An environmental services associate terminal cleans a COVID-19 isolation room during the New York City pandemic surge.

Image courtesy of Crothall Healthcare

The pandemic has presented environmental services (EVS) teams with a unique opportunity to demonstrate their value and have a major impact on safety in hospitals across the country. 

In many ways, EVS departments are the protectors of these institutions. They’ve been working around the clock to give administrators, medical staff and patients a safe workplace. In many cases, these teams can clean and disinfect hundreds of patient rooms every day in a single hospital.

Hospitals must be a safe place to heal, visit and work. To ensure that this is the case, and using learnings from COVID-19, EVS managers need to review their current programs and consider measures to improve operations.

It begins with a holistic program that consists of five pillars of infection prevention. These pillars have proven to be the most effective way to reduce health care-associated infections (HAIs) over the past decade and are especially crucial while fighting the spread of the coronavirus.

But the pandemic has required an even higher level of action. During the past year, the five pillars strategy has been expanded to meet the areas of greatest infection risk. Additional technologies and protocols have been employed. Areas to be regularly disinfected have expanded beyond patient rooms and clinical spaces. And a broader spectrum of cleaning products has been leveraged to thwart pathogens and reduce the infection risk.

This proactive approach can effectively reduce potential risks in the health care environment. This article dives deeper into the five pillars and how they can be implemented into EVS operations.

The five pillars

The five pillars are built on 25 years of experience, as well as data collected and verified from researchers, product manufacturers and hospitals. Working together, the pillars have proven to mitigate infection transmission throughout a hospital, ranging from high-touch patient surfaces to food trays, biomedical equipment and wheelchairs. The goal is to improve patient safety and outcomes.

1. Hand hygiene. Nearly every American now knows they should wash their hands for 20 seconds to ensure they are properly disinfected. This routine is especially crucial — even life-saving — in a hospital. According to the Centers for Disease Control and Prevention (CDC), the majority of infections in a hospital are spread via hands. One study estimates that 20% to 40% of HAIs have been attributed to transmission by the hands of health care personnel.

Patients are the prime source for spreading these pathogens. Surfaces that are frequently touched by patients and health care personnel — like side rails, bedside tables and bathroom surfaces — become prime targets for contamination. 

While gloves can prevent hand contamination, they don’t provide an absolute barrier. Unfortunately, the CDC notes that health care personnel sometimes don’t practice proper hand hygiene. 

The CDC has clear recommendations about when hand hygiene should be performed. At a minimum, it needs to happen before entering and leaving a patient’s room. While this practice seems simple enough, thousands of new EVS employees enter the workforce each year, including many who have never worked in a health care facility. This makes employee education about proper hand hygiene crucial during the onboarding process. 

At some cleaning provider companies, each new employee must watch a video and pass a test about the science of hand hygiene, correct gloving technique and the importance of high-touch surface cleanliness. And before cleaning patient rooms, they are paired with a seasoned EVS associate to observe when and how often to wash their hands. 

The importance of overemphasizing proper hand hygiene cannot be overlooked during the onboarding process and must be continually reinforced in trainings for all EVS personnel, both new and veteran.

The intense focus on keeping clean hands could be seen at hospitals around the country. For example, hand sanitizer use skyrocketed last year at NYC Health + Hospitals, a network of hospitals in New York City. Between the second and fourth quarter of 2020, the amount of hand sanitizer rose by nearly 90% at NYC Health + Hospitals’ Kings County Hospital Center and approximately 130% at Elmhurst, another system hospital.

The increase was spurred by the addition of new hand sanitizing stations throughout the hospital system, intense training and education of EVS associates, and more frequent disinfecting throughout the facilities. As a result, the system’s HCAHPS cleanliness score jumped 9.5% between the second and third quarters.

2. Standard processes for people and protocols. Employees need to follow a standardized and detailed cleaning and disinfection process every time they clean a patient room. The process needs to be methodical and reproducible day in and day out. A good practice is a high-profile patient room cleaning protocol that increases frequency of disinfections and focuses on disinfecting all high-touch surfaces, including all areas of the patient’s bathroom as well as less obvious spaces, like the inside and outside of waste bins. 

COVID-19 has also provided the opportunity to look at the effectiveness of new products and technologies. At night, when fewer people are in the hospital, electrostatic sprayers are used to cover all surfaces in public areas. Additionally, air purification systems are used to scrub the air in enclosed spaces, mitigating aerosolized droplets from coughing and sneezing. These machines are essentially an air filtration system, drawing in the air and processing it through a high-efficiency particulate air (HEPA) filter and UV light.

