Arianny Gomez, lead environmental services technician at Montefiore Nyack Hospital, performs electrostatic disinfection following the two-step cleaning process for a discharge room.
Image by Jose Dominguez
The COVID-19 pandemic has presented many challenges for environmental services (EVS) departments. However, the role of the EVS technician has been highlighted and recognized now more than ever before, demonstrating their front-line responsibilities for infection prevention and the important place they have on the patient care team.
EVS technicians performed their life-saving work on the front lines at Montefiore Nyack Hospital in Nyack, N.Y., under extreme circumstances, demonstrating resilience, agility and professionalism.
Unlike anything before
It quickly became apparent that this pandemic was unlike anything before in the hospital, demanding knowledge-sharing and timely decisions to gain trust. Initial meetings were scheduled around the clock to keep EVS staff informed of Centers for Disease Control and Prevention (CDC) and Association for the Health Care Environment (AHE) updates, system processes and facility adjustments to the rapid escalation of the surge.
EVS staff members were frightened, and some were discouraged by friends from working in this environment; anxiety was high, making the routine seem insurmountable. In fact, employee assistance was contacted to help manage the emotional support needed to assist staff coming to terms with working during the pandemic.
But the EVS staff battled through this with tremendous grit and determination, and the department created a “wall of warriors” photo display with over 70 images of some of the staff during this time. They were being put in a difficult position, which included their families not wanting them to come to work, fearing what they may bring home, while at the same time being overwhelmed with what they were seeing at work.
Daily collaboration with the facility’s infection prevention and procurement professionals was instrumental in staying prepared and adjusting as needed. During the crisis, obtaining personal protective equipment (PPE), hand-hygiene supplies and some disinfectant products became difficult, as demand outpaced supply. Additionally, equipment that was out for repair would not return for months because of businesses closed in quarantine. Hospital employees found vendors that have always described themselves as “partners” unavailable, unwilling or unable to provide support in critical moments.
The hospital census increased by 50% capacity. Several areas of the hospital were converted into intensive care units, and daily cleaning and waste volumes were exacerbated by the great number of isolation rooms. This became even more difficult when the contracted service that manages sharps would not service isolation rooms, putting a greater demand on an already stretched staff.
Although some outpatient areas were not operational, staff members were still challenged, and contracted staffing was used to supplement them as COVID-19-related absences increased at a time when demand for service increases were requested. The EVS department continued their emphasis on infection prevention while working 24/7 to provide assurance to hospital staff that they were in a safe environment so they could continue to provide patient care without worrying about environmental contamination.
COVID-19 recovery plan
A recovery plan was developed at the apex of the surge to enable a smooth transition to routine operations once the opportunity became available. It would be implemented as follows:
General scope of EVS recovery. The EVS department will return the facility to a clean, sanitary and safe environment in support of exceptional patient care. The first 30 days of implementation will be critical to “reset” the facility to standard operations. Decontamination of all inpatient rooms will require collaboration to make rooms available and allow for proper disinfection processes to be completed. Key areas of focus for EVS recovery include:
- Employing principles and best practices by establishing staffing requirements and controlling supply and equipment expenditures during the recovery process.
- Maintaining staff compliance for exhibiting the hospital’s “WE CARE Standards” and maintaining engagement with each department to enhance the quality of service provided throughout the facility.
- Contributing to the professional growth of each staff member through continuous education, training and competency verifications to meet standards of clean.
- Meeting or exceeding all AHE, CDC, Joint Commission, Environmental Protection Agency, National Fire Protection Association, Occupational Safety and Health Administration, Association of periOperative Registered Nurses, New York State Department of Health, New York State Department of Environmental Conservation, and similar regulations, guidelines and recommendations.
- Providing environmental infection prevention and control by utilizing best practices for cleaning and disinfection.
- Performing terminal cleaning and performance of hydrogen peroxide fogging of all patient rooms. When COVID-19 admissions decline to a level where cohorting can be maintained on individual units, some inpatient units will be designated as non-COVID-19.
- Terminal cleaning and electrostatic disinfection (sporicidal) of perioperative areas, procedure rooms and equipment.
- Instituting high-touch focus and increased service once visitor restrictions were rescinded in public restrooms, main lobby, lobbies and waiting areas; and on seating, elevator buttons and handrails (including stairwells).
- Cleaning and disinfecting surfaces of fixed and movable medical equipment, patient transport devices and lifts.
- Terminally cleaning and disinfecting clinical care areas to enable resumption of routine, daily cleaning services.
- Performing daily, routine, preventive, corrective and maintenance care of carpeted and hard-surface floors.
- Maintaining waste management processes within the facility to include municipal solid waste, regulated medical waste, hazardous waste and recyclables.
- Outlining staffing and timelines for patient rooms, public spaces, sterile environments and corridors as well as the emergency department and cancer center.
- Maintaining linen and patient transport department services.
- Reviewing procedures for cleaning over floor graphics and directional/distancing graphics.
- Confirming placement of cough stations and portable hand sanitizer stands with infection prevention.
Staffing decisions. Staffing level will be determined by a specific staffing process, based on fixed and variable factors, including cleanable square footage, density, census and special needs. Key areas of focus for staffing include:
- EVS will collaborate with hospital departments working in a given area to determine special needs and access scheduling as needed.
