Susan G. Klacik, BS, CRCST, FCS, is a clinical educator with the International Association of Healthcare Central Service Materiel Management (IAHCSMM) and a liaison to the Guidelines Advisory Board of the Association of periOperative Registered Nurses (AORN). Klacik is also a representative to the Association for the Advancement of Medical Instrumentation. She engaged Infection Control Today® in a wide-ranging discussion about environmental services (EVS) in general and AORN’s new guideline on environmental cleaning that includes an interdisciplinary team that features infection preventionists, EVS staff, and sterile processing experts, among other healthcare workers.
Infection Control Today®: There seems to be a big emphasis on teamwork.
Klacik:The AORN guidelines are heavily based on research and they say we should have an interdisciplinary team involving sterile processing, perioperative nursing which is the operating room, environmental services and infection prevention. They recommend that because that allows input from personnel who perform the environmental cleaning in the perioperative areas and also people who have expertise in other areas. We get a 360 view of cleaning. There are so many really good recommendations in the guidelines that could really be applied throughout the hospital. For instance, we should identify the high-touch objects and surfaces to be cleaned. Control panels and our work areas. As an interdisciplinary team, we need to identify those areas and say this is what needs to be cleaned. The interdisciplinary team can even go as far as recommending how to clean it. Meaning what cleaning products and disinfectants to use. Of course, we’re always going to go back to the manufacturer's instructions for use, because they may have a preferred detergent or maybe point out what chemical not to use. For instance, some manufacturers say do not use bleach on my product. So, we’re always going to go back to manufacturer's instructions.
ICT®: What else about the new AORN guideline?
Klacik: It wasn’t just added, but I like where they say they’re going to test for cleaning efficacy. Quantitative methods versus qualitative methods. Qualitative is when I walk into a room and I could see that it’s not really clean. Or maybe I think it’s clean and maybe you don’t, or vice versa. If I’m using a quantitative method such as ATP [adenosine triphosphate testing] or culture, I’m going to swab the surface. And then I’ll get a readout of how clean that surface is. The AORN guidelines talk about establishing cleaning thoroughness. We can establish a process to evaluate how good we’re doing. Let me tell you, you and I clean quite differently. I’m a really, really good cleaner and if you compare my surface to yours after we both clean, I’m going to get a better result. This interdisciplinary team can go around and do the highest high touch areas and also determine how often should we clean this. Obviously, you’re not going to clean the door handle every time somebody touches it. But there should be a schedule of how often to clean these high touch areas. And the other thing is there should be assigned responsibility so that nursing personnel don’t just assume environmental services are going to clean the door handle or the computer keyboard. Not just making the assumption that somebody else is going to do it. It should be written down exactly. Who is responsible to clean what?
ICT®: That hasn’t been automatically laid out in the past?
Klacik: I was in the business for a very long time and I’ve seen [oversights] happen. Identify who’s responsible for cleaning and those people should be aware that it is their responsibility for cleaning and that comes with education. And again, this is based on research. You should perform cleaning in a methodical pattern that limits the transmission of microbial organisms. We’re going to clean from clean to dirty. We’re not going to go to the dirtiest part of the room and clean over to the clean side. We should have a method. We should have a routine. We should always use the same types of cleaning materials so we’re getting a consistency. That’s sterile processing. We don't mix the decontamination cleaning with sterile processing cleaning. That outer perimeter is cleaner than the center of the OR where the procedures are being performed. You’re going to get most of the blood and body fluids. The recommendation is start from the outside and then work your way in. And if you’re going to take that logic to nursing units, obviously you would clean the patient room and then the bathroom.
ICT®: Who would lead the interdisciplinary team?
Klacik: That’s a good question. It would probably be between infection prevention and environmental services. I would say one of them. Each facility differs.
ICT®: We’re talking about housekeeping when we say EVS, correct?
ICT®: So, we’re talking about blue-collar workers. And you want them to have the same knowledge that white-collar workers have about the danger of infection. How do you impart that knowledge?
Klacik: The one way is obviously showing the cleaning efficacy by using those cleaning verification tools—the quantitative and qualitative. AORN has an entire section on that. What they recommend is providing education and competency verification activities related to the principles and processes. So housekeeping, the worker should have an idea of infection prevention. Exactly what it is. Some basic principles of microbiology. They should also know, if we're educating them, how do they know that they’re going into an isolation room? So, they need to understand what the signs are and the labels coding throughout the hospital. That’s the education that they need. They need to understand that you’re going into a contaminated room, like the sterile processing has a decontamination room. They need to be educated that they have to wear personal protective equipment (PPE) in that room. If they’re going after surgery, they’re going to have to wear a specific type of attire. Sterile processing, the same. They need to be educated: This is what you need to wear. They need to know the location of the safety data sheets, the hazardous materials, how to handle hazardous and medical waste disposal. They need to identify what is hazardous and what is not. And how do I handle this to protect myself and the environment?