To inform the public about additional measures and to give them peace of mind, many hospitals have posted signs in waiting rooms and other areas to let visitors know about the increased level of disinfection. The broadening of protocols — and making sure those in the hospital are aware of the enhanced approach to cleaning — reassures visitors, patients and medical staff that the building is safe.

3. New ways to measure surfaces. On top of the enhanced cleaning and disinfecting, it is important to accurately measure if a surface is clean. More accurate and effective tools to analyze surface cleanliness have emerged during the pandemic.

Tools that detect adenosine triphosphate (ATP), the universal unit of energy in all living cells, can tell instantly whether surfaces are truly clean and safe. This verification ensures the room is safe for the current or next patient to occupy. 

One ATP verification product begins disinfecting in only 15 seconds, providing EVS departments and hospitals with an affordable, easy-to-use method for verification of surface cleanliness. This product’s performance can be aligned with an EVS department’s software, allowing users to know immediately if surfaces have been properly disinfected. By entering the ATP measurements into the software, problem areas can be quickly remediated.

Over time, benchmarks and trends for cleaning thoroughness results can be established and reports on the cleanliness and safety of patient rooms can be generated for hospital committees, record keeping and employee evaluations.

Other tools help keep high-touch surfaces cleaner for longer. For example, one product only needs to be applied once every 30 days to provide optimal protection on all surfaces. With just one application, it will prevent harmful pathogens from attaching to surfaces between treatments.

Multiple studies conducted at MedStar Georgetown University Hospital in Washington, D.C., and other hospitals link the use of ATP verification systems to reduced infection rates. This research shows that implementing a monitoring program immediately improves compliance to cleaning procedures, resulting in a cleaner hospital. This correlates directly with decreased HAI rates and improved patient experiences as reported in HCAHPS scores.

EVS and infection prevention and control teams need quick results to verify a room is clean, turn beds over faster and collect quantifiable data for meaningful analysis. While many new products work well and help achieve these goals, EVS managers also need to realize that some do not. For example, blacklight detection of fluorescent gels is an excellent training tool but fails to measure the actual removal of biological matter. And while microbiology testing gives the most quantitative, specific results for pathogens or bacteria on a surface, its results are slow and tests are expensive. 

4. New technologies, innovations and solutions. New technology is providing EVS managers with more options than ever before to keep hospitals safe. As they’ve cleaned more frequently and widened the spaces disinfected during the pandemic, more solutions are still needed. It is crucial for EVS organizations to work closely with product manufacturers to find the right solution for a health care organization. 

Here are three different solutions that have been clinically validated to mitigate infectious transmission of disease:

• Ultraviolet light (UV-C) technology. Often used to augment cleaning of operating rooms before the pandemic, the use of UV-C technology has been expanded to augment cleaning of public areas like restrooms and medical offices.

UV-C technology is effective because it has multiple emitters. This process allows the disinfection of all areas of the health care environment in a single cycle. With three emitters operating simultaneously, no exposed surface is left untouched. This results in a more efficient delivery of energy, a faster room turnaround time and optimal room disinfection. This leads to the destruction of C. difficile spores, MRSA and other multidrug-resistant organisms.

The use of UV-C technology has driven favorable outcomes for many health care systems. For example, MedStar Health, which operates 10 hospitals in Baltimore and Washington, D.C., uses this technology in all 10 hospitals as part of its “culture of cleanliness” initiative. As a result, C. difficile rates dropped across the system, with a 59% reduction in just three years.

• Electrostatic applications. A one-step disinfectant cleaner can be applied electrostatically with the ability to reach all surfaces typically encountered in the health care environment. No rinsing or wiping is required, and patient rooms can be quickly reoccupied.

At a 13-hospital system in North Carolina, an electrostatic spray application protocol system was implemented in addition to terminal discharge cleaning and disinfection protocols. While still early in the data collection process, the systemwide C. difficile cases decreased by 60% during a one-year period. 

It’s important to note that electrostatic sprayers must be in the disinfectant manufacturer’s instructions for use.

• Mobile air purification systems. The use of mobile air purification systems has become more common because they remove bacteria, virus, mold, particulates and odor from the air through the use of continuous UV, HEPA filtration and a carbon odor management system. This technology captures airborne pathogens in large volumes of fast-moving air, holding pathogens close enough and long enough for total UV-C eradication.

