008, Vol. 29, No 11; 1074-1076

HCAHPS results are publicly reported on Hospital Compare as “top-box,” “bottom-box” and “middle-box” scores. The “top-box” is the most positive response to HCAHPS survey questions. The “top-box” response is "Always” for five HCAHPS composites (Communication with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Pain Management, and Communication about Medicines) and two individual items (Cleanliness of Hospital Environment and Quietness of Hospital Environment), "Yes" for the sixth composite, Discharge Information, "‘9’ or ‘10’ (high)" for the Overall Hospital Rating item, and "Would definitely recommend” for the Recommend the Hospital item.

The “bottom-box” is the least positive response category for HCAHPS measures. The “bottom-box” response is "Sometimes or never” for five HCAHPS composites (Communication with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Pain Management, and Communication about Medicines) and two individual items (Cleanliness of Hospital Environment and Quietness of Hospital Environment), "No" for the sixth composite, Discharge Information, "‘6’ or lower (low)" for the Overall Hospital Rating item, and "Would not recommend” for the Recommend the Hospital item.

The “middle-box” captures intermediate responses to HCAHPS survey items. The “middle-box” response is "Usually” for five HCAHPS composites (Communication with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Pain Management, and Communication about Medicines) and two individual items (Cleanliness of Hospital Environment and Quietness of Hospital Environment), "‘7’ or ‘8’ (medium)" for the Overall Hospital Rating item, and "Would probably recommend” for the Recommend the Hospital item. There is no “middle-box” response in the Discharge Information composite.

HCAHPS On-Line, the official HCAHPS Web site, houses a series of tables that summarize current and historic HCAHPS results. These HCAHPS Tables, available exclusively on HCAHPS On-Line, are based on the HCAHPS data participating hospitals submit to CMS. Before being publicly reported, data are adjusted for the effects of patient-mix and mode of survey administration.

To view the full set of current results on each HCAHPS measure for individual hospitals, please visit the "Survey of Patients’ Hospital Experiences" section of the Hospital Compare Web site (www.hospitalcompare.hhs.gov).

I wrote some general cleaning procedures back here and several people thanked me and asked for more. So I want to take some time and give you some more general and some specific cleaning procedures, along with some important definitions.

I have two ways to explain what I feel clean is. First, the absence of removable soil. Sometimes that means the object may be clean but still look bad, such as a wall that needs paint, or a desk that is scratched. It might also be that there is a stain, something that is not removable so the object does not really look clean. Second, I like to say that it will look brand new, or as close to that as possible.

In healthcare cleaning, we go beyond the look of something. It is the visible dirt that makes us unhappy, but it is the invisible “dirt” that makes us sick. We clean surfaces that may already look clean to the naked eye but under a microscope it could be crawling with bacteria.

So what is cleaning?

cleaning present participle of clean (Verb)

1. Make (something or someone) free of dirt, marks, or mess, esp. by washing, wiping, or brushing: "chair covers should be easy to clean"; "he expected other people to clean up after him"; "Anne will help with the cleaning".

What is green cleaning?

Green cleaning can be defined as “effective cleaning that protects health without harming the environment.”

The federal government has defined “green” and “environmentally preferred purchasing” as “…products and services that have a lesser or reduced effect on human health and the environment when compared with competing products and services that serve the same purpose.” — Executive Order 13101 which can be seen at www.ofee.gov/eo/13101.htm.

Both definitions focus on the impact cleaning has on the health of people as well as the impact it has on the environment. Both definitions also describe a goal of striving to make sure cleaning has as positive an impact on human health and the environment as possible. ⁽¹⁾

What is Terminal Cleaning?

Terminal cleaning methods vary, but usually include removing all detachable objects in the room, cleaning lighting and air duct surfaces in the ceiling, and cleaning everything downward to the floor. Items removed from the room are disinfected or sanitized before being returned to the room. Terminal cleaning of patient rooms should include the following steps: ⁽²⁾ 

• Using an EPA-approved, hospital-grade disinfectant, the following items should be cleaned:

> Top, front and sides of the bed’s headboard, mattress, bedframe, foot board and side rails, and between side rails

> TV remote

> Nurse-call device and cord

> All high-touch areas in the room including tabletops, bedside tabletop and inner drawer, phone and cradle, armchairs, door and cabinet handles, light switches, closet handles, etc.

• In the bathroom, start with the highest surface and clean the toilet last; clean the sink and counter area, including sink fixtures, and if there is a shower, the support bars and shower fixtures and surfaces

• Privacy curtains should be removed, placed in a plastic bag in the room and double bagged into a laundry bag with the assistance of another member of the ES staff standing at the door outside the room. The person outside the door should wear gloves. After completing the task this person should remove gloves, wash hands with an antimicrobial soap and water or apply an alcohol rub to their hands.

