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Infection preventionists can work with environmental services (EVS) leadership to implement a routine practice for quality assurance checks that EVS leadership can follow. These metrics can then be reviewed as an aggregate with the IP department to target whether further education may be beneficial.
When many hear the words “frontline healthcare worker,” roles of physicians, nurses, or other healthcare professions are usually what come to mind first. Many ancillary roles within healthcare also hold essential positions, and one such area that is often overlooked by both the public and by staff is that of the environmental services (EVS) team. The EVS department is an indispensable team that is often left unnoticed when things are going well. However, if patterns of hospital-acquired infections (HAIs) emerge, the role of the environment is an area that is quickly emphasized to review.
The arrival of coronavirus disease 2019 (COVID-19) has brought a focus on how the environment plays a part in the potential transmission of infections. Although just how much contact surfaces contribute to the transmission of SARS-CoV-2, the virus that causes COVID-19, is unknown, routine disinfection is still one prevention strategy that is important to stop the spread of COVID-19.
As the hospital room and its surroundings are so critical to the wellbeing of patients and staff and the prevention of the transmission of infections, it is vital that infection preventionists (IPs) work closely with the EVS department to ensure that both teams are on the same page with best practices.
The partnership between IP and EVS is multifaceted. Many hospitals have moved away from hiring their own EVS employees and instead contract out to larger EVS companies. When this is done, the contracting company usually puts together a cleaning and disinfection plan for the hospital based off of a standard for their company. Although there are many positives to this process, as many of the methods used have been tried and improved at other facilities, it is still important for IPs to be involved in ensuring the standards that the EVS team is using are appropriate for the facility.
If the EVS department is not contracted, the IP relationship may have to be closer to help to provide recommendations and options for common disinfection processes. Regardless of whether your EVS department is contracted, the following items are important for every IP department to be aware of as it relates to a facility’s EVS program.
There is a large variety of disinfectants that are available in the hospital setting and the disinfectant wipes that may be routinely found on the units are often not the same disinfectants that the EVS team will use for daily and terminal cleaning of rooms and areas throughout a facility. The IP department should be aware of the disinfectants the EVS department uses for different surfaces as well as the contact wet time for each chemical. The EVS department should always have a bleach or sporicidal disinfectant at minimum to ensure disinfection against organisms such as Clostridioides difficile and Candida auris. Oftentimes at least 2 main disinfection chemicals will be used so as not to degrade equipment if using only bleach.
IPs spend a large amount of time educating healthcare providers on how important the prevention of the transmission of infections is in the healthcare environment and encouraging everyone to follow best practices and be comfortable in the work that they are performing. When providing this education, it is also essential to also target EVS staff and to do so on a routine basis. Explaining the different isolation signs and the personal protective equipment (PPE) that is associated with each isolation is critical to ensuring that the EVS team not only ensures its safety, but also minimizes the risk of transmitting infections to another room as further rooms are cleaned each day.
When educating EVS staff, IP staff should be cognizant of the methods used. As EVS practices are manual, providing more visual education through in-services is often more helpful to staff than providing handouts or writing emails. Additionally, when providing education on PPE donning and doffing, it is helpful to provide practice sessions so that staff feel comfortable with wearing PPE. Stressing the role PPE plays to EVS staff is important to help alleviate any fears in entering patient rooms as well.
When disinfecting a room, one should work from the area that is most to least dirty. Many contracted EVS companies have their own standard approach to room disinfection so that each employee follows the same order when disinfecting a room to limit variation and also allow staff to remember the process. IPs should review this process as well and offer feedback on any opportunities for improvement they may notice.
Apart from daily room disinfection, it is important that a system is in place for EVS teams to be aware of patient discharges so that terminal cleaning of rooms can be completed as soon as possible. In doing so, a system should be in place for notification upon discharge to EVS, and also so that the EVS team is aware if the room being disinfected is an isolation room. Depending on whether or not the room housed a patient who was on isolation, PPE may need to be worn during the disinfection process. Some ways to ensure this transparency is to allow the EVS team to connect with a hospital electronic medical record system so that they can view whether or not a patient was on isolation or, if isolation signs are used throughout the facility, to keep the sign on the door after a patient has been discharged so that the EVS team is aware of the isolation when it arrives to perform a terminal disinfection.
As the importance of the role the environment plays in the prevention of hospital-acquired infections has continued to stay relevant, additional disinfection methods to pair with manual terminal cleaning have been explored. Two such common methods to reduce surface contamination after manual cleaning are ultraviolet (UV) light devices and hydrogen peroxide systems. Multiple studies have demonstrated the benefits regarding using one of these methods in addition to already established disinfection practices. These methods will not remove soil from items but can disinfect and inactivate organisms that may still reside on surfaces. Although these devices can be beneficial, they do come at a large cost. When providing a business case to your facility on the utility of using an additional device, a plan must be developed for how to staff the machine to get the most use out of it. If one of these machines lays idle, it brings into question the utility of its purchase, and so it’s helpful to provide this information as a part of the business case for its purchase.
Validating the compliance of following the disinfection expectations is a way to provide education to the EVS team of potential opportunities for improvement. IPs can work with EVS leadership to implement a routine practice for quality assurance checks that EVS leadership can follow. These metrics can then be reviewed as an aggregate with the IP department to target whether further education may be beneficial. Two such ways to perform a review of disinfection practices are though blacklight inspections and Adenosine triphosphate (ATP) monitors.
Blacklight inspections are the process of an individual marking different surfaces with a fluorescent gel or powder prior to disinfection of a room. After the room has been disinfected, the marked areas can be checked using a blacklight. If the area that was marked was disinfected properly, the fluorescence will no longer be present. If, however, the area was missed, the area will light up. If the same area is respectively found to not have been disinfected, this can be a talking point to staff as a reminder to disinfect the area. If areas are found to always be compliant, this is also a way to provide encouraging feedback to staff as well.
ATP monitors work by using bioluminescence to detect residual bioburden on swabbed surfaces. ATP devices can be found through a variety of healthcare vendors and give off a number to identify the amount of bioburden on a surface in relative light units. EVS teams can use this method to swab high-touch surfaces such as bedrails, doorknobs, call lights, and tray tables, to identify whether or not bioburden had been removed from these surfaces. Higher numbers through these swabs can signify the need for re-education and feedback to staff.
COVID-19 and EVS
COVID-19 has helped to stress the importance of the role the environment plays in preventing the spread of infections and how vital the EVS team is in these efforts. As we learn more about COVID-19 and its role in the environment, keeping your EVS team informed is critical to maintaining their trust in IP and in the work that they do. COVID-19 has not limited the work that the EVS team does but rather has increased its workload and so it is vital to always make sure the team is aware of the positive impact it has each and every day.
ANJALI BISHT, MPH, CIC, is the lead infection preventionist at an academic medical center that comprises a number of hospitals and an extensive primary care network in the Los Angeles region.