The goal of any Environmental Services Department within a healthcare facility should be to prevent the spread of infectious agents among patients and healthcare workers by meticulous cleaning and appropriate disinfection of environmental surfaces. To reach this goal, the EVS department will need to have a comprehensive training program, the objective of which should be to provide department staff with the information they need to accomplish their jobs safely. The training program should be a part of the big picture of “How to Protect Yourself.” At a minimum the training program should include the following:

1. Identification of occupational risks and hazards associated with handling infectious waste.
2. Sharps safety.
3. Blood borne pathogens.
4. Infection control training – (a) Microbiology and (b) Transmission.
5. Hand hygiene.
6. Personal Protective Equipment (PPE) including donning and doffing.
7. MSDS and hazards associated with using chemicals (cleaning agents, disinfectants, etc.)
8. Product usage training including proper cleaning and disinfection techniques.

The benefit behind breaking the training into sections is two-fold. First, it allows the person responsible for training to involve other departments such as Infection Control or Occupational Health & Safety where specific knowledge and expertise can be called upon. Second, by segmenting the areas into shorter pieces the trainee is not overwhelmed. The individual sections also allow for developing unique methods of delivery. Education should be tailored to the size, topic and needs of the group. Not all programs must be instructor-led in classroom setting. They can also consist of CD programs and/or video-based programs or a series of self-study modules. For example, the product usage training may be better suited to a traditional classroom setting where employees can observe someone performing the task while other sections such as Blood Borne Pathogens can use video-based training. Switching up the method of delivery helps keep the trainee engaged.

A basic understanding of these eight topics doesn’t require a stethoscope or coke-bottle glasses, or even the ability to squint. It takes knowledge, imagination and responsibility. Knowledge… to know basic microbiology, where pathogenic microbes are found, and how they cause disease; to know how cleaning and disinfectant products should be used; to know how to be protected from exposure to blood borne pathogens and sharps injuries; about the proper use of PPE. Imagination… to be able to actually picture the microbes all around us. Responsibility… to take reasonable action to prevent disease.

One person dies every six minutes from hospital-acquired infection. It’s tragic that this is allowed to continue and that an Environmental Services department can be allowed to operate without ongoing, targeted and evolving education.

Time spent properly training staff is an investment that pays dividends for a long time. Training should be a constant process, not just something you do for new employees or to meet the annual requirement. Whenever new products, equipment or procedures are introduced into your department, all staff should be trained on their safe and proper use. Research has shown that adults learn differently than children do, they generally learn more and retain more if they are involved in the training process. Adults learn best by doing, not by listening to lectures or by viewing videos. Lectures and videos have a place in the training process, but trainee involvement needs to be included.

Feel free to share your thoughts and comments.

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 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…

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.

Clostridium difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). It accounts for 15-25% of all episodes of AAD.

Clostridium difficile is a bacterium that may develop due to the prolonged use of antibiotics during healthcare treatment. Clostridium difficile infections cause diarrhea and more serious intestinal conditions such as colitis. The CDC provides guidelines and tools to the healthcare community to help end clostridium difficile infections and resources to help the public understand these infections and take measures to safeguard their own health when possible.

C. difficile is an anaerobic, gram-positive bacterium. Normally fastidious in its vegetative state, it is capable of sporulating when environmental conditions no longer support its continued growth. The capacity to form spores enables the organism to persist in the environment (e.g., in soil and on dry surfaces) for extended periods of time. Environmental contamination by this microorganism is well known, especially in places where fecal contamination may occur. The environment (especially housekeeping surfaces) rarely serves as a direct source of infection for patients. However, direct exposure to contaminated patient-care items (e.g., rectal thermometers) and high-touch surfaces in patients’ bathrooms (e.g., light switches) have been implicated as sources of infection.

How is Clostridium difficile transmitted?

Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item.

Transfer of the pathogen to the patient via the hands of health-care workers is thought to be the most likely mechanism of exposure. Standard isolation techniques intended to minimize enteric contamination of patients, health-care–workers’ hands, patient-care items, and environmental surfaces have been published. Hand washing remains the most effective means of reducing hand contamination. Proper use of gloves is an ancillary measure that helps to further minimize transfer of these pathogens from one surface to another.

What can I use to clean and disinfect surfaces and devices to help control Clostridium difficile?

Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC’s "Guidelines for Environmental Infection Control in Health-Care Facilities." [PDF 1.4 MB] Routine cleaning should be performed prior to disinfection. EPA-registered disinfectants with a sporicidal claim have been used with success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of Clostridium difficile. It is important to distinguish the need for a disinfectant with a sporicidal claim. Currently only specific bleach containing products have this registration. Bleach harms surfaces and is hazardous to the user. Normally, HAI’s can often be controlled with good cleaning practices and a non bleach disinfectant.

The recommended approach to environmental infection control with respect to C. difficile is meticulous cleaning followed by disinfection using hypochlorite-based germicides as appropriate. I recommend using microfiber towels and an accelerated hydrogen peroxide based disinfectant. There are now a few products with a C.difficile claim. One I have tried is Dispatch wipes. I found the odor to be acceptable for most of my staff but the film left after using is a significant and required a second cleaning to remove it for an acceptable appearance.

