Environmental Cleaning

August 14, 2013

Objectives

• Summarize the literature connecting environmental

cleaning and infection transmission risk

• List the key members to include on an evaluation of EVS

cleaning processes

• Describe the importance of senior leadership support in

improvement efforts

• Describe best practices for environmental cleaning and

monitoring

Environmental Risk • Environmental Contamination

- Contaminated surfaces contribute to transmission risk1

- Patients colonized or infected with resistant organisms

such as MRSA, VRE, and C. difficile shed organisms

into their immediate environment

- Resistant organisms can live in the environment for

weeks to months

3

Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

1) Amer Jour of Inf Control 2013; 41(5): S6-11

Environment and Infection

Transmission Risk

• Studies suggest increased risk of acquisition for

patients in a room where previous occupant was

infected/colonized

- Increased VRE risk if prior room occupant VRE

colonized or VRE colonized occupant in room in

previous 2 weeks1

- Patients more likely to acquire MRSA and VRE when

prior occupant was positive2

• Clostridium difficile spores can survive in the

environment for several months 1) Clin Infect Dis 2008; 46(5):678-85 2) Arch Intern Med 2006; 166(18): 1945-51 3) Clin Infect Dis 1998;26:1027-34

Cleaning Best Practices

• Centers for Disease Control and Prevention

- Guidelines for Environmental Infection Control in

Health-care Facilities

- Guidelines for Disinfection and Sterilization in

Healthcare Facilities

• Associated for the Healthcare Environment

• Association for peri-Operative Nurses (AORN)

• Canadian Provincial Infectious Diseases

Advisory Committee (PIDAC)

5

Hospital Impact

• Regulatory - Joint Commission and CMS focus on cleaning

standards

• Patient experience - HCAHPS (Hospital Consumer Assessment of

Healthcare Providers and Systems) scores

• Financial - Reduced reimbursement for hospital acquired

infections and patient experience

• Public reporting - Certain hospital acquired infection rates

6

Partnership

Infection Control

Focus on C-Diff

Reduction

Infection Control

• Focus on C-Diff Reduction

Environmental Services

• Focus on patient experience scores for cleanliness

Allina Health Project

• Recognized gaps/variation in environmental

cleaning polices across 11 hospitals

- HCAHPS scores not at desired goal

- C. difficile infection rates increasing

• Core group formed to conduct assessment of

current process and gap analysis

- Operations Director

- Environmental Services managers

- Infection Preventionists

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Project Plan

• Conduct gap analysis

• Establish a planning team - IP

- EVS

- Operations

- Education

- Performance Improvement

• Create Allina Health standard

• Identify barriers

• Present Business Case to Senior Leaders

9

What We Did

Step 1- Customer Service and EVS Role Training

We trained over 400 EVS employees in all eleven

hospitals on the expectation and perception of the

patient, their individual role and responsibility in

the reduction of HAI’s and the role of the EVS

Aide as part of the care team.

“Not JUST a janitor anymore”

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What We Did

Step 2- Created a comprehensive four hour

instructor led classroom training program. Three hours

classroom one hour hands on demonstration in patient room.

Curriculum Included: Infection Control Concepts

Basic cleaning and disinfection techniques

Chemical utilization

High Touch Surfaces

Room Zoning

Isolation and Special Cleaning Procedures

Personal Protective Devices

Equipment Cleaning Procedures

Quality Control Guidelines

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What We Did

Step 3- Created an Allina EVS Certification

Program for employees who successfully

completed the program

Certification Awarded when the employee:

Completed four hour class room training

Successfully passed written post tests

Successfully pass a supervised return

demonstration of cleaning an occupied daily

room and a discharge patient room.

Successfully pass two unannounced UV-

Gel/Black light test.

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What We Did

Competency Statement:

Performs patient room cleaning using

standardized process, tools and chemicals in

order to create a clean and disinfected

environment for the safety of our patients.

Senior leaders recognized EVS staff for successful

completion of certification program

- Personal letter sent to their home

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Presenter Name and Title

presents

United Hospital Environmental

Services Certification to

Employee Name for

2012 Allina Environmental Services Patient

Room Protocol Training

August 7, 2013

Allina Hospitals & Clinics

1. Disinfect bed with minimum of one patient room(color) rag.

2. Starting back at the door, use a fresh(color) rag, begin disinfecting the rest of Patient

Room in a clockwise path. Change rags as needed to assure proper saturation and avoid

cross contamination(approximately 3-4 rags).

3. Using 2-3 bathroom(color) rags, disinfect the restroom and always finish with the

toilet.

Allina Standard Room Cleaning Procedure

Room Cleaning Focus

• Consistent process used every time.