- EVS staff is scheduled 24 hours a day, seven days a week to provide for the department’s mission and scope of services. The initial recovery efforts will be scheduled five days per week to provide for maximum supervision and support. When necessary, part-time employees will be scheduled to cover unforeseen shortages of staff. Overtime will meet terms of the collective bargaining agreement. In addition to Montefiore Nyack EVS staff, contracted staffing will be used to expedite the facility recovery process.
Budget considerations. Supply, equipment, capital and labor costs will be reconciled with the budget and responsibility report justification to isolate COVID-19 recovery-related expenses. Key areas of focus for budgeting include:
- Schedules and assignments will be reviewed and adjusted for accuracy as needed.
- Variable activities when identified will be trended and compared for continuity.
- Additions to and reductions of the physical plant that change the cleanable square footage will be taken into consideration.
- Miscellaneous, unforeseen changes in the scope of service will be adjusted as needed.
Enhanced cleaning processes
COVID-19 adjustments to EVS processes were implemented once the surge subsided to a level allowing for routine cleaning and disinfection to be scheduled. Enhanced cleaning was scheduled with adjustments to consider the more aggressive approach taken in response to the pandemic. A third (adjunct) step of electrostatic disinfection then followed the CDC-recommended, two-step process for cleaning and disinfection in many areas.
Safety considerations were implemented requiring all EVS assignments to properly don and doff PPE, be fit-tested and wear N95 respirator masks (no beards permitted with N95 use), and use eye protection when within 6 feet of patients.
The enhanced processes include implementing a five- to 10-minute reentry for areas receiving the electrostatic disinfection to limit exposure concerns. Of significance is the between-case cleaning and disinfection in the operating and labor-and-delivery birthing rooms. The two-step cleaning process is followed by the third step with an expectation of the entire process taking 25 minutes. Terminal cleaning in perioperative procedure rooms (e.g., operating rooms and endoscopy) include the third step with a 10-minute reentry.
Inpatient discharge rooms receive the two-step cleaning process followed by the third adjunct step of electrostatic disinfection using quaternary ammonium compound disinfectant. Hydrogen peroxide disinfection also is used to provide an additional step for C. difficile and C. auris. This requires a one-hour reentry time.
Dialysis units receive a two-step cleaning process followed by third-step electrostatic with a sporicidal and a 10-minute reentry. The hematology/oncology two-step cleaning process will be followed by third-step electrostatic quaternary ammonium compound.
Cancer center treatment and exam rooms use a two-step cleaning process, followed by third-step electrostatic quaternary ammonium compound.
In other spaces, the following routines were implemented:
- Dressing rooms are cleaned and disinfected after patient visits and routinely scheduled every day.
- Waiting rooms and stairwells are cleaned and disinfected each day.
- Public restrooms and elevators are scheduled to be cleaned and disinfected frequently throughout each day.
- Meeting rooms are cleaned and disinfected each day and also between meetings and trainings as required.
- The cafeteria is cleaned and disinfected each day and supported with adjunct electrostatic disinfection scheduled twice weekly.
As the EVS department transitions to post-pandemic health care, there are three distinct areas to consider when creating and transitioning to a new way of service delivery for EVS.
First, attracting and recruiting staffing for health care environments as emerging pathogens develop, and repairing the damaged spirit of existing health care staff for retention may continue to be difficult. The EVS department was overwhelmed and outmatched for the rapid ascension of the wave that hit. The hospital’s EVS staff observed absolute horror surrounded by grief, sadness and a helplessness that is indescribable. Many are dealing with personal loss and loss of co-workers to this disease. Without resolving these concerns, moving forward will be difficult.
The second is operationally from a high-level view and involves clinical adjustments that will drive change for work flows and processes. Will dedicated off-site practices be put in place to isolate infectious or “patient under investigation” patients, further reducing hospital inpatient census and revenues? Will the next emerging pathogen garner the same level of attention, or will the results from COVID-19 elicit a response that is indifferent or subject to selective amnesia?
On a more granular level, EVS must maintain greater visibility to ensure patients, families and staff that the environment of care is receiving aggressive cleaning and disinfection routinely. Also, controls should be in place to mitigate safety concerns (e.g., a redesigned operating room to accommodate and isolate COVID-19-positive patients, keeping them separate from others in pre-admission testing and post-anesthesia care units, and providing dedicated clinical and EVS staff for COVID-19-positive and -negative areas).
Likewise, there is no more self-serve food and beverage. The facility also has added plexiglass barriers, distance markers and signage for social distancing. Additionally, New York’s governor mandated a 90-day supply of PPE in preparation for flu/COVID-19 surges, and the department has placed added cleaning supplies into storage for additional surge capacity.
Third is supporting and assisting affiliates, medical practices and communities by providing guidance to achieve continuity of practices with cleaning and disinfection best practices across the health care and public safety spectrum. This includes contributing to a podcast on “Radio MD” and working with community and local government agencies, physician offices and even a local barber to provide education and guidance for maintaining safety in their places of business. In fact, a short guide was prepared for these businesses, and the EVS department continues to field questions and provide solutions for various community entities.
Finally, the importance of EVS professionals maintaining a relationship and employing support from AHE will be essential to success and being prepared for the next disruption of normal.
Tom Mattice, CHESP, CMIP, T-CHEST, is the director of environmental services at Montefiore Nyack Hospital in New York. He can be reached at firstname.lastname@example.org.