Cleaning procedures are performed with a germicidal detergent which is designed to kill the most common kinds of harmful bacteria. This solution does not kill all of the bacteria, but reduces them to a safe level. The only way to kill all bacteria is to apply a very high temperature for long periods of time such as done in an autoclave.

Since many bacteria ride from place to place on dust particles, cleaning procedures are designed to prevent scattering of dust; therefore, damp-dusting and treated dust-mops are effective. Straw brooms for sweeping or feather dusters would scatter bacteria and are not used in healthcare facilities.

There are certain kinds of harmful bacteria that the germicide does not kill, but these are reduced to a safe level if proper procedures are used. The cleaning process is mainly a transfer of bacteria from one place to another. Bacteria are transferred from the surface being cleaned to your mop-head or micro fiber towel.

It is important to use solutions properly. Too much soap will leave a sticky residue or film, while too little will not clean properly. Always use your chemical dispenser and never mix chemicals yourself.

Always pick up trash inside the room to prevent bacteria from spreading to other areas. Covers should always be kept on trash barrels of cleaning carts.

There has been a lot of media attention about the Institute of Medicine’s (IOM) report “To Err is Human,” especially over outbreaks of community-based Methicillin-resistant Staphylococcus aureus (MRSA). However, we should concentrate on the second report from the IOM, “Crossing the Quality Chasm,” which provides a road map for quality.

In this report, the IOM describes “Six Aims” to ensure health care quality. The Six Aims are identified as: safe, timely, effective, efficient, equitable and patient-centered health care. So what does this mean for ASHES members?

There is no other service in the health care environment that more intimately and consistently touches patients than environmental services. The patient comes in constant contact with our products, from the textiles that they wear and sleep on to the furniture, fixtures and various pieces of equipment they touch on a daily basis.

Taking this into consideration, our base of operations must be in complete balance with the Six Aims. A health care institution may employ the best in clinical care and purchase the finest technology available, yet little of it will matter if the institution is not properly cleaned and disinfected where appropriate. At its very core, environmental services’ reason for being is patient-centered. If we do not perform our roles in a safe, effective, efficient, equitable and timely manner we compromise the quality and health of our patients.

Environmental services staff and the roles they play are often the forgotten heroes in the quest for quality. As the rest of the institution works to achieve and improve upon the Six Aims, our services are often viewed as a way to improve timeliness and the core purpose is defeated. It is our job and obligation to make sure that everyone in the institution and within the industry is aware of how vital our services are to the safety and the healing environment of the patient.

There is no substitute for a clean environment that is free from potentially harmful organisms. The quality initiatives of environmental, waste, linen and transport services cannot be minimized or overlooked as insignificant in the quest for quality improvement.

What can you do? Get involved! In the IOM report, quality is defined as, “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Professional knowledge is not limited to our profession. Be knowledgeable about other professions and their roles in quality as well. Be knowledgeable about what is going on in your institution. Make sure when the rest of your institution is working on the Six Aims, that you and your staff are involved and that you have allies in the infection control, safety and quality departments so you are included in the discussions and decisions when initiatives are being developed.

It is common for improvement initiatives that seem simple in the planning phase to turn into a problem for another department further down the continuum of care. This is not done intentionally; it usually occurs from lack of awareness about the rest of the cycle. Do not let this happen to you. Keep your eyes and ears open to what improvements are being discussed in your institution and play an active role.

Quality should be a topic when you meet with your boss, your peers across the institution and your staff. They tend to know more than we do at times, because they are on the units every day.

What steps have you taken in order to be consistent with professional knowledge? Let’s talk about it.

On the road to excellence!

Tina L. Cermignano, CHESP
Operations Manager
Children’s Hospital of Philadelphia
Philadelphia

We know that our primary purpose is cleaning. We train our staff to recognize dirt and soil in so many forms and to remove it. We educate, coach and celebrate our successes. We also know that good strategies for combating infection and cross contamination include things such as hand washing and personal protective equipment. In fact recent studies point more often to poor hand washing practices then the environment as the primary cause of hospital acquired infections.

We in Environmental Services understand the importance of hand washing as well as the importance of a clean environment. No matter how well hospital employees adhere to hand washing policies we simply cannot keep pathogens out. Without a top quality training program focused on cleaning and disinfecting the environment, infections will continue to be a problem; germs must be killed wherever they exist within the hospital environment.

I teach my staff to focus on cleaning. Our primary purpose is cleaning, and we never stop and say good enough. We clean and disinfect so that our surfaces not only look clean, they are free of contamination also. I work closely with our infection control department to track results and the partnership has helped to develop best practices that have proven very successful.

When you think about your role in healthcare, remember that without a healthy environment, patients will get sicker, and ultimately, go somewhere else for their healthcare. Support you facility with excellent cleaning, a team relationship with your infection control department as well as your staff. And don’t ever lose focus on cleaning for success.