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By Teresa Daniels, MSN, RN, CIC
To achieve reduction in healthcare-associated infections (HAI), healthcare organizations concentrate on patient-centered care. This focus is typically targeted toward clinical staff but should include support service’s team members in order to be successful. Support services include, but are not limited to, materials, facilities, environmental services (EVS), registration and dietary. This article will discuss this infection preventionist’s journey in reducing HAIs over the last six years. The HAI reduction program was developed to nurture, educate and support the EVS department.
Mid-2010 was the beginning of the infection prevention journey. This journey began as a new director of infection prevention which was based in a 76-bed rural hospital composed of medical/surgical, intensive care, and centers for women and baby inpatient units. Upon the collection of the HAI data of the first year, the following baseline data was discovered: Clostridium difficile (C. diff) HAI occurrence baseline data was seven and HAI multidrug-resistant organisms (MDROs) was six for the year 2010. This data evolved into the infection prevention department’s performance improvement (PI) project. Immediately, isolation education was initiated for clinical staff. There were new isolation signs developed and were put into place. The Centers for Disease Control and Prevention (CDC)'s MDRO-education sheets were placed into policy for clinical staff to use as a resource for patient education.1 To measure this initiative, isolation personal protective gear and hand hygiene compliance were monitored. Also, documentation audits were initiated, as well as overall MDRO and C. diff-related HAIs were monitored.
Up to the middle of 2011 there was not a measurable improvement in HAI-related MDROs and HAI C. diff (see Figure 1). What was the miss? Our facility followed best practices, audits for isolation had trended to 100 percent, and we were educating patients and families. This is when the realization of what an infection preventionist is, came to light -- continuous observations, education and thinking outside of the box. EVS staff interviews were initiated. The EVS staff members were asked about basic knowledge of MDROs. The majority of the EVS staff members interviewed would state, “I really don’t know about them, I’m just a housekeeper.” This gave birth to our EVS annual education.
The infection prevention department developed a PowerPoint presentation based on the recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), “Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas” (HICPAC, 2003).2 Also included were MDROs, common HAI-related organisms' kill time for disinfectants, as well as the surface life of organisms. In the fall of 2011 the first annual EVS class was conducted. The reaction of the staff to the information was very positive. They were engaged and excited to have learned valuable information relating to their job.
2012: The Beginning of Change
Throughout 2012, the EVS team remained informed of HAI numbers at their monthly staff meetings. We had our annual EVS education during EVS week. We also incorporated the CDC Environmental Checklist for Monitoring Terminal Cleaning.3 We implemented the checklist by visual inspections. There was an overwhelming reduction in MDRO and C. diff-related HAIs (see figure 2). Our facility contributed this reduction to EVS education, EVS engagement, as well as clinical staff isolation and PPE adherence.
At the end of 2012, HAI trends for MDROs and C. diff were excellent but surgical site infections trended upward (see figure 2). A gap analysis based on best practices and national guidelines for surgical departments, facilities, central sterile, and EVS was performed. This article will focus on the EVS findings and improvements.
2013: Gap Analysis
The gap analysis EVS findings were based on consistency. Only two EVS staff members were trained in surgical terminal cleaning. During the inspections, it was noted a mixture of EVS staff members performing terminal cleans during the assigned regular EVS staff member’s absence. It was also found that EVS staff were being rushed during surgical room turnover cleaning and linen clothes saturated in disinfectant were used for cleaning.
Education: During the 2013 annual education, terminal cleaning for the operating room was added. We devised a system to signal if a room had been terminally cleaned, bed up in high position and procedures lights down towards bed. By doing this everyone knew the room was clean and ready for use.
Double-check system: We also initiated a double-check system, requiring trained EVS staff members to check behind one another after surgical room terminal cleans. We developed a check list for this with two areas for EVS staff’s initials.
