Panel Tackles Environmental Hygiene-Related Issues

A panel discussion, "Improving Patient Outcomes: Building Bridges Between Infection Preventionists and Environmental Services Professionals," was held at the AHE annual conference Sept. 27, 2011. Panel members were William Rutala and Ruth Carrico, as well as Linda Dickey, RN, MPH, CIC; Marita Nash, MBA, CHESP; and Kathy Roye-Horn, RN, CIC. These experts in infection prevention and environmental hygiene discussed disinfection as a patient-safety issue, as well as explored the role of the healthcare environment in pathogen transmission.

The Association for Professionals in Infection Control and Epidemiology (APIC) and the Association for the Healthcare Environment (AHE) are partnering to strengthen the relationship between infection prevention (IP) and environmental services (EVS) to improve patient outcomes and reduce infections.

A joint educational campaign, "Clean Spaces, Healthy Patients: Leaders in Infection Prevention and Environmental Services Working Together for Better Patient Outcomes," will incorporate educational resources, training materials and other solutions to help IP and EVS professionals combat the spread of healthcare-associated infections (HAIs).

To determine the focus of the educational campaign, 2,000 members of APIC and AHE were surveyed to determine how they work together to protect patients. Survey results were presented at the AHE 2011 annual conference in Kissimmee, Fla. In late September.

"These survey results indicate that we can make improvements to ensure that the environment in which care is rendered helps to combat infections," says Ruth Carrico, PhD, RN, CIC, clinical advisor to AHE, and associate professor at the University of Louisville School of Public Health and Information Sciences in Louisville, Ky. "Strengthening collaboration between infection prevention and environmental services staff will advance this goal and contribute to reducing infections and improving patient outcomes."

The process of cleaning and disinfecting healthcare facilities is of the utmost importance to best ensure patient safety and prevent the spread of HAIs. According to AHE practice guidance, daily cleaning and disinfecting of an occupied patient room with attention to high touch surfaces such as bedrails, knobs, call buttons, etc., will take approximately 25 to 30 minutes per room. A terminal/discharge cleaning will take longer, 40 to 45 minutes and up to 60 minutes, depending on room size, number of horizontal and high-touch surfaces, and number of tasks to be performed in an efficacious manner.

"As the government and accrediting bodies increase scrutiny in this area, rigorous environmental cleaning becomes even more important," says William Rutala, PhD, MPH, CIC, clinical advisor to APIC, and director of hospital epidemiology at the University of North Carolina Health Care in Chapel Hill, N.C. "There are well-established guidelines for proper cleaning and disinfection, and making this information available to professionals and front line staff is vital."

The survey found that infection prevention and environmental services professionals believe there is a need for additional education and resources to facilitate successful prevention of HAIs:

Half find it difficult to locate useful resources about proper cleaning and disinfection (51 percent).

73 percent say their facility educates EVS front line staff well about their role in infection prevention; 54 percent believe other staff could be better educated about their role in cleaning.

About six in 10 respondents believe educational resources on cleaning, disinfection, and infection prevention and control should be directed to executives and also to physicians. Half believe patients and families of patients should be a target audience, while one-third state the general public should be an audience.

Nearly 9 in 10 respondents believe EVS team members are treated with respect (85 percent).

Almost 9 in 10 are interested in hearing how other facilities have created successful IP-EVS partnerships (88 percent).

In conjunction with the aforementioned partnership announcement, a panel discussion, "Improving Patient Outcomes: Building Bridges Between Infection Preventionists and Environmental Services Professionals," was held at the AHE annual conference. Panel members were William Rutala and Ruth Carrico, as well as Linda Dickey, RN, MPH, CIC; Marita Nash, MBA, CHESP; and Kathy Roye-Horn, RN, CIC. These experts in infection prevention and environmental hygiene discussed disinfection as a patient-safety issue, as well as explored the role of the healthcare environment in pathogen transmission.