• Cleaning of window curtains, ceiling or walls is not necessary unless visibly soiled.

• Following patient discharge, clinical equipment must be cleaned and disinfected, moved to the door of the room for removal to central supply or to the sterile processing department.

• Following the terminal cleaning of a patient room, gloves should be removed so as to avoid touching the outside of the gloves. Hands should be washed with an antimicrobial soap and water or an alcohol rub applied to the hands prior to donning a new set of gloves.

Best Tip for cleaning:

Use microfiber towels and mops. This is the single most effective change you can make. Microfiber is a scientific discovery that is the foundation for a greener, safer, healthier environment. Microfiber is able to accumulate and absorb more particles of dirt and bacteria than any other fabric known. It can absorb up to 7 times its weight in dirt or liquid. Microfiber is a lint free, non-abrasive, and hypoallergenic product that allows you to clean without the use of chemicals. Unlike ordinary cotton towels that move, or push, the dirt and dust from one point to another, Microfiber actually gets underneath the dirt and lifts it from the surface. It then stores the dirt particles in the towel, until it is washed. Microfiber dust cloths are safe on all surfaces.

Using a traditional cotton loop mop for wet mopping in hospitals has been standard operating procedure in floor cleaning for healthcare facilities for decades. Recently, the healthcare industry has begun to look long and hard at evaluating a different method for cleaning hard surface floors within healthcare facilities with the hope of reducing chemical use, water use and increasing employee and patient health as well as improving overall cleanliness on site. ⁽³⁾

Microfiber mops are densely constructed polyester and nylon fibers able to hold 6 times their weight in water. Because the fibers are positively charged, it attracts and picks up dust (which is negatively charged), and these microfibers are able to penetrate the microscopic surface pores of any material.

Using the traditional cotton loop mop, it was required that the mop head and water be changed every two or three rooms to reduce the risk of cross contamination. This meant dumping gallons of water and chemical down the drain along with the hardship on employees of lifting the heavy bucket to do so.

Using the microfiber mops, the risk of cross contamination is reduced greatly in that you use one mop per room. With the microfiber system, 20 rooms can be cleaned using 1 and ½ gallon of water and 1 and ½ ounces of chemical.

Use of microfiber in hospitals and other organizations has been endorsed by:

• The Environmental Protection Agency (EPA)
• The American Hospital Association
• The American Nurses Association
• Association for Professionals in Infection Control and Epidemiology (APIC)

Last but not least, use some Elbow Grease                                                               

Elbow grease is an idiom for working hard at manual labor, as in "You need to use some elbow grease." It is a humorous reflection of the fact that some tasks can only be achieved by hard effort and human energy, contrasting with the idea that there should be some special oil, tool or chemical product to make the job easier. Even with green chemicals and microfiber, cleaning takes effort. You can’t swish a towel around and expect a surface to be clean. You need to put some effort in and scrub. This is one area where there are no shortcuts. Can’t get those minerals off the toilet?, scrub. Shower walls have a film? scrub it.

References:

1 http://www.waxie.com/what_is_green_cleaning_.html

2 “Practice Guidance for Healthcare Environmental Cleaning” from the American Society for Healthcare Environmental Services (ASHES).

3 American Journal of Infection Control Volume 35, Issue 9, November 2007, Pages 569 – 573 William A. Rutala PhD, MPH, Maria F. Gergen MT (ASCP) and David J. Weber MD, MPH

I’m closing your hallway door, Mrs. Smith. We always want your room to be as quiet as possible.

We always strive to clean your bathroom twice a day.

It’s really second nature for us to always make sure you understand your medications.

It’s customary for our team to always answer call lights within five minutes.

It’s routine for us to always inquire about how well we’re managing your pain.

We make it a practice to always answer your questions without delay.

Service “all the time” is routine for us… We want your experience with us to always be excellent

I wrote about goals a few days ago and one question I received was “what are your department goals for this year? That is a great question because I make it a practice to write out what I call major objectives for the new year each December. These are sort of mid-range goals, not short term, and not long term. That is why they are objectives. Sometimes they continue for more than one year. No serious rules here, just get some things down on paper you so you can plan the necessary action steps to achieve them.

Here are my four major objectives in 2011

1. To improve Infection control within the medical center

2. To improve environmental services staff knowledge of their role in infection control

3. To monitor the cleanliness of the facility with data driven results

4. Better patient outcomes

There you go. Those are the foundational objectives that I have used to develop a number of goals and an even greater number of action items to achieve them.

Enjoy…

Our profession is so immensely diverse because of the level of talent and professionalism our members bring to the table. Many years ago, various housekeeping departments were just that–housekeeping–but due to the evolution of health care environmental services managers, we have become multifaceted department managers with responsibilities encompassing a wider array of functions.

