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By Thomas J. Fitzgerald III, CHESP
New Issues, and Why the Relationship Must be Strong
The 2003 release of the Centers for Disease Control and Prevention (CDC)’s Guideline for Environmental Infection Control in Health-Care Facilities formalized what infection control practitioners (ICPs) have known all along: that there is a strong link between environmental cleanliness and interruption of infectious disease transmission. Emerging pathogens such as Severe Acute Respiratory Syndrome (SARS) have also shown us that ignoring this link can have dangerous consequences. Despite the use of airborne and contact precautions in healthcare facilities caring for SARS cases, transmission still occurred, possibly due to environmental contamination. Other more common pathogens, such as norovirus and the influenza virus, continually remind us that the highest standards of environmental cleaning must be in place to keep disease transmission in check. Yet not all hospital infection control (IC) programs have forged strong relationships with their environmental services (ES) department. At best, they are missing out on the benefits a close partnership with ES can provide. At worst, they are setting their healthcare facility up for a potential infection control disaster.
What can be accomplished if IC and ES work together?
At our facility, IC and ES have worked together to implement the 2002 CDC Hand Hygiene Guidelines. IC has taken the lead in working with patient-care staff to select the most appealing alcohol-based hand sanitizer product, and in educating healthcare workers on the proper use of the product. With the help of our facility safety officer, we determined the most appropriate firesafe locations to mount the product. ES has overseen the installation of the alcohol-based hand rub dispensers, ensured that housekeepers have access to adequate supply of product to replace the containers when empty, and will provide valuable product usage data to assist with monitoring compliance. Without this collaboration, we would not have been able to implement the CDC’s new hand hygiene recommendations as effectively and completely as we have.
Another instance in which partnership between IC and ES departments is critical to the control of hospital infections is during an outbreak. Last year, media reports of norovirus outbreaks on cruise ships and in nursing homes across the country brought to everyone’s attention the importance of frequent cleaning of environmental surfaces in controlling the transmission of this gastrointestinal illness. One morning last February we learned of an outbreak of gastrointestinal illness affecting both patients and staff in one of our nursing homes. The symptoms were highly characteristic of norovirus, and we knew we needed to act quickly to get things under control. One of the first phone calls we made was to our ES director. We informed him of the outbreak, the fact that both patients and staff were getting sick, and that many of the patients on this ward suffered from dementia, making it difficult to keep ill patients completely isolated in their rooms. We explained that all bathrooms and all surfaces frequently touched by patients and staff would need to be wiped down with disinfectant almost continuously. Last, but not least, we informed him of the very real risk to his staff — they would need to wear isolation gowns and masks when cleaning up the inevitable “accidents,” and be extremely diligent about hand hygiene to prevent themselves from getting ill. He responded without hesitation that he would increase the ES staffing to the nursing home and provide overtime coverage during the outbreak. Soon, a team of housekeepers arrived at the nursing home, carrying buckets of wipes soaked in hospital disinfectant. The buckets were placed in each patient room and in key areas such as hallways, dining, and group activity rooms to allow nursing staff to clean surfaces in between times. When not cleaning bathrooms, the housekeepers continually moved up and down the halls, wiping down the hand rails and door handles. Within two weeks the outbreak was contained, a success we believe would not have been possible without the cooperation and diligence of our ES department.
The aforementioned examples depict the kind of teamwork that can take place once a respectful and empowering relationship between IC and ES has been established.
How to Develop or Improve the Relationship
If the IC/ES relationship does not already exist, or needs to be improved, a good way to start the process is for the ICP to begin to meet regularly with the director of ES for the facility. The goal of these initial meetings should be to bring the ES director on board with infection control issues that are of latest concern to the ICP. The ES director needs to have a basic understanding of the different ways infectious diseases can be transmitted. Once this understanding is established, he or she will begin to see ways in which the ES department can help to bring infection rates down. The ICP can also offer to provide infection control training sessions at ES staff meetings, covering a range of topics from bloodborne pathogens to norovirus control measures to bring frontline housekeepers into the loop and help them understand their importance in keeping the hospital environment safe.
ES needs to be represented and have a strong, proactive presence on the IC committee. The IC committee representative for ES should have an understanding of the ways in which ES can assist in the effort to bring down nosocomial infection rates. They need to be able to communicate to ES managers and their staff any infection transmission issues discussed at the IC committee meetings, make recommendations for improvements, and report back to the IC committee any improvements that have been made. ICPs should always include ES representation on any interdisciplinary task forces developed to target particular infection control problems. For example, our ICU has formed an MRSA-reduction task force which includes nurses, physicians, respiratory therapy, infection control, and ES. The ES representative provides hand-hygiene compliance feedback to the task force by monitoring and reporting usage rates of alcohol-based hand rubs. They also play an active role in identifying areas for improvement and educating their staff on how to prioritize their work to ensure that the most frequently touched surfaces in the patient’s rooms are cleaned frequently.
Lastly, ES departments should be acknowledged in IC committee minutes for the ongoing role they play in helping to control hospital infections.
Thomas J. Fitzgerald III, CHESP, is chief of environmental management service at the VA Palo Alto Healthcare System and also is president-elect to the American Society for Healthcare Environmental Services (ASHES).