ICT®: Bet that’s a big one.
Klacik: Oh, absolutely, it is. What could occur is you could actually record. And I’ve seen this happen. People take their cell phones and they record the techs or the staff cleaning a room. So, you record them cleaning your room and you go back and you review it maybe with a couple of other people. You might say: This staff person is going back and forth an awful lot of times. There are wasted steps that they’re doing. So that’s one way to get more efficiencies.
ICT®: I guess there’s always a tradeoff between efficacy and time, right?
Klacik: When it comes to that tradeoff, you’ve got to go with the quality every time. You might find ways to be more efficient to maybe use new products that are more efficient when you’re talking about cleaning and disinfecting. And here’s another thing that’s very important, especially with disinfection. Many disinfectants have a specified wet time or contact time. That’s on their instructions. That has to be also figured in. And that's part of the education process—how to use these chemicals. How long do they have to stay there? More information that’s very important. How often do I change my water? My cleaning solutions? That would be an EVS issue. I believe they do it after each room, or when the water appears dirty.
ICT®: Do EVS staff sometimes get a little bit intimidated about going into an operating room and cleaning it?
Klacik: In different hospitals, they have different staffing patterns. I would say most use EVS, but not all of them. During the day, they may have patient care technicians. That might be part of their job. But they have to follow the guidelines up there. In as far as being intimidated: We have a big push in hospitals now. We don’t want to bully people. We need to really work together as a cohesive team.
ICT®: How would EVS fit in with this, this interdisciplinary team? I guess there’d be the head of EVS on the team, right?
Klacik: Typically, you get the team leads, yes. The leadership of the department. The way that I understand it is you would have the head of infection prevention, the nursing head, which here we’re talking about OR.
ICT®: And how often would it meet? Weekly? Monthly?
Klacik: That’s determined by the interdisciplinary team. And the AORN guideline talks about that also. You should inspect the area, have a walk through. Even with plant operations. If you have, for instance, a stainless-steel ceiling tile, this team can look at that and say, “Well, that needs to be replaced.” Are the ventilation vents clean? Are the doorknobs clean? Are the work surfaces being cleaned? Because we don’t want any dust bunnies hanging around. Sometimes you could actually see a herd of them. It often comes down to nobody knowing who’s supposed to clean the work surfaces. It’s either they don’t know, or they’re not held accountable.
ICT®: You’re talking about communication, right?
Klacik: Absolutely it’s communication. And accountability. It’s about making the rounds and about using tools, the qualitative and the quantitative. You really need to look at the instructions for the products you’re using and determine your own level from the facility. For the disinfectant, do you know the EPA registration number that you should be using and looking at that? Because when we’re cleaning, we’re using low to intermediate level disinfectants. Now for cleaning agents for cleaners? Detergents? There’s no oversight on those products.
ICT®: Does that strike you as being a bit of a problem?
Klacik: Well, yeah.
ICT®: Do certain products work better than others?
Klacik: Some products do better than others, yes.
ICT®: How do the new AORN guidelines affect the way EVS staff does its job?
Klacik: They provide more feedback about what kind of a job they’re doing. Because they’re talking about qualitative and quantitative measures. How clean is this getting? Are we really, really doing a good job?
ICT®: What do you think is most important for people to take from the new guidelines?
Klacik: I think they need to have an interdisciplinary team. I love the team concept. We need to work together, identify the areas that really need cleaning, you know, the high touch areas. Have policies and procedures in place about how to clean. And education is very important. But also, I really like the idea of having accountability and asking: Am I truly cleaning this product?
ICT®: We’re talking operating rooms.
Klacik: You’re talking the whole hospital, and I’m basing the whole hospital off of the AORN recommendations even though they’re not for the whole hospital. But why wouldn’t we do it? I mean they have some really, really good recommendations. You know, talking about scheduled cleaning. Making rounds. And when you’re making rounds you have a checklist so that you know exactly what it is you’re going to be looking at. You’re looking at the floors, the ventilation, new doors. Making sure that everything is thoroughly cleaned. In surgery, we definitely have checklists. And in sterile processing we have checklists. Every time we do a tray, there’s a checklist to make sure that everything is in that tray perfectly.
ICT®: So now there’s a checklist for EVS.
Klacik: Yes, you should have a checklist for them.
ICT®: Have you ever seen that happen in real life?
Klacik: I’ve been out of the hospital a couple years, but we did used to make rounds. I made two different rounds. One was with the interdisciplinary team and another one was … they would send a person from EVS to make rounds with me and it was like the shift leader or a supervisor. And they did have a checklist and we would go through the department and at the end, I would go through with them at the very end of the process. They had the checklist. And we talked about it as we went through the department and at the very end, they signed it and I signed it. I don’t know if all facilities do that, but I thought it was a good process.