A Critical Part of Prevention
By Bill Slezak
December 23, 2013 | Formats: Article | Content Areas: Environmental Sanitation Operations | Tags: Emerging Pathogens, Environmental hygiene and sanitation, Evidence-Based Practice Solutions, Infection Prevention and Epidemiology, Policies
There’s been some news of late that might lead one to believe we’re making advances in the battle against infections associated with healthcare. (1) As the regular reader of EXPLORE knows, there are indeed pockets of progress in the battle.
But, the truth is, preventable healthcare-associated infections (pHAIs) are still a major challenge in this country’s healthcare facilities. For example, there’s finally long-needed updated research available that should be enough to jolt all of us: A report (2) published in the Journal of Medical Economics estimates that HAIs arising in U.S. acute care facilities cost our society as much as $147 billion annually. (3) This new data reveals a more accurate and up-to-date perspective on the extent of the HAIproblem and supports the view of many that HAIs are at epidemic levels.
Clearly, this makes a powerful case for looking beyond the popular single initiatives to full-blown multimodal intervention to prevent HAIs. An aggressive intervention initiative is needed to address this problem as rapidly and completely as possible. Further, there’s never been a stronger and more well-defined need for the role of Environmental Services (EVS) as the First Line of Defense in this initiative. And there are successes that bear this out.
Wash Your Hands, Yes, But…
U.S. hospitals are going to great lengths to make sure doctors, nurses, and staff are washing their hands in an effort to reduce the high rates of HAIs. If you’re running a hospital, there are compelling reasons for these efforts. HAIs can be deadly, but if that fact alone isn’t enough of an incentive, there are countless new federal rules where hospitals will lose reimbursement dollars when patients acquire preventable infections.
While it’s true, there have been some notable hand-hygiene programs of late showing improved compliance rates, there have been reports to the contrary as well. (4)
It’s simply unrealistic to view hand-hygiene programs as a singular solution to reducing the number of HAIs. All the hand washing in the world won’t do a bit of good if clean hands immediately come in contact with contaminated surfaces, such as a cubicle curtain, a bed rail, a chart, or any other hot spot.
As Darrel Hicks, BA, REH, CHESP, has said, “As long as environmental surfaces are inadequately processed, the best hand hygiene program will fail.” Hicks advocates a process of specific, prescribed steps that lead to a clean, safe environment not only for the patient but also for caregivers and family members.
Hicks advocates a process of specific, prescribed steps that lead to a clean, safe environment not only for the patient but also for caregivers and family members.
Do Everything Else, Too
The popularity of hand hygiene can’t be denied. The same can’t be said for multimodal intervention. It’s a little more complicated— beginning with understanding all of its parts.
The story (5) goes, when asked how his particular county in Sweden was achieving pace-setting results in total health-system performance, the chief executive of learning and innovation replied, “Here’s the secret: We do everything!” Realize this and you’ll understand the idea behind multimodal intervention to prevent HAIs.
Discussion of the multimodal approach was ever-present at the Association for the Healthcare Environment (AHE) EXCHANGE 2013 conference earlier this year. For example, Jennie McVey, RN, CIC, spoke of engaging leaders and building stronger alliances to ensure optimal disinfection outcomes; Tim Wiemken, PhD, MPH, CIC, encouraged cultivating collaborative partnerships with EVS, infection prevention, and other healthcare professionals; consultant Mark Heller also made the case for collaboration for “cohesive win/win solutions”; and Amber Wood, MSN, RN, CNOR, CIC, CPN, examined the role of the EVS leader as part of a multidisciplinary team approach to environmental cleaning in the perioperative setting.
The working concepts in these breakout sessions were ones of collaboration, multidiscipline involvement, and the team approach. Whatever one calls it, the only program that has any chance of success in confronting old but still prevalent pathogens, such as Clostridium difficile (C. difficile) and Methicillin-resistant Staphylococcus aureus (MRSA), and the new and quickly spreading HAI challenges such as carbapenem-resistant Enterobacteriaceae (CRE), is an enterprise-wide multimodal intervention program—a program that is supported and heralded from the hospital C-suite to the basement, including effective and comprehensive environmental hygiene.
Include the First Line of Defense
Though once considered healthcare’s lowest-tech activity, every EVS department is the true first line of defense in providing a safe patient environment in reducing pHAIs.