5. Exploring emerging solutions. It’s important to never accept the status quo when it comes to environmental hygiene and patient safety. Instead, emphasize strategic partnerships with manufacturers to test and analyze new cleaning products and access cutting-edge technology.

Some cleaning companies work regularly with major U.S. hospitals and third-party infectious disease and infection prevention and control experts on clinical testing to help identify new solutions. After scientific testing of emerging antimicrobial product technology, the findings are published in peer-review literature.

A few years ago, the ECRI Institute, a nonprofit organization dedicated to patient care, determined bed mattresses to be the second leading spreader of HAIs. After an extensive review and evaluation, a contract cleaning company selected a mattress, bed deck barrier and pillowcase made of a high-tech breathable fabric that blocks fluid, soils and microbes from passing through in either direction. It is applied to a bed immediately before admission and removed immediately after discharge. The decision to switch to these products was made after reviewing existing data, including 29 studies that documented that cleaned/disinfected mattresses are still contaminated after terminal cleaning and 12 studies that documented mattress failures while still in use. 

To continually improve and expand support services, EVS managers must allocate resources for pilot programs and study the results of each new technology or innovation.

Key takeaways

While the pandemic will subside, the significant burden it has placed on hospitals has provided EVS managers with opportunities to explore new solutions to improve safety and cleanliness and to better support the future of patient safety. 

In addition, administrators and medical staff now have a better understanding of the impact EVS managers and their departments can have and the highly integrated role they should play. 

Infection prevention can be accomplished by following a disciplined cleaning and disinfection process, which can be enhanced and expanded during a public health crisis like COVID-19. EVS managers play a pivotal role in ensuring patient and workplace safety, and the five pillars provide a sound foundation for all EVS organizations to accomplish that goal. 

Rich Feczko is director of systems, standards, innovation and global support at Crothall Healthcare, Wayne, Pa. He can be reached at Rich.Feczko@Crothall.com.

Seven ways Mount Sinai kept patients safe during the pandemic

Slightly more than a year ago, New York City was the nation’s COVID-19 epicenter. Working closely with the city’s Mount Sinai Health System, Wayne, Pa.-based Crothall Healthcare’s facilities management team took several important safety measures to help doctors treat patients and save lives. 

There were multiple challenges: finding enough beds for patients; isolating these patients so they didn’t infect others; making sure there was enough oxygen supply; and keeping the Crothall management team safe. Fortunately, everyone was well prepared. Crothall has served the Mount Sinai Health System since 2013 and participated in several emergency planning drills in recent years. Here’s how the teams responded: 

• Converted patient rooms to airborne isolation rooms. In a short period, hundreds of patient rooms were converted into negative-pressure rooms for COVID-19 patients. This process stopped the flow of air under closed doors, preventing airborne particulates from escaping. Windows also were removed; walls were opened; and more than 700 small fans were installed to ensure negative pressure in each room.
• Turned Central Park into a hospital. In Central Park, Mount Sinai assisted with the opening of a field hospital with 14 tents and 68 beds. Crothall helped acquire the tents, secure the building permits and construct the air conditioning system for the tents’ airborne infection isolation units. Crothall also secured and built a liquid oxygen farm and installed the plumbing, water and emergency power. 
• Helped supply oxygen. Treatment of COVID-19 patients placed a significant demand on oxygen supply systems. It heavily taxed bulk and cylinder supplies, which quickly reached their limit. By reaching out to vendors and suppliers to have additional supply systems, the organization had enough supplies to get through the crisis. 
• Split the management teams. With approximately 2,000 COVID-19 patients under the hospital’s care at one point, Crothall split their management into two teams to reduce their exposure. While one group worked its hospital shift, the second team worked remotely to handle all other responsibilities, providing 24/7 support.

Because of these actions, these results were achieved for Mount Sinai:

• More than 500 hospital patient rooms were converted into negative-pressure rooms to treat COVID-19 patients.
• The tent hospital in Central Park significantly increased Mount Sinai’s capacity to patients in need of immediate care.
• Actions taken to expand the oxygen supply systems enabled the hospital system to increase the oxygen delivery rate by five to six times the normal rate.

Sidebar by Chris Hariegel, vice president of Crothall Healthcare’s facilities management service line, Wayne, Pa.