Empowerment: Empowerment focused on removing fear associated with speaking in order to do what is best for the patient. The EVS staff members were encouraged to speak up if anyone, even surgeons, attempted to rush them during the surgical room cleaning process. This can only be successful if there is a culture of safety within the institution; we are fortunate to have such a facility. Figure 3 demonstrates the success we had in reducing HAIs.
2014: Always Looking to Improve
During the 2014 period, we wanted to take EVS importance facility-wide. Each unit and multiple staff members were interviewed. The interviewed staff included nurses, nursing assistance, registration, radiology, laboratory, dietary, providers, and administration. They were asked two simple questions. The questions and responses were videoed. The questions were simple: “What does EVS mean to you?” and “What would happen if we didn’t have EVS?” All the responses were combined to a movie and played for the EVS team. We also had all directors cater the meal at the EVS education in 2014, as this confirmed their commitment to the EVS team. This intervention ensured the staff knew that they are appreciated, needed, and an important healthcare team member.
We collected terminal clean audits based on the CDC checklist. We began drilling down the data for improvement opportunities. This information would later be used for cleaning improvement opportunities house wide. The data (see figures 4a, and 4b) was also shared at the annual EVS education in June. By informing the EVS staff of their improvement opportunities an upward trend occurred thereafter.
After the June EVS education, we wanted to ensure surgical room terminal cleaning was hardwired. We also wanted to discontinue the use of linen cloths from our operating room terminal clean practice. We found that our linen company, Logan’s, had partnered with UMF Corporation PerfectCLEAN microfiber products. The system also offered an EVS Hygiene Specialist Certification for operating room terminal cleans.4 We enrolled our experienced EVS staff in the program.
By the first quarter of 2015, our EVS staff had completed the Hygiene Specialist training and received their certification. We held a celebration of recognition, which consisted of all of administration’s executive officers speaking. Cake, punch, new ID badges with Hygiene Specialist listed as well as Hygiene Specialist pins and certificates were provided. HAI occurrences have continued to decrease over the past six years (see figure 5).
EVS staff members play an important role in patient safety. EVS staff members deserve the opportunity to be acknowledged, educated, and recognized for their contribution in patient safety. Without competent EVS staff members there would be an overwhelming increase in HAIs. The interventions discussed in this article have proven to reduce HAIs as demonstrated in figure 5. EVS staff member empowerment, knowledge and dedication are key aspects in patient-centered care.
Teresa Daniels, MSN, RN, CIC, is currently the market director of infection prevention for Central Kentucky, East. She is an active member of LifePoint Health’s Infection Prevention Advisory Board. Daniels has practiced as a registered nurse for more than 20 years in many different areas of nursing which include legal nurse consultant, wound care consultant, emergency department, home health, and various inpatient specialty departments. She is also a professor at Eastern Kentucky University, where she facilitates courses focused on community health nursing, nurse leadership, and complex health.
1. HICPAC. Guidelines for Environmental Infection Control in Health-Care Facilities. Morbidity and Mortality Weekly Report, 52(RR10), 1-42. June 6, 2003.
2. Centers for Disease Control and Prevention (CDC). FAQs. Retrieved from: https://www.cdc.gov/mrsa/pdf/shea-mrsa_tagged.pdf
3. Centers for Disease Control and Prevention. CDC Environmental Checklist for Monitoring Terminal Cleaning. Retrieved from: HAI toolkits: https://www.cdc.gov/HAI/toolkits/Environmental-Cleaning-Checklist-10-6-2010.pdf
4. San Diego Business Wire. March 4, 2013. UMF Corporation’s PerfectCLEAN® OR Program Awarded AORN Seal of Recognition. Retrieved from: http://www.enhancedonlinenews.com/portal/site/eon/permalink/?ndmViewId=news_view&newsId=20130304005516&newsLang=en&permalinkExtra=AORN-Seal-of-Recognition%E2%84%A2/PerfectCLEAN-%C2%AE-Operating-Room-program/UMF-Corporation