OR WAIT null SECS
Kathy Roye-Horn, RN, CIC, is putting into action her beliefs about the importance of collaboration between infection control professionals (ICPs) and environmental services professionals (ESPs). In June, she spoke in Denver before the membership of the Association for Professionals in Infection Control and Epidemiology (APIC), and this month, she will find herself in San Antonio addressing members of the American Society for Healthcare Environmental Services (ASHES). It’s two different cities, but the critical message — fostering teamwork between ICPs and ESPs for the sake of fighting healthcare-acquired infections (HAIs) — remains the same.
Roye-Horn, director of infection control services at Hunterdon Medical Center in Flemington, N.J., advocates for a comprehensive infection prevention and control plan that can be implemented collaboratively between the two departments as they align departmental and organizational quality improvement goals. This collaboration is essential especially in an era of increased federal scrutiny by the Centers for Medicare & Medicaid services (CMS) and new pay-for-performance mandates set to go into effect next month, in addition to continued expectations of meeting other agency regulations, standards, and guidelines.
One such piece of guidance is the Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC/HICPAC, which was issued in 2003 and outlines pertinent sanitation and infection prevention strategies relating to the physical environment in healthcare facilities. The role of the environment in the transmission of pathogenic organisms is a contested topic; while some studies indicate microbial contamination of environmental surfaces contributes to disease transmission, some healthcare professionals point to the CDC’s statement in the guideline that, “The environment is rarely implicated in patient infections.”
“I think there are several unresolved issues raised in the guideline,” says Roye-Horn. “The question can be asked, what is the role of the environment in transmission of infection, and then there is the part that asks, do we need to use different products than what we’ve been using? In terms of the environment, I think we all believe that it does contribute to patient infection. Previously, when the infection control community was of the firm mind there was very little contribution, it was a time when there were fewer resistant organisms and less of a problem with the spore-forming Clostridium difficile in hospitals than we see now. I think both have contributed to changing our thoughts on this. Years ago we were concerned about how long viruses persisted in the environment and their threat to healthcare workers (HCWs) and patients, whether it was hepatitis or HIV. These days, we are concerned about resistant organisms like methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). I think we agree now that it’s easy enough for these organisms to be transmitted to a patient’s skin, where, while they may not cause an infection, they may colonize the patient. That colonization may lead to an infection later, even if it’s during another admission or at another time entirely. I think there’s still a question as to how much of a role the environment plays but we’re more concerned about it these days.
Roye-Horn continues, “As far as what products we should use, that’s where the bigger question may still lie because is it the product that’s important or is it that you do enough physical cleaning to remove the organisms from the surface? Listening to and speaking with Dr. Bill Rutala, he has a lot of data indicating that our old products work. But are we cleaning adequately? Are we using the elbow grease and getting to all of those surfaces? That’s the new question, I think.”
Let’s take a look at what some studies indicate in terms of the contribution the environment makes to disease transmission. Crnich et al. (2005) point out that “Exogenous colonization originates from a very wide variety of animate and inanimate sources in the intensive care unit environment.” The researchers looked at the causes of ventilator-associated pneumonia (VAP) and noted that a substantial proportion of episodes of VAP are of exogenous origin and caused by healthcare-associated organisms that are not part of the normal oropharyngeal flora, such as Pseudomonas aeruginosa, other multi-resistant Gram-negative bacilli, and Staphylococcus aureus, especially methicillin-resistant strains.
They also looked to environmental sources of colonization in the animate and inanimate environments, with the contaminated hands of HCWs as a leading vector. Crnich et al. (2005) report, “Larson found that 21 percent of hospital employees’ hands were persistently colonized by Gram-negative bacilli, including Acinetobacter, Klebsiella, and Enterobacter, and Goldmann et al. found that as many as 75 percent of neonatal ICU HCWs’ hands were colonized by potentially pathogenic Gram-negative bacilli. Maki found that the hands of 64 percent of ICU personnel sampled at random were colonized at some time by S. aureus, and 100 percent showed transient carriage of a variety of Gram-negative bacilli at least once during the period of surveillance.”
Hota (2004) notes, “Despite documentation that the inanimate hospital environment (e.g., surfaces and medical equipment) becomes contaminated with nosocomial pathogens, the data that suggest that contaminated fomites lead to nosocomial infections do so indirectly. Pathogens for which there is more-compelling evidence of survival in environmental reservoirs include Clostridium difficile, vancomycin-resistant enterococci, and methicillin-resistant Staphylococcus aureus, and pathogens for which there is evidence of probable survival in environmental reservoirs include norovirus, influenza virus, severe acute respiratory syndrome-associated coronavirus, and Candida species. Strategies to reduce the rates of nosocomial infection with these pathogens should conform to established guidelines, with an emphasis on thorough environmental cleaning and use of Environmental Protection Agency-approved detergent-disinfectants.”
