Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

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Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread.

September 2019 Bug of the Month

ICT spoke with Caroline Haggerty, RN, MSN, MBA, LSSBB, manager of quality and patient safety for 

 in West Chester, Penn., about the importance of shared accountability relating to environmental cleaning in the healthcare environment. At this year's 

 annual meeting, Haggerty was the recent presenter of a talk titled, "Who Cleans What? Improving Cleanliness of the Hospital Environment," in which she shared how her 700-bed hospital created a multidisciplinary-shared accountability model for cleaning the patient environment and equipment. Haggerty addressed the steps they undertook to ensure environments and equipment were clean, staff could speak to the cleaning process, and overall cleanliness was improved.

: You shared with the audience how you developed a strategy to engage an interdisciplinary team to identify and address potential vulnerabilities in cleaning processes. What was the impetus behind this pilot project?

Haggerty: First and foremost, we wanted to provide our patients with a clean and safe environment. It was also driven by our desire to be survey-ready and compliant with regulations from the Joint Commission. We were about a year out from our survey, and we knew that the surveyors were asking frontline staff about cleaning processes, including how is equipment cleaned, who cleans it, and how do you know it was cleaned? We knew what was coming, and we wanted to be prepared for this process.

: What was the level of readiness in your facility before launching the pilot study?

Haggerty: Before we conducted our study, we did not feel as though staff could speak to cleaning processes for all equipment. All the stakeholders were aware of this issue so we were definitely ready to address it. We have a unique position assigned to each nursing unit called a support associate. The support associate is charged with managing the equipment, including taking it out of the room and cleaning it. This process was being done, but how did staff know if the equipment was actually clean, and how did staff actually determine this? We also needed to ascertain who was cleaning what in the patient environment and in the unit environment. We suspected there were some gaps that needed to be addressed.

: Your presentation at APIC drew a big crowd; what does that tell you about the size of the challenge for many healthcare facilities?

Haggerty: The large audience is indicative that many people are struggling with the issue of who cleans what.  We shared the results of our pilot study with our local APIC chapter prior to the national meeting, and it was well received there, too, with many people wanting to adopt our program. We have seen some similar types of programs at other hospitals, but it wasn't quite to the level of ours. The grid is highly visible for all staff on a daily basis and it is very clear who is responsible for what, in terms of cleaning. A clean environment has such an impact on overall health of patients and staff, but so many institutions are struggling with exactly how to achieve it.

: Did you involve infection prevention in your efforts?

Haggerty: Infection Prevention was instrumental with the success of this project from start to finish. At that time I was a performance improvement adviser at the hospital who partnered with the Infection Prevention department. Our director was one of the team leaders. The level of knowledge and expertise our Infection Prevention department has and shares, in terms of cleaning and regulatory requirements, is incredible.

: You and your team designed a detailed visual grid so staff could quickly and easily identify which team members hold primary accountability for maintaining clean equipment and frequency of cleaning. Tell us more about the work behind this effort, which seemed to be key to the program's success.

Haggerty: We did so many iterations of the grid! Initially, the first edition of the grid had a column indicating who was responsible for cleaning but we felt that was not good enough. We felt people would still have questions about how a piece of equipment was supposed to be cleaned and how often it was supposed to be cleaned. That's when we came up with the idea of adding columns to the right of that first column to convey information about frequency of cleaning as well as indicate the appropriate cleaning material to use. We also color-coded columns in the grid to the colors of the scrubs worn by various hospital personnel, as an easy and fast visual cue to who cleans what. We thought that compliance could be boosted if people could simply refer to the grid to match the color of their scrubs to the kind of equipment that needed to be cleaned. The grid embraced the idea of shared accountability, a concept that we used on all of the program's material. We had people actively use the grid and provide feedback, and incorporate that feedback, and that's probably the reason why it has been so successful.

: What were the objects that were falling through the cracks in terms of regular cleaning?

Haggerty: One of the pieces of equipment that was being neglected was the commodes in patient rooms. Environmental services personnel are responsible for cleaning the toilets in the bathrooms, but if a patient is using the commode it was unclear who was responsible. Typically patient care staff would clean the bucket but what about the surfaces of the commode? We identified cleaning of the seats and handles of the commode as a gap.