- Start with the bed every time

• Focus on high touch areas

• Standardization of chemicals and tools

• Importance of saturation and kill time

• Separate color rags for cleaning in patient room

and bathroom

• High touch surfaces

• Use of UV Gel-Black light Testing for QA

Evaluated Current Products

• Inventory of all chemicals and standardization

• Cleaning tools

- String mops

- Cotton rags

• EVS carts

17

Evaluated Current Practice and

Procedures

• Daily cleaning

- Scope

- Process

• Terminal cleaning

- Scope

- Process

• Isolation vs. Standard Room Cleaning

• Employee education/knowledge gaps

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Research Best

Practices/Products

• Microfiber cloth and mop literature reviews

• Cleaning chemical assessment and use (water

pH, chemical testing for residual)

• Room cleaning procedures and processes

• End user evaluation and feedback

• Evaluation of cleaning

- Process

- Effectiveness

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Outcome

• Standardized daily and terminal room cleaning procedure

• Recommendation to change to microfiber cleaning cloths and mops

• Standardized cleaning carts and organization of materials on cart

• Developed educational material and standardized training

• Implemented cleaning process and effectiveness evaluation

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UV fluorescent gel

After patient is discharged, 18 highly touched

surfaces are marked with a gel that fluoresces

when exposed to ultraviolet light

Results

22

66.5

69.46

70.71

72.04

65

66

67

68

69

70

71

72

73

2010 2011 2012 2013-YTD

Allina System Wide HCAHPS "top box" Room Cleanliness

“How often were your room and bathroom kept clean?”

Sites include: ANW, Buffalo, Cambridge, Mercy, New Ulm, Owatonna, River Falls, PEI, St. Francis, United and Unity

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90.6%

88.0%

88.7%

95.6%

96.2%

82.9%

96.0%

89.5%

94.7%

82.8%

89.0%

90.2%

94.4%

92.1%

94.5%

94.2%

0.0% 50.0% 100.0%

High Touch Surface Passing Rate

Toilet Seat

Toilet Flush

Bath Sink

Toilet HandRails

Bath Door

Bath Lt Switch

Rm Sink

Bedside Table

Pt Chair

Tray Table

Keyboard

Telephone

Call Box

Rm Lt Switch

Rm Door

Bed Rail

0

2

4

6

8

10

12

2010 2011 2012 2013 (Jan-June)

Clostridium difficile Rate

C. difficile Rate

25

Key Learnings

• EVS staff must be partners in the process and

understand their role in infection prevention

• Immediate feedback on thoroughness of

cleaning improves performance

• Process is more important than product

• Right tools

• Leadership support is essential

• Consistency improves employee satisfaction,

infection rates, and patient satisfaction

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Monitoring and Assessment

• Infection Prevention

- Fluorescent marking- evaluates cleaning process

- ATP monitoring- evaluates cleaning effectiveness

• After 80% success rate for UV monitoring

• Phase 2- Bringing non-EVS staff into the project

- Developed assessment of all items in a patient room

and unit – assigned responsibility for cleaning

- Procedural area cleaning standardization (OR, ED,

Radiology, Ambulatory Care)

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ATP Monitoring

ATP

- Measured in Relative Light Units (RLU)

- < 250 RLU = PASS

- 251-500 = INTERMEDIATE (CAUTION)

- > 501 = FAIL

- Measurement of organic material, not specific to

microorganisms

Alternative Room Disinfection

Technologies

• Help reduce environmental contamination after

terminal room clean and disinfection with

germicide

- Ultraviolet irradiation

- Hydrogen peroxide vapor

- Silver-ion water

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Ultraviolet Irradiation

• Numerous products on the market

• Effective disinfection of room surfaces and equipment, including C.diff spores

• No residual health effects

• Does not deteriorate surfaces

• High capital equipment costs

• Cleaning still must precede disinfection

• Need to move furniture and UV equipment during cycle

• No studies of impact on Hospital-acquired infections

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UV-C Published Studies

• Studies done by leading experts in hospital

cleaning and disinfection (Rutala, Weber, and

Boyce) show that using UV technology in

conjunction with routine cleaning eliminates

bacteria (both vegetative and spores) on

contaminated surfaces.

Hydrogen Peroxide Vapor

• Effective disinfection of room surfaces and equipment, including C.diff spores

• No residual health effects

• Uniform, automated dispersal of HPV

• HVAC system must be disabled and door gaps sealed with tape

• High capital equipment costs

• Cleaning still must precede disinfection

• Requires 2.5-5 hours per cycle

• Studies support reduction of HAI

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Summary • Environmental contamination contributes to

transmission of HAI

• Collaboration between EVS and IP is essential for process improvement

• Senior leadership support needed for successful implementation

• Standardization of process, products, and tools builds consistency

• On-going monitoring of performance provides Quality Assurance

• Alternate technologies available to augment manual cleaning processes if HAI rates not decreasing

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Thank you

Team Members:

• Laurie McPhee

• Aaron Freeberg

• Ben Pries

• Mike John

• Michael Roberson

• Steven Sandeen

• Mary Braulick

• Jeff Louks

• Thomas Paquette

• Kim Ober

• Jimly Harris

• Cindy Larson

• Mike Wenzel

• Kim Sorbel

• Jessica Nerby

• Thomas Paquette

• Sue Erdman

• Megan Steil

• Colleen Andrews

• Don Petersen

• Amy Rasmussen

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