By Karin Lillis
Hospital environmental services (EVS) workers want to do the best job they can to keep healthcare facilities clean and ultimately protect patients from harm. But often there is a lack of understanding of proper hand hygiene protocol—and an accompanying lack of training.
“Sometimes EVS workers think that hand hygiene is to protect themselves,” says Fiona Nemetz, CHESP, system director for environmental services at Northside Hospital in Atlanta. “They’re not always aware that good hand hygiene is ultimately to protect the patients or that the goal is to reduce the risk of nosocomial infection moving from one patient to another.
“Hand hygiene is such a simple process that’s overlooked so easily. When you think about the domino effect it can have on infection transmission and patient outcomes, it’s significant when proper hand hygiene protocol is not in place,” Nemetz says. “It’s our responsibility to engage with staff so they can engage with our patients. It’s our job to make sure they have all the resources and training they need to get the job done.”
“Very rarely does someone say, ‘No, I won’t wash my hands,’” says Kelley M. Boston, MPH, CIC, division director of infection prevention for Methodist Healthcare System in San Antonio, Texas. “When someone isn’t following proper hand hygiene protocol, you have to find out why they missed it.” Boston currently serves on the communications committee for the Association for Professionals in Infection Control and Epidemiology (APIC).
“EVS staff are often left out of infection control training, which usually focuses on doctors, nurses and other clinicians,” says Kimisha Causey, MPH, a health program specialist with the Nevada Department of Health and Human Services who helped design a presentation to help EVS workers understand infection control. “Contact precautions are still a big missing link in preventing healthcare-associated infections, and hand hygiene is the first line of defense. EVS workers may think that because they’re not touching any patients, they’re not at risk for picking up or spreading pathogens. It’s not that EVS staff doesn’t want to know how to protect themselves and patients—it’s that no one has taught them.”
One of the most common scenarios centers on EVS workers wearing the same pair of gloves as they complete different tasks over the course of a shift.
“EVS workers are good about washing to protect themselves after exposure, but they might not be conscious of cross-contamination of the gloves,” says Boston. “They will go from collecting trash to touching something in the patient room.”
For example, that EVS worker might finish cleaning a patient room and head down the hallway to dispose of trash—without changing gloves. He or she may contaminate the knob on the door to the trash room—and pass that contamination on to the next person who touches the door handle.
Nemetz relays a breach of hand hygiene protocol she often sees: “An EVS person is pushing a trash cart. It’s a dirty task, so that worker feels like he or she should be wearing gloves. Then he or she pushes the elevator button with dirty gloves. There’s the risk of cross contamination because that might be an elevator used to transport patients.”
She explains, “You have to spend a lot of time educating the staff as to the time and place for proper hand hygiene. Wash your hands before you go into the room and then put on the gloves. Make sure every time you exit the room, you take off the dirty gloves, wash your hands and put on a fresh pair of gloves.”
The Time Crunch
Boston and Nemetz acknowledge that EVS workers are under constant pressure to turn over rooms quickly and efficiently. But those time constraints can sometimes lead to dangerous shortcuts. Hand cleansing and changing gloves are often the first steps that are compromised.
For example, the EVS worker, who just collected the trash, may forget to wipe something if he or she is distracted. “If something distracts that worker, he or she can’t move in the same workflow as planned – cleaning the area next to the patient and then working your way out of the room. Maybe something interrupts the EVS worker—there is an urgent call for assistance or a patient request that the EVS worker call a nurse,” Boston says.
Or an EVS worker on a patient floor might have 15-30 rooms that require daily and post-discharge cleaning—and he or she also has to clean the hallways and the bathrooms. Or the next patient scheduled for that room might be stuck waiting in the ER until that bed is ready.
Education and Reinforcement
“You have to have observation of staff members to make sure they’re practicing good hand hygiene. Our hospital has an infection prevention task force called ‘Nip It.’ Team members do observations throughout the hospital on staff from all disciplines to determine whether they are participating in appropriate hand hygiene. Our staff is very knowledgeable. They understand when they need to wash with soap and water or use alcohol-based hand rubs.”
EVS and infection control departments need to work closely together, Nemetz says. “If I don’t have a partnership with infection control, then I don’t have a program. That partnership has to be driven by excellent communication and support of each other,” she notes.
At Northside, infection preventionists regularly hold education sessions for EVS workers on ways to prevent the spread of pathogens and infections. “It has a little bit more of an impact on staff if someone from outside of EVS is providing that education,” she says. Hand hygiene education is a continual process for all disciplines and departments across the hospital.
EVS workers at Northside also undergo annual competency training “on all facets of their responsibilities,” including hand hygiene, Nemetz says. “We provide computer-based learning and the employees are required to pass a test afterward. We also use participative show-and-tell. We’ll call on two or three staff members to participate in the demonstration. Participation is key,” she says. “You can sit in a classroom all day long, and you might retain 30 percent of what you learn.”
When any new EVS staff member is brought on board, he or she has two days of classroom orientation “before going on the floor and working alongside someone,” Nemetz says. “We then test their knowledge.” The trainer uses a teach-back method for techniques like hand hygiene.
“We’ve recommended the trainer use a glow gel and black light to help EVS workers understand the right way to cleanse their hands,” Causey says. “You can demonstrate how much of the gel is removed by rinsing hands, compared to using an alcohol-based hand rub or soap and water.”
Back to Basics
Trixi Babcock, MS-HSA, LPN, who heads HCI Consulting Group in Aurora, Colo., recommends that an infection control nurse conducts “basic education” for all EVS workers coming on board—as well as regular competency training for existing staff.
“In the classroom, break down the concept into very basic levels. These are your germs, and here is how they spread. Walk them through the entire chain of infection,” she advises. “It’s critical to help EVS workers understand the role environmental contamination plays in health and wellness.
“If your EVS staff don’t understand how infections are spread, they won’t understand that they need to change out gloves and wash hands. But if you get down to the ‘why,’ they’re more likely to follow proper protocol.”
Additionally, lack of supervisor training or easy access to supplies can also lead to breaches in hand hygiene.
For instance, EVS supervisors—especially in smaller facilities—may have once been staff workers. “If they haven’t taken a certification course, they don’t necessarily know how to follow things like good hand hygiene and they’re teaching staff the wrong things. If infection control nurses don’t get involved in the training, then how are EVS staff supposed to know anything about infection prevention?” Babcock notes.
It’s especially important to recognize a staff member who goes above and beyond the scope of the job.
“Some hospitals have recognition programs for ‘good catches,’” Boston says. “Maybe an EVS worker helped a patient in distress. Or after a case of C. difficile infection on a unit, the diligent work of EVS workers and nurses brought it under control. Tell their story to hospital leadership—it’s a great way to recognize your EVS workers. It drives home the concept that they are part of the healthcare team.”
‘Not Just a Housekeeper’
“A lot of EVS workers don’t think their job is important, but that’s far from the truth,” Causey says. “They’re just as critical to preventing the spread of infection as any other healthcare worker—and you have to drive that point home.”
“EVS workers aren’t just maids or housekeepers. They as essential to saving lives as all other healthcare workers.” Boston says. “You really have to champion the essential role that EVS staff plays in patient health. Help them understand the important of collaborating with them, and help them recognize that they’re saving lives. We don’t recognize that—and we certainly don’t celebrate it—as much as we could.”
Karin Lillis is managing editor of EndoNurse, an Informa Exhibitions publication.