Persistence of pathogenic organisms is a related concern. Kramer et al. (2006) observe, “The most common nosocomial pathogens may well survive or persist on surfaces for months and can thereby be a continuous source of transmission if no regular preventive surface disinfection is performed.” The researchers’ review of the literature revealed that most Gram-positive bacteria, such as Enterococcus spp. (including VRE), Staphylococcus aureus (including MRSA), and Streptococcus pyogenes, survive for months on dry surfaces, while many Gram-negative species, such as Acinetobacter spp., Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, Serratia marcescens, or Shigella spp., can also survive for weeks to months. Candida albicans, a significant nosocomial fungal pathogen, can survive up to four months on surfaces.
Inanimate surfaces come into play as HCWs’ hands easily become colonized by pathogenic microorganisms from handling contaminated equipment or touching inanimate surfaces in patients’ immediate surroundings. Crnich et al. (2005) observe, “A variety of nosocomial pathogens can be recovered from surfaces of the inanimate hospital environment. The capacity of these organisms to persist for weeks to months on surfaces such as tabletops, bed railings and linens raises concern about indirect horizontal transmission of pathogenic microorganisms. Many Gram-positive organisms, especially enterococci and S. aureus, retain viability for periods in excess of three months when incorporated in dried organic materials commonly found on hospital surfaces.
In contrast, Gram-negative organisms subsist for much shorter periods, in the order of hours, with the exception of Klebsiella species, Acinetobacter species, and Enterobacter species, which can retain viability for several days. The capacity of surface organisms to secondarily contaminate HCWs’ hands and clothes without any direct patient contact provides support for the role of hospital surfaces in the horizontal spread of hospital pathogens.”
While HCWs may better understand the need for thorough cleaning and disinfection of inanimate surfaces coupled with other evidence-based practices such as hand hygiene, it does not ensure that the decontamination process may actually occur. One source of contention in healthcare facilities is to whom the responsibility of cleaning patient-care equipment falls — nursing or housekeeping? And while each side debates the issue, the cleaning doesn’t get done.
“Cleaning is everyone’s responsibility,” Roye-Horn emphasizes. “I started speaking to the problem of both groups not cleaning a few years ago, and when I first included this topic in our annual infection control meetings, some of our healthcare professionals were upset. They would say to me, ‘Cleaning is not part of my job.’ It requires a major culture change; whether or not an organization can make such a change says something about how they respond to problems in general and how they are able to change behaviors leading to unsafe practices. After about three years of a great deal of resistance at my facility on the part of HCWs who insisted that it was not part of their job, we now have HCWs who realize that cleaning is so much a part of their job that they will say to another practitioner, ‘Don’t forget to wipe that after use.’ It’s a constant education, as we get new HCWs fresh out of school who haven’t had infection control as part of their education, or people from other facilities where it isn’t so much the norm. Now, HCWs understand that if they are the last user of something like a wheelchair, that they are the ones responsible for cleaning it. It’s not as if we are asking them to clean the floor.”
Making the imperatives behind environmental cleaning clear to all personnel, be it clinical or environmental services staff, is a must, according to Roye-Horn. She incorporates a very popular image into her PowerPoint presentations; the photo of a typical patient room is peppered with neon green Xs that denote the numerous high-touch surfaces that require decontamination. Seeing is believing, Roye-Horn says, but seeing in this eye-opening manner also aids in improved compliance.
“I think it’s a matter of people engaging their imagination (about the hidden hot spots of contamination),” she explains. “That was the theme of my annual presentation this year; we have to enable HCWs to begin to imagine where the bugs are hiding.” Roye-Horn says she used the John Lennon song ‘Imagine’ in her presentation to make her point. “I also use cartoon of bugs hiding on keyboards and in between fingers; it’s powerful to connect visual images with aural cues to stress the fact that we have to believe in the presence of microbes.” Roye-Horn says she has tried several ATP products with bioluminescent properties to evaluate a cleaning tool, but the product didn’t work well with the type of surfaces found at Hunterdon. “There are other, more expensive products we haven’t tried yet. I do think there is value in using a product like GloGerm, where people can see the ‘bugs’ still on their hands right after they clean them. I think that has a big impact on hygiene practices.”