Now, EVS staff are responsible for cleaning the commode surfaces daily the same as they would be for cleaning the toilet. The other major challenge were the soiled linen hampers. When EVS personnel would turn over a room, they were not addressing the soiled hampers because they were kept just outside the room for easy access. These soiled linen hampers had the highest level of bioburden when we conducted our ATP testing. What surprised us was how high the level was on the hamper lids, and that was quite alarming. We also found that high-touch keyboards, which weren't washable, had significant levels of bioburden. We were concerned about that, and it took a long time for IT to agree to pilot washable keyboards at the nurses station on one of our oncology units –and it made a big difference.

The cleaning process for the keyboards, which was questionable before, now has a solid process in place.  The other surprising finding was the level of contamination of our workstation on wheels and cleaning them properly was a struggle. Now each workstation has a bracket that holds the appropriate wipes for cleaning them.

: What kind of training and education around cleaning did you do as part of your pilot study?

Haggerty: Educating staff was a priority. Infection prevention constantly relayed to workers the importance of cleaning and disinfecting, including dwell times. At one point we switched from a product with a three-minute dwell time to a one-minute dwell time, which helped staff turnover rooms. We also addressed the overall competency relating to cleaning of equipment. Cleaning competencies of staff responsible for cleaning, including central processing, environmental services, and nursing, were solid. What we did want to emphasize was our shared accountability model and that everyone has a responsibility for a clean patient and unit environment. We were able to accomplish this by rounded shoulder to shoulder on every unit multiple times during day and night shifts to talk about the grid, share the tool kit, talk about shared accountability and answer any questions staff had. We wanted to talk to as many individual staff members as possible. 

:  What happened after the pilot study was completed?

Haggerty: After the initial pilot study was finished, we continued our rounds and tested random pieces of equipment. Staff did not know what we were going to be testing. We focused on the ATP testing on pieces of equipment that we thought  would have the highest level of bioburden, such as the tops and handles of isolation carts. Nearly everything passed; it was rare that something failed. At the end of rounds we would debrief staff. They could not wait to hear the results of the ATP testing, knowing the results was the most important piece of the whole program to them –how did they do, and could they keep improving?

: Is your program scaleable to all kinds of institutions?

Haggerty: This effort is definitely transferable to all kinds of practice settings. The University of Pennsylvania is a very large institution, but I can't say that we have a plethora of resources. The important thing is working with what you have. It is very important to work with your staff to figure out how this concept will work for them –that's the key. How is it going to work for your frontline staff? You might not have the ability to put wipes into every patient room, as it increases your use of wipes, but isn't that a good thing because it means more cleaning is being done. So, you must look at it that way. If you give staff the tools they need, where they need them, you are going to have a better outcome. Success is also about listening to staff, knowing what resources are available, and working with various stakeholders to make sure healthcare teams can do their very best –no matter the size of your institution.

Shared Accountability: A Strategy to Reduce Infection Risk

Contamination incidents can be compounded by the operational/staffing challenges at healthcare  facilities. As an industry, we are faced with an expectation of doing more with less –less staff, lower reimbursement rates, less inventory, and smaller budgets to name a few.  Coupled with the ever-growing patient population requiring more extensive and specialized facilities, longer life expectancy,  more uninsured and under-insured patients, higher expectations of the public for safer healthcare facilities and the reasonable demand for fewer Healthcare Associated Infections (HAIs), administrators are looking for options to meet the daily challenges they face.

Patient Protection and Affordable Care Act

Centers for Medicare and Medicaid (CMS) Hospital Value-Based Purchasing Program

 is a reality, and healthcare providers face new challenges never before seen. The CMS Roadmap for Implementing Value-Driven Healthcare in the Traditional Medicare Fee-for-Service Program explains:

A new concept and standard is in order: Environmental Services (EVS) infection prevention microfiber textile products should no longer be purchased and owned by that department. Instead, the facility laundry/linen (L/L) department or contractor must take on the responsibility of providing infection prevention microfiber products just as they do other healthcare textiles. In the case of a hospital operated laundry, they give the infection prevention textiles. In the case of a co-op laundry or a contracted healthcare laundry, ownership of the EVS textiles is theirs, just as they own all other healthcare textiles.