Rutala said that over the past decade, there has been growing appreciation of the role that the environment plays in disease transmission, especially the fact that colonized and infected patients contaminate their environment, especially the high-touch surfaces within their immediate reach. Drug-resistant pathogens persist in the environment unless they are removed and/or inactivated, and they are picked up on the hands of healthcare workers and passed along to other surfaces and objects, as well as other healthcare workers. Rutala emphasized that along with proper hand hygiene, improved disinfection and cleaning can reduce this risk of transmission.

Carrico explained that the environment is an extension of the patient, and that patient outcomes depend upon the care of the environment that is performed daily and upon discharge (terminal cleaning). She emphasized the need for not judging cleanliness of the environment by whether or not the hospital floors are shiny, but instead, putting evidence-based science into practice to dictate better environmental cleaning.

In terms of how practitioners can reduce the impact of the role of the environment in the spread of healthcare-associated infections, Roye-Horn said that education and motivation were imperatives. She explained that not every practitioner understands the role of the environment in HAI prevention and that consistent education and training was necessary. She added that this education should be accompanied by motivation and incentives to do the best job they can, all of the time.

 Dickey suggested that the development of "clean teams" within hospitals can help cultivate ownership and accountability among environmental services professionals as well as nursing staff members.

Rutala noted that manufacturers could play an important role by providing better systems and products to help environmental services workers identify which hospital environmental surfaces have been cleaned and disinfected, and which have not, by use of temporary dyes added to the solutions. He also said that products with persistent antimicrobial properties could be very helpful in the fight against pathogen persistence on surfaces and objects in the patient room.

Carrico suggested that environmental services professionals need constant feedback about their cleaning performance, and that the ES department and infection prevention department must collaborate in order to share information about outcomes to boost cleaning performance. She noted that since there is no silver-bullet solution, the only way to improve is to receive specific and constructive feedback, garnered through the monitoring of cleaning practice. Rutala added that facilities should celebrate their successes and provide incentives and small rewards.

The panel tackled the hot topic of room turnover, with Rutala emphasizing that hospitals should include disinfectant contact times in any discussion of the need for speed versus the efficacy of cleaning. He acknowledged that while the CDC guideline established a minimum one-minute contact time for non-critical items, many disinfectants' instructions call for a contact time of up to 5 minutes or more, although some EPA-registered products have contact times of between 3 and 5 minutes, and a dry time of up to 2 minutes. Rutala also noted that these times might not be practical in large facilities; he explained that at UNC, which has more than 2 million square feet of space, a 1-minute contact time is observed, and a risk assessment was developed around this policy to satisfy surveyors. Rutala pointed to as many as 20 papers currently in the literature that indicate that low-level disinfection will kill a large number of bacteria in seconds, and added that label claims and disinfectant test methodologies may come more in line with actual practice in the future.

Nash said that at her facility, rushing through the cleaning process is not an option, and that environmental services professionals are asked to report barriers to practice so that they can receive assistance to work through these barriers to achieve optimal cleaning. She added that environmental services workers alert management if tasks cannot be completed, and additional staff is added temporarily to get the job done.

Roye-Horn suggested that facilities study how many environmental services staff members are needed to perform cleaning properly, and also allow adequate time for this cleaning to occur. She advocated the creation of relationships and partnerships between nursing staff and environmental services staff to facilitate better communication.

Carrico suggested that environmental services departments work with infection control committees to gain buy-in and administrator support needed to procure additional resources and full-time employees to help advance the environmental cleaning agenda and achieve a zero-infections goal. She emphasized that both parties needed to be clear about time requirements, provide data and demonstrate leadership that will all contribute to improved cleaning practices.

Dickey noted that patient throughout must be a shared goal between departments and that policies and procedures should be examined regularly in order to streamline the process. She suggested that information from the literature demonstrating the link between environmental cleaning and reduced pathogen transmission should be shared at infection control committee meetings. She further encouraged committee members to be collaborative, not adversarial.