Regardless of the tools used or the education strategies employed, at the heart of solid collaboration between departments, Roye-Horn says, is swapping personnel — having an ES director sit on an infection control committee and having an ICP join an ES committee. At Hunterdon, Roye-Horn says an ES director is also part of her department’s MRSA prevention team. She pushes for improved communication and good relationships between ES professionals and clinical staff, with an emphasis on a “tell me, don’t tell on me” approach. Her facility also established an infection control hotline, through which all staff could report breaches in protocol and practice by repeat offenders if a gentle reminder doesn’t work.
At Hunterdon, Roye-Horn says, all ES personnel are required to attend an annual infection control update lecture, while infection control is invited to share its successes and failures with plenty of data and feedback at ES staff meetings. The facility also holds its annual ES Week celebration. Additional strategies for fostering collaboration include making a business case for infection prevention and ensuring that it is a team effort, and using financial data in a proactive manner to support the need for more ES employees so that patient-touchable surfaces can be cleaned daily in high-risk areas of the hospital. It’s essential for both departments to “own” the facility’s infection prevention issues, as well as to approach administrators regarding the infection prevention team’s concerns, operational needs or requests relating to resource allocation.
It comes down to resources, says Roye-Horn, who emphasizes in her presentations that it has become the norm in healthcare to under-invest in infection prevention and environmental cleaning. “There are always going to be very limited resources in healthcare,” she says. “Yet you will always need to make a very large investment in the care of patients, as it should be. Whether you can afford all of the people, tools, technologies and resources you want is certainly going to be doubtful. People will have to prioritize which ones have the best data, or which things make the most sense or which things they can afford, and it’s always going to be something each institution must figure out for itself.”
“We’re certainly getting an added push to do the right thing from agencies like CMS,” Roye-Horn adds. “In some facilities, ICPs and ES directors have an easier time of getting their points across without having to have federal regulation hang over their heads. They may have the ear of somebody who holds the facility’s purse strings, or they may be able to get themselves an audience with their administrative executives. But in many facilities, that is difficult and doesn’t happen very readily. Still, I’d like to think there are places where hospital CEOs and CFOs are the ones coming to ICPs and ES directors with questions rather than us having to get their attention all the time.”
Roye-Horn says that cultivating the right stakeholders can also serve the infection prevention agenda. “While we have just one FTE for infection control, there are ways to get others to invest in infection prevention. For instance, the clinical nurse leader (CNL), who is our patient safety nurse, is really an extension of infection control; they are not under my department but they play a big role in infection prevention by observing practices out on the floor, by educating people, or by deciding certain competencies are needed because of what they are observing. So, having CNLs is almost as good as having more ICPs at my facility.”
Observational rounds performed by ES directors and ICPs is another important collaboration that pays big dividends in improved infection control by noting any variations in practice that could be hampering compliance. These rounds have helped Hunterdon to develop a cleaning sequence for patient-touch surfaces that is a helpful teaching tool, according to Roye-Horn.
“When addressing environmental services practices, it works well for me to go with our ES director,” Roye-Horn says. “She is as committed to infection prevention as I am, and so we like to observe staff practices together. That way, it becomes a little less formal and intimidating, as we are chatting together and with them. In other kinds of observations, for instance, our CNLs perform clinical practice observations relating to direct patient care. It may be difficult for them because they are in the role of having to correct people, but it’s been such a valuable process. For years we had people who were on the performance improvement council for nursing observe handwashing, and we would always have 100 percent or 98 percent compliance — that’s because they were sitting at the desk and if people clean their hands in a room, they mark ‘yes’ on a form. Now, we have people who actually observe how they did it, did they rub their hands together for the right amount of time, with the right amount of product, and did they do it before a patient interaction and after? That’s when we saw numbers that were much worse. The quality and detail of the observation is what makes a difference. We detected many things via direct monitoring that surprised us. We thought people know a certain protocol, but when you actually watch what the practice is, step by step, it’s eye-opening. I don’t think we’ve found a more valuable tool than direct observation.”
Crnich CJ, Safdar N, and Maki DG. The role of the intensive care unit environment in the pathogenesis and prevention of ventilator-associated pneumonia. Resp Care. Vol. 50, No. 6. June 2005.
Hota B. Contamination, disinfection, and cross-colonization: Are hospital surfaces reservoirs for nosocomial infection? Clin Infect Dis. 2004;39:1182-1189.
Kramer A, Schwebke I and Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious Diseases. 2006;6:130.