Infection control consultant Nancy Bjerke, BSN, RN, MPH, CIC, has reinforced this notion: “They [EVS teams] are where the action is.6 They witness the environmental infractions, perform the expected sanitation and disinfection practices to reduce reservoirs for potential microbial proliferation, promote safety by their interventions that maintain a clean environment, and decrease occupational exposures with proper use of chemical agents as they interface with the patients which, in turn, affects the facility’s patient satisfaction scores.”
In other words, in the best healthcare settings, C-suites are beginning to grasp the difference EVS can make not only in the lives of patients, but also in a hospital’s reputation and its financial health.
Within these settings the EVS staff member, from a C-suite and clinical perspective, has been recognized as that first line of defense in combating HAIs. He or she has participated in a strategy that includes learning best practices for effective infection prevention, in-service education and training, plus effective hygiene management in patient rooms and all other areas of the hospital. These programs reinforce the significance of combining environmental and hand-hygiene initiatives. They also underscore why infection prevention needs to be an organizational priority.
Because of programs like these, more hospitals are beginning to see decreases in infection rates and increased Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.
EVS Success Stories
When Jewish Hospital-Mercy Health in Cincinnati hit a C. difficile rate of 25.27 per 10,000 patients several years ago, hospital officials swung into action with a number of changes that eventually cut the rate of infection in half over six months.
The changes included standardizing care, adopting stricter antibiotic controls, and incorporating new environmental hygiene, or patient room-cleaning protocols.
“But in all honesty, the changes made to our environmental cleaning practices had the most significant impact of all the changes we made,” said Jenny Martin, manager of quality administration at Jewish Hospital-Mercy Health, in a published report. (7)
Other research, published in April, found that a dedicated EVS staff that adequately cleans and disinfects rooms contaminated by C. difficile using a standardized process can be more effective than other disinfection interventions. (8)
In yet another example, (9) EVS leadership played a significant role in lowering infections and raising HCAHPS scores at Rush-Copley Medical Center in Aurora, Ill. In this case, leadership at the 210-bed Level II trauma center set out in 2010 to improve patient satisfaction. In 2012, the hospital enrolled in the State of Illinois’ Campaign to Eliminate C. difficile, of which environmental cleaning and monitoring is a primary element for success.
This two-pronged initiative has helped Rush-Copley to decrease its C. difficile rates by more than 50 percent, well below the national average. And, the work has resulted in a significant improvement in the hospital’s national HCAHPS percentile ranking for patient satisfaction with room cleanliness, putting Rush-Copley ahead of other local hospitals.
An interesting aspect of the Rush-Copley case is that, as part of its initiative, EVS staff members have been given a role in informing patients and their families of how a thorough cleaning process is protecting them. According to the manager responsible for Hospitality and Environmental Services at Rush-Copley, EVS staff members are instructed on how to enter the patient room, introduce themselves, let patients know they are there to clean and disinfect, that they will use separate color-coded wipers and flat mops for the patient room and the bathroom, and only use them in that one specific room—to prevent the spread of bacteria and eliminate cross-contamination.
The scripting while in the room is very important, the manager said, because the EVS staff member is actively telling the patient how the cleaning is protecting him or her, thereby changing the perception of the cleaning and the sense of room cleanliness. And, one might add, changing the perception and importance of Environmental Services at a critical juncture in the battle against HAIs.
References
- “Hospital Infections Cost U.S. $10 Billion a Year,” Reuters, Sept. 12, 2013.
- “Economic Burden of Healthcare-Associated Infections in U.S. Acute Care Hospitals – Societal Perspective,” Journal of Economics, Sept. 11, 2013.
- By comparison, an earlier report by the Centers for Disease Control and Prevention estimated the direct medical costs of HAIs to U.S. hospitals as $28.4 billion to $33.8 billion per year.
- “Hand Washing Not a Priority for Docs,” Spotlight on Prevention, Nov. 2009.
- Speech, “The Moral Test,” given by Donald M. Berwick, MD, IHI National Forum, Orlando, FL, Dec. 7, 2011.
- “Defining the Qualifications for Proper Environmental Services Operations,” by Nancy B. Bjerke, Health Facilities Management, October 2011.
- “How to Prevent C. diff: Rethinking cleaning’s role in preventing C. diff and other hospital acquired infections,” Healthcare Facilities Today, March 27, 2013.
- “Dedicated Cleaning Staff Shown to Reduce C. difficile Contamination in Hospital Rooms,” Infection Control and Hospital Epidemiology.
- “Improved Environmental Hygiene Lowers Infections and Raises HCAHPS Scores at Rush-Copley,” Case Study, April 25, 2013.