In on-premises laundries, the L/L department historically has ownership of all other HCT products used by the facility. On-premises laundries have pushed  back  from  purchasing  microfiber  EVS  infection prevention textile products due to initial inventory and unrealistic  replacement costs and healthcare laundry contractors, who own all of the stock, have also pushed back for the same reason. If pushed by client hospitals, healthcare laundries have preferred to rent infection prevention microfiber textiles to healthcare clients, thus laundering and charging for microfiber on a per piece or each basis. Doing so eliminates the potential for CMS reimbursement as rental products are not reimbursable, only valid service contracts, not rentals, not leases, are reimbursable “events.”

The cost of infection prevention textiles has drastically declined since their introduction in the 1990s. High-quality micro denier (the smallest and most efficient of the microfiber family) products are available. For not much more than the cost of a cotton washcloth, healthcare laundries can purchase reusable wipers that will have a real life of 120 laundry cycles; a cotton washcloth has perhaps 40 cycles in its useful life. A micro denier flat mop is not more than a bed sheet but has a much longer useful life.

The question of shrinkage is always in the mind of an EVS director and laundry/contractor; to be honest, shrinkage does exist. However, far less than the shrinkage of other HCTs. Bear in mind, replacement costs are part of the overall cost of a laundry operation, not a direct EVS expense, and CMS addresses operational laundry costs.

If the point of this report has not become evident, then here it is: EVS textiles should not be in a separate category, EVS should not purchase them, they are healthcare textiles and, specifically,  infection  prevention  textiles. In the same  way that OR drapes, surgical huck towels, nursery items, patient linen, scrubs, cubicle curtains, and other textile products are charged to individual departments or units, EVS textile products should be included  in the L/L inventory with the  attendant costs involved in each department’s or unit’s costs.  All textile products should be the responsibility of the L/L department or healthcare laundry contractor with appropriate departmental input about item specification, quantity, and efficacy.

When cubicle curtains changed from cotton-based to human-made fabric, when bed pads changed from cotton to cotton/polyester blends, and when bed sheets changed from cotton to cotton/polyester blends as well as synthetic knit fabric for fitted sheets, no change in the purchasing or ownership was made. When a new textile product was needed to meet healthcare’s needs, such as flame-retardant material or coating, or copper infused bedding, the product was incorporated by the L/L department or the contractor to fulfill the mission of improved patient care, outcomes, and safety. A textile product is a textile product, regardless of the department using it or the fabric content.

when an EVS department inexplicably continues to use discarded washcloths or other terry cloth items (a rag has no value, and cotton mops have no infection prevention properties)

Cotton used in products used for mops, cloths, and dusters during the past 100-plus years are now recognized as inadequate, ineffective, inefficient, and a vector for organisms that directly cause HAIs.

By taking the step to transfer ownership and cleaning costs of textile products to the L/L department or healthcare laundry contractor, costs would be absorbed by the entire facility and charged out to each department, and the purchasing, cleaning, and replacement costs of the textile products would no longer fall inequitably on EVS.

As mentioned previously, there is the consideration of CMS reimbursement to keep in mind. CMS guidelines state that Environmental Services is chargeable based on a weighted square foot cost basis and, thus, must be part of the daily (patient days) reimbursement payment received based upon the patient diagnostic related group (DRG).

Studies have shown that a healthcare environment that has not been thoroughly cleaned and disinfected is a definite contributing factor in the spread of HAIs. When used correctly in the processing of patient care environments and other healthcare discipline areas, the use of microfiber and micro denier textile products can result in a six-log reduction of surface contaminants including microbes that contribute to HAIs. Cotton products cannot accomplish this task.

First and foremost, the goals in patient care and treatment are patient safety and quality patient outcomes. Regardless of how good a microfiber or micro denier infection prevention product is, it is useless and a danger to the health of patients and staff if the product is not adequately processed and returned to a hygienic state. There is no greater potential exposure of a patient to bacteria than when they put on a gown and lie in a hospital bed.

Therefore, healthcare laundries and on-premises laundries must follow the Centers for Disease  Control and Prevention (CDC) Guidelines for Environmental Infection Control in Health-Care  Facilities, 2003 Edition.  Other organizational standards such as the Healthcare  Laundry  Accreditation Council (HLAC) Standards may be implemented to receive accreditation to show they produce hygienic infection prevention textiles.

