Caring for the Enviroment

Environmental contamination of the healthcare setting is increasingly being viewed as a potential link in the chain of infection transmission. As the evidence continues to mount, greater emphasis will continue to be placed on the vital role that the environmental services (ES) department plays in eradicating dangerous pathogens. Through proper training and partnering with infection control (IC) personnel, the ES team can get the knowledge and tools it needs to help make the hospital a safer place.

Bala Hota MD, MPH, assistant professor in the section of infectious diseases at Stroger Hospital of Cook County/Rush University Medical Center, says that while the idea of infectious agents being transmitted via the environment is somewhat controversial, it may be becoming more accepted as risk factor or co-factor, particularly in the presence of resistant pathogens.

The environment definitely can harbor organisms, and these can be antibiotic-resistant organisms, he says. These organisms can persist in the environment for long periods of time, and I think theres a lot of data to show thats the case. What the role is of that environmental contamination is in promoting nosocomial infection with these organisms is a little more controversial.

We know that these resistant pathogens such as Clostridium difficile (C. diff.), vancomycin- resistant enterococcus (VRE), and Acinetobacter baumannii are pretty resilient organisms; they can live for a long time in the environment, and theres some evidence out there that transmission can occur from the environment to the healthcare workers hands and then to the patient, says Philip C. Carling, MD, director of hospital epidemiology, Carney Hospital, assistant professor of medicine at Boston University School of Medicine. Theres not a lot of evidence about that because studies to show that are almost impossible to do.

Hota also asserts that definitive studies proving the environment is to blame for an outbreak would be extremely difficult to perform. Typically what happens is when people look at resistant organisms, its in the setting of an outbreak, he says. A number of things are done in that situation to try and reduce the rate of infection with that organism, and typically many things are done at once, and so the result is that you cant really identify the single thing that led to the decrease in the outbreak. With VRE for example, a few patients might get it, and then a facility might put out educational messages to healthcare workers so they start washing their hands more frequently, you might start monitoring the behavior of healthcare workers to make sure theyre washing their hands, you might give out educational messages to environmental services staff members so they end up cleaning the rooms better, you might end up putting more patients on contact precautions, more gowns are worn, etc. All of these things together may terminate the outbreak, but its difficult to know what the environmental role in that was.

Hota notes that there is good data to show that the environment harbors C. diff. spores. If you clean the environment, thats the only thing you can do to stop more cases of C. diff. from occurring. With that organism its generally accepted that the environment is to blame; the spores can live for a long time and even after a patient leaves; if that room isnt cleaned, the next patient could be at risk. With methicillin-resistant Staphylococcus aureus (MRSA), there are two situations that seem like they might put patients at risk. One is in burn units, and it may just be that patients in burn units are shedding the organism into the environment so much more that the environment gets more heavily contaminated.

In burn units, it looks like when new patients acquire the organism the environment may have played a role. The same kind of situation can occur in neonatal ICUs (intensive care units). When theres one case, frequently many cases can occur, and the environment may play a role. The other situation with MRSA is that there have been some case reports of common sources such as a whirlpool bath. There have also been a couple studies looking at VRE where the environment seems to be a risk factor for new infections.

A recent study showed a reduction in VRE infections after routine environmental cleaning efforts were enforced.¹ The study looked at 748 ICU admissions over the course of nine months. The baseline VRE acquisition rate was 33.47 cases per 1,000 patient days. After a period of educational training to improve environmental cleaning, the rate dropped to 16.84, and eventually decreased again to 10.40 cases per 1,000 patient days at risk for the fourth period of the study, which included hand hygiene intervention.

In terms of guidelines for environmental cleaning, Hota points to recommendations from the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC).² They support the use of cleaning chemicals that show good activity against most pathogens that youre going to find in hospitals, he says. Applying the guidelines uniformly and having good cleaning practices should be enough. Thats probably the best thing to do, but sometimes in infection control I dont think we do a good enough job of looking at how well the rooms are being cleaned, if daily cleaning is taking place, if terminal cleaning is being done when patients are discharged, and if all the sites in the room being cleaned properly. Are we observing the housekeepers and auditing their performance in terms of cleaning? It may not be that the technique is bad or the idea is bad of cleaning, it just might not be being applied.

Joan M. Wideman, MS, MS, MT(ASCP)SLS, CIC, of JMW Consulting LLC, contends that the ability of a hospital to hire and retain qualified ES staff members who will do what theyre expected to do can be a big challenge. I think the infection control professional can partner with environmental services management to work on how the basic education and training is done, she says. Also to look at the different types of products and how easy it is for the environmental services staff to safely dilute them; to make sure theyre not mixing them incorrectly or using more than they should. Several companies have the automatic dilution stations, which can take the mystery out of that, but you want to make sure that anything put into secondary containers is labeled for recognition, and thats part of Occupational Safety and Health Administration (OSHA) regulations. Ive been very impressed with some of the newer products out there such as the microfiber mops and cloths. That has been a great improvement in my experience.

