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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
8
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”
10
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
11
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.
12
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
13
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
18
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
19
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
20
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
24
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
26
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)
27
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
29
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
30
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
32
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
33
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
34