With the increased complexity of the job, such as emerging pathogens and potential worldwide outbreaks like avian bird flu, there is demand for professionals who are both experienced and have Certified Healthcare Environmental Services Professional (CHESP) certifications in health care systems throughout the world. We all need to be ready to step up and take the extra challenge on, view it as an opportunity and allow it to shape us as professionals.

Another impacting grand approach is to ensure you have an active succession-planning program in place for your future environmental champions. This profession has provided a lifelong career to many individuals and provides a clean, safe, healthy and healing environment to the patients we serve every day.

Lose the weight. I’m not talking about physical weight but dead weight from your department. Deal with staff who negatively affect the department. They “weigh” on time, energy and morale and are preventing the team from achieving excellence.

Exercise your role and lead by example. Now that you can move about freely because you cut away the dead weight, use the time and energy wisely to walk and talk to your staff on a daily basis. Share in their world; hear their suggestions, concerns and ideas. They are the people who make it happen daily. Demonstrate that you value the staff members who make the department and institution look good every single day.

In view of the evidence that transmission of many healthcare acquired pathogens (HAPs) is related to contamination of near-patient surfaces and equipment, all hospitals are encouraged to develop programs to optimize the thoroughness of high touch surface cleaning as part of terminal room cleaning at the time of discharge or transfer of patients.

Download the Environmental-Cleaning-Checklist-10-6-2010 from this link or go directly to the CDC site.

In the great work presented in Options for Evaluating Environmental Cleaning, December 2010 by Alice Guh, MD, MPH and Philip Carling, MD, objective monitoring of environmental surfaces was studied and presented as a necessary component of training. In view of the evidence that transmission of many healthcare acquired pathogens (HAPs) is related to contamination of near-patient surfaces and equipment, all hospitals are encouraged to develop programs to optimize the thoroughness of high touch surface cleaning as part of terminal room cleaning at the time of discharge or transfer of patients. A two level approach to this is presented and quite well discussed.

For now please draw your attention to the 8 locations above. The importance of targeted cleaning to these surfaces must be taught to your staff and reinforced on a regular basis. While many of our staff have an excellent understanding of the basic policies and procedures involved in terminal room cleaning, most will benefit from focused educational interventions related to our evolving understanding of the role of the environment in healthcare-associated pathogen (HAP) transmission. Specific targeted cleaning will not only reduce HAI’s it will greatly increase the awareness level of your staff.

As part of the proposed changes to healthcare, reimbursement for hospital care and post-acute care will be bundled; patient readmission’s will be at a lower rate in some cases; hospital reimbursement and performance will be directly linked; and physician self-referral will be more closely regulated. Out of those four important items, environmental services has a direct impact on two—readmission rates and performance-based reimbursements. A sufficiently staffed environmental services department plays a major role in minimizing patient readmission’s. The proliferation of microorganisms affecting our communities and the patient population demands a properly cleaned and disinfected care environment. It is my belief that investing in the environmental services department and assuring proper funding, staffing, training, and consistent cleaning procedures and protocols will have a positive impact on lowering the infection rates, lowering the rate of “never” events like patient falls and improving patient satisfaction rates. Each of these examples provides a direct link between our departments and performance-based reimbursements.

So what does this all mean to the environmental services department? This is an opportunity to position the department as the front-line quality assurance and infection control team able to facilitate cost containment for the health care facility and ensure a proper setting for care delivery throughout the continuum of care. Speak up and make sure your senior leaders know the value you and the departmental staff bring to the health care facility. Make the business case for what you do and the big-picture impact on finances, patient readmission and performance-based reimbursement.

We are currently experiencing economic situations not seen in many years. The times are extreme and uncertain. What does this mean for us in support services departments? Given the current economic environment, we need to develop extreme leadership skills, which means being more, doing more and accepting more. Not only must we be conservative with budgetary issues, but we must utilize the resources we are responsible for in a way that gets the job done and accomplishes what is expected.

Be an extreme leader in these extreme times. Get out of the office, share your knowledge and include your staff and peers in the solutions. In doing this, you will be part of the solution and will show how invaluable your knowledge and skills are to your organization. True leaders rise to the occasion during the most extreme times, so be a positive force in making necessary changes.

Accomplishing the difficult in a positive, optimistic process is a true example of extreme leadership. As part of my practicing extreme leadership I have taken over the safety and security department, the hospital safety officer responsibility and am chair of the environment of care and emergency preparedness committees. I also serve as vice chair of our service excellence council. I do these things because as a leader and advocate for environmental services I am responsible for providing guidance, resources and knowledge. What better way to gain more knowledge and resources to share and to learn as much as I can about the hospitals business beyond the ES department.