The staff needs to ensure that they are utilizing the correct chemicals and cleaning procedures at all times, and they must also ensure that they are washing their hands and changing gloves as they become soiled and or torn, says Thomas J Fitzgerald III, CHESP, NP, CNSA, chief of environmental management service at VA Palo Alto Health Care System. Fitzgerald is also past president of the American Society of Healthcare Environmental Services (ASHES).

They should be changing their mops as required by their local cleaning policies and procedures, and changing out their hospital-grade (EPA-approved) germicide as required. We also need to pay special attention to all horizontal and vertical surfaces, which usually serve as hosts for pathogens. Fitzgerald also suggests that all ES staff members should be trained annually at a minimum on bloodborne pathogens and infection control procedures and how they impact the healthcare environment. They should also receive education on pathogen eradication and cross-contamination prevention, and should have a clear understanding of healthcare-level cleaning procedures.

Wideman says infection control personnel should participate in ES staff training. One of the challenges with education and training is, not infrequently, the housekeeping component may be a contracted service, and depending on that contract the employees are actually hospital employees vs. contracted and direct employees of that service. This sets up a whole other potential challenge what do you do for pre-screening of those employees? Some parts of the country have a higher prevalence of TB (tuberculosis), or if its a pediatric or womens or cancer hospital, what do you require for immunizations? What do you do with a needlestick or other exposure? How are you addressing or including housekeeping staff in your emergency preparedness? They may be scared or reluctant to learn some of this information look at the lessons learned from SARS (severe acute respiratory syndrome) and the anthrax scares.

Some of the vendors offer very good educational and training programs that help augment and extend the resources, Wideman continues. Another area that sometimes gets overlooked is the additional training required by OSHA. For example, per the Department of Transportation (DOT), if theyre packaging medical regulated waste for disposal, theres additional training that needs to happen.

Open lines of communication and teamwork between infection control and environmental services are vital, Fitzgerald adds. If the ES department is not the first call made by the IC department after notification of an outbreak, there is a big disconnect and a potential for further cross-contamination and an increased HAI (healthcare-associated infection) rate, which is bad for all, he says. I would recommend that the director of ES sit as a voting member on the hospital infection control committee so that we have a voice and first-hand knowledge about emerging pathogens and eradication plans. So many times the ES department is an afterthought in regard to eradication, and that is not acceptable. I would also suggest that the IC staff members train all environmental services staff members quarterly.

CDC RECOMMENDS N95S FOR SURGICAL PLUME AND SMOKE PROTECTION I think the training and education to make sure that communication is clear is important, Wideman concurs. For example, with the increase in resistant organisms such as MRSA, VRE, and C. diff., without compromising patient privacy, there has to be a method to communicate and to ensure that the environmental services staff members recognize that so they protect themselves.

Wideman notes that she has seen several different methods used at different hospitals in this respect. One is to put some type of additional marker such as a red dot on a certain place on the contact precautions sign. Another is to have the computerized ability to communicate with the environmental services manager as to which rooms have which types of patients. One of the concerns with C. diff. especially is to use a bleach-based product, per CDC recommendations. You also want to make sure with those C. diff. patients that people are washing their hands with soap and water rather than an alcohol-based hand rub.

Fitzgerald urges facilities to make infection control a part of the ES culture. We need to ensure that our staffs understand the HAI rate and the role we play in keeping it at a low level, and this can be achieved by providing a dynamic IC training program which includes proactively educating staff members about pathogens that have not touched the United States yet, such as avian influenza. Fitzgerald also notes that ES leadership should be well versed in CDC, World Health Organization (WHO), and Association for Professionals in Infection Control and Epidemiology (APIC) guidelines and recommendations. This should trickle down to all subordinate staff so that the ES department provides seamless infection control. We need to ensure that all staff members are appreciated and understand the role they play in the healing process, decreasing length of stay, and that they are also a part of the treatment team each and every day.

I think generally environmental service workers are trying to do a good job and believe they are, but it may be a situation where infection control practitioners could really make a difference in terms of improving the quality, Hota says. Institutions may not appreciate how important the cleaning of rooms is, or that it may make a difference in terms of infection rates.