There has been talk that EVS textiles cannot be rendered hygienic during the laundry processing.  If  that was the case, then patient bed pads/incontinence pads, bed linens, towels, staff scrubs (when laundered by the on-premises or healthcare laundry contractor), towels, washcloths, or other reusable healthcare textiles could not be used by neonatal intensive care units, burn units, transplant units, chemotherapy units, and other critical-care units.

Fortunately, healthcare laundries effectively render HCTs sanitary and hygienic daily. Healthcare  laundries –OPL, Co-op, or contractor –produce hygienic products that ensure, to the greatest extent possible, a hygienic environment and contribute to quality patient outcomes.

All healthcare textiles must be processed to the highest standards possible to meet patient needs. HCTs–bed sheets, towels, infection prevention textiles, isolation gowns or operating room textiles–need to be laundered to the exacting standards of the textile manufacturer, CDC, and CMS in the case of long-term care facilities, accrediting bodies, and healthcare laundry best operational processes to ensure a sanitary and hygienic product.

The U.S. government, through  CMS, reimburses healthcare for many operating expenses. These  Medicare reimbursement rules are described in the Provider Reimbursement Manual and detailed in CMS cost reporting forms (spreadsheets) for different types of healthcare facilities.

The Provider Reimbursement Manual –Part 1 states in Section 2102.2 Costs Related to Patient Care: “These include all necessary and proper costs which are appropriate and helpful in developing and maintaining the operation of patient-care facilities and activities. Necessary and proper costs related to patient care are usually costs which are common and accepted occurrences in the field of the provider’s activity.”

The Case for Moving Infection Prevention Textiles to the Linen/Laundry Department

An isolation strategy of contact precautions in multiple-bed rooms was non-inferior to contact precautions in a single-bed room for preventing transmission of ESBL-producing Enterobacteriaceae, a recent study found.

“Non-inferiority of the multiple-bed room strategy might change the current single-bed room preference for isolation of patients with ESBL-producing Enterobacteriaceae and, thus, broaden infection-control options for ESBL-producing Enterobacteriaceae in daily clinical practice,” wrote Marjolein F. Q. Kluytmans-van den Bergh, MD, PhD, with the Department of Infection Control at Amphia Hospital in Breda, Netherlands, in a recent 

Use of single-bed rooms for control of extended-spectrum Î²-lactamase (ESBL)-producing Enterobacteriaceae is under debate because the added value when applying contact precautions has not been shown, Kluytmans-van den Bergh wrote.

The researchers conducted a cluster-randomized, crossover, non-inferiority study on medical and surgical wards of 16 Dutch hospitals. During two consecutive study periods, either contact precautions in a single-bed room or contact precautions in a multiple-bed room were applied as the preferred isolation strategy for patients with ESBL-producing Enterobacteriaceae cultured from a routine clinical sample.

Eligible index patients were 18 years or older, had no strict indication for barrier precautions in a single-bed room, had a culture result reported within 7 days of culture and before discharge, and had no wardmate known to be colonized or infected with an ESBL-producing Enterobacteriaceae isolate of the same bacterial species with a similar antibiogram.

A total of 693 index patients and 9,527 wardmates were enrolled in the study and 463 index patients and 7,093 wardmates were included in the per-protocol population.

The primary outcome was transmission of ESBL-producing Enterobacteriaceae to wardmates, which was defined as rectal carriage of an ESBL-producing Enterobacteriaceae isolate that was clonally related to the index patient's isolate in at least one wardmate. The primary analysis was done in the per-protocol population, which included patients who were adherent to the assigned room type.

Then, the 16 hospitals were randomized, eight to each sequence of isolation strategies. All hospitals randomized to the sequence single-bed room then multiple-bed room and five of eight hospitals randomized to the sequence multiple-bed room then single-bed room completed both study periods and were analyzed.

Transmission of ESBL-producing Enterobacteriaceae to at least one wardmate was identified in 4 percent of 275 index patients during the single-bed room strategy period and for 7 percent of 188 index patients during the multiple-bed room strategy period.

The study was funded by the Netherlands Organisation for Health Research and Development.

Netherlands study details ESBL-producing Enterobacteriaceae strategy.

ICT Sep 01, 2019 Vol 23 No 07

September 2019 Bug of the Month

Shared Accountability: A Strategy to Reduce Infection Risk

The Case for Moving Infection Prevention Textiles to the Linen/Laundry Department

Study: Single-Bed Rooms Preferred to Control Certain Bacteria