Today there is more to environmental services than keeping the environment safe and clean. Success is achieved through a strong commitment to professional development and extreme leadership

There are thousands of health care facilities in the United States. I imagine there are mock surveys and actual surveys everyday somewhere. And during each one, many regulations and requirements are checked for compliance. An increasing focus is being paid to regulated medical waste or RMW.

Most health care facility professionals understand the need to be familiar with the regulatory complexities of managing waste. In Environmental Services we deal with a lot of waste, including RMW.

There are many regulations and standards, including the Joint Commission’s Leadership (LD), Environment of Care (EC) and Emergency Management (EM) standards, as well as the federal Department of Transportation, Environmental Protection Agency and many state and local rules and regulations.

Quite a few of the standards related to regulated medical waste can be found in these standards:

• LD.04.01.01
• EC.01.01.01 (EP 5)
• EC.02.02.01 (EP 11, 12)
• EC.04.01.01 (EP.01, 8, 15)
• EM.02.02.05 (EP 4)

An organization can be fined thousands of dollars per day per violation by local, state and federal authorities if it is found noncompliant with waste regulations. Many of these fines vary by state. It is very important to be familiar and understand your own state’s current and emerging regulations to avoid these costly fines and remain a compliant leader within the health care industry and their community

Do have your 2011 yearly goals written down yet? I sure hope you do. If not, while no one is looking, get busy and do it already. Do you have your 90-day goals written down? Your weekly goals? How about your daily goals?

Unfortunately, the vast majority would have to admit that they do not have these written goals and that is a gigantic blunder.

Did you know that upwards of eighty five percent of all written goals come to pass. With that being the case, why don’t more people use this incredibly powerful tactic? First, most probably had no idea that was true and secondly most are living in a situation called the tyranny of the urgent. They are dealing with day to day situations all day long and never get to thinking about or planning for the future.

If you are one of the few, great job. You are achieving more than most. If not, get some paper and a pen, and start with long range goals. What do you want to be in ten years? If that is too far out, try for five. Work backwards from those long term goals and build smaller goals, steps really, to help you achieve them.

So now you have these goals all written out. What next?

First of all, unless someone is critical to helping you achieve your goal(s), do not freely share your goals with others. The negative attitude from friends, family and neighbors can drag you down quickly. It’s very important that your self-talk (the thoughts in your head) are positive.

Reviewing your goals daily is a crucial part of your success and must become part of your routine. Each morning when you wake up read your list of goals that are written in the positive. Visualize the completed goal, see the new home, smell the leather seats in your new car, feel the cold hard cash in your hands. Then each night, right before you go to bed, repeat the process. This process will start both your subconscious and conscious mind on working towards the goal. This will also begin to replace any of the negative self-talk you may have and replace it with positive self-talk.

Every time you make a decision during the day, ask yourself this question, "Does it take me closer to, or further from my goal." If the answer is "closer to," then you’ve made the right decision. If the answer is "further from," well, you know what to do.

If you follow this process everyday you will be on your way to achieving unlimited success in every aspect of your life.

What? You are housekeeping, not plant operations! Why should you care about life safety you ask?

For 2011, all hospitals, including critical access hospitals, will have a life safety surveyor for at least two days of a Joint Commission survey. Those hospitals with more than 1.5 million square feet will have a third day. Yet an additional day will be added for every three buildings classified as health care occupancy. This is considerably more than we are used to and it is not enough to be focused on cleaning. We in environmental services are the only department in a hospital to service every patient room daily, and all other areas at least periodically. We are the eyes for every facility service department.

So what are the areas we should be looking at during our daily cleaning and rounding.

1. Penetrations: Holes in walls, ceiling tiles, and around fire sprinklers. These tend to happen and often get overlooked. Make a point of looking around and putting work orders in.
2. Doors: The majority of fire, smoke and corridor doors will be checked. Make sure they positively latch. My staff close each patient door on a regular basis and makes sure they latch. We tell the patients that we are checking the door for proper operation for their safety. It is appreciated. This is a good time to check the hardware and look for missing screws. Yes, missing screws in the hinge have been found on many survey’s.
3. Look up: Sure holes in ceiling tiles are important to correct, and so are stained or broken tiles. Get those reported and changed. Also ceiling grilles and diffusers are being checked for dust accumulation. Same goes for fire sprinklers. Dust and dust bunnies are just not appreciated anymore.
4. Corridor Clutter: Recent inspectors are coming down hard on hospital clutter. The only items allowed to keep in corridors are code and isolation carts and equipment in use, E.G. not stationary for more than 30 minutes. Other than those you need to maintain either the 4’ or 8’ clear corridor width.

There certainly can be more things our staff can find that need to be corrected. If you are not already on board start with one area and build on it.