A Process Improvement Effort

Carling has recently been involved in a focused effort to improve environmental cleaning through directly educating ES staff members on the importance of their efforts and demonstrating how they can become more effective and efficient. Carling and colleagues explained their rationale and methods in a study titled, Improved Cleaning of Patient Rooms Using a New Targeting Method.³

The authors used an invisible fluorescent marker to target standardized high-touch surfaces in hospital rooms. An initial evaluation of 1,404 surface objects in 157 rooms in three different hospitals showed that 47 percent of targets had been cleaned. After the implementation of an educational intervention, sustained improvement was noted in the cleaning of all objects. Additionally, cleaning of surfaces that were previously cleaned less than 85 percent of the time was more than twice as good after the educational intervention.

At the outset of his effort to develop a tool to improve environmental cleaning efforts, Carling looked at previous studies that explored how well cleaning was being done. I started looking at the literature on this, and discovered that its all culture-based [i.e. cultures are taken from rooms], he says. Thats very labor-intensive and expensive. There have been a couple of good studies that have come out in recent years, but theyre very small-scale, and basically noted that the thoroughness of the cleaning itself wasnt optimal. I started trying to think of ways we could evaluate the thoroughness of the cleaning something simple that would allow whole hospitals to evaluate whats going on rather than just five rooms on one cleaning occasion. Thats how this project evolved.

The study explains that a viscous, translucent targeting solution was formulated using a stable, nontoxic base. A chemical marker that fluoresces under black light was then added. The material dries rapidly on surfaces, and remains stable for several weeks. Approximately 0.2 mL of this solution was applied to 12 standardized sites in each hospital room to create small targets. These sites were chosen on the basis of the CDCs recommendation that enhanced cleaning activities should be directed at high-tough objects (HTOs) frequently contaminated with hospital-associated pathogens. Targeting material was placed on areas easily accessible to cleaning. Although the dried marking solution resists abrasion, it was completely removed by wiping with a damp cloth using light finger-tip pressure after sprayed with a disinfectant.⁴

Applications of the solution were made after a room had been terminally cleaned, following the discharge of its occupant. After at least two new patients had occupied the room and the room had been terminally cleaned, a hand-held black light was used to determine whether the marked HTOs in the room had been cleaned. Whereas almost all targets that had been cleaned contained no residual marker, the few targets that showed substantial removal of the marker were accepted as having been cleaned.

When suboptimal cleaning of HTOs was discovered in the three hospitals, ES staff members in each hospital were educated on their role in infection prevention and safety improvement within the hospital, and expectations with respect to cleaning HTOs were defined.

After initial success with this approach, Carling has taken this system to many other facilities. It seems to be working extremely well as a tool to evaluate the thoroughness of environmental cleaning, he says. Its still a very focused kind of evaluation; its looking only at terminal patient room cleaning right now, and only with a limited number of hospitals.

What weve done since the article appeared is expand this to a larger group of hospitals to see if the tool is user-friendly and to get a sense of where the opportunities are for improvement in hospital cleaning and to see if the tool can be used to enhance the thoroughness of terminal room cleaning. We have some pre- and post-intervention data that show pretty good improvement.

In addition to being effective, the system has been extremely well received by those who have used it. The reception has been very positive by the ES staff, even though it could be potentially threatening to them, Carling says. But from the first introduction, weve been absolutely assiduous about making sure they understand this is going to be a positive thing it will show people what they do, and theyve gotten that message and the reaction has been positive because it shows that people care about what theyre doing. The presentation is one thats designed from the beginning to help them understand that they have a role in infection prevention and patient safety. I dont think this has necessarily been emphasized that much in many hospitals.

In some hospitals, the ability to change has been quicker than others, and there are many reasons for this there are language barrier issues, educational barrier issues, political environmental issues, and sometimes leadership issues among ES folks who dont think this is important and dont want to be involved. In other hospitals, there have been no issues at all, and things improve very rapidly and stay improved. Its a tool, and its yet to be seen how it will be used on a broader scale, but so far the results have been very exciting.

Carling has been particularly encouraged by that fact that in some hospitals, this tool has already changed the ES staffs perspective of what they do. It hasnt happened in every place quickly, but the ICPs tell me that these folks look at what they do differently because they see themselves as part of the patient safety effort. In one hospital, theyre very anxious to move this ahead because theres been a lot of wrangling between nursing and ES folks because the nurses dont think the ES staff is doing a very good job, and the ES folks think the nurses are being unreasonable. Im excited about the potential this has for letting nurses and physicians see what these folks are doing and helping them do it better. The positive way this has been viewed has been kind of a revelation to me. 

References:

1. Hayden MK, et al. Reduction in acquisition of vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis. 2006 Jun 1;42(11):1552-60.

2. Sehulster L, Chinn RY; CDC; HICPAC. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003 Jun 6;52(RR-10):1-42.

3. Carling PC, Briggs JL, Perkins J, Highlander D. Improved cleaning of patient rooms using a new targeting method. Clin Infect Dis. 2006 Feb 1;42(3):385-8.

4. Ibid.