The Vital Role of the EVS Worker on the Patient Safety Team David P. Calfee, MD, MS October 19, 2017 1
What is your main job activity? A. Frontline EVS worker (i.e., housekeeper) B. EVS manager, supervisor, or director C. Infection preventionist or hospital epidemiologist D. Other
Where do you work? A. Hospital B. Long-term care facility (nursing home) C. Outpatient facility (clinic) D. Other
Do you consider yourself to be a member of the infection prevention and patient safety team at your facility? A.Yes B.No
By the end of this presentation, I want you to believe 3 things. 1. The environment is an important source of germ transmission in health care facilities. 2. Effective cleaning and disinfection of the environment can prevent germ transmission and infection among patients. 3. YOU play an important role in preventing infections in patients admitted to your facility.
The environment is an important source of germ transmission in health care facilities.
The hospital environment is frequently contaminated with germs. Germ: Acinetobacter Occupied hospital room Non-contaminated hospital room Contaminated hospital room
The hospital environment is frequently contaminated with germs. Germ: MRSA Germ: Acinetobacter 42% Non-contaminated hospital room Contaminated hospital room
The hospital environment is frequently contaminated with germs. Germ: Acinetobacter Germ: MRSA Germ: C. difficile (C dif) 42% 73% Non-contaminated hospital room Contaminated hospital room
The hospital environment is frequently contaminated with germs. Germ: Acinetobacter Germ: MRSA Germ: C. difficile (C dif) 42% 73% 100% Non-contaminated hospital room Contaminated hospital room
Germs are frequently found in the hospital environment after cleaning. After daily cleaning Occupied hospital room Non-contaminated hospital room Contaminated hospital room
Germs are frequently found in the hospital environment after cleaning. After daily cleaning 34% After discharge cleaning Non-contaminated hospital room Contaminated hospital room Shams AM. Infect Control Hosp Epidemiol 2016; 37: 1426
Germs are frequently found in the hospital environment after cleaning. After daily cleaning 34% After discharge cleaning 18% Non-contaminated hospital room Contaminated hospital room Shams AM. Infect Control Hosp Epidemiol 2016; 37: 1426
Environmental contamination leads to contamination of healthcare workers’ hands. Hands on bedrail and over-bed table for 5 seconds Bhalla A. Infect Control Hosp Epidemiol 2004;25:164-7.
Hand contamination after contact with the environment: OCCUPIED ROOMS 53% Bhalla A. Infect Control Hosp Epidemiol 2004;25:164-7.
Hand contamination after contact with the environment: VACANT ROOMS 24% Bhalla A. Infect Control Hosp Epidemiol 2004;25:164-7.
1 out of 2 high-touch surfaces in hospital rooms is not cleaned at discharge. 14 High-Touch Surfaces, 36 hospitals 52% Not Cleaned Cleaned (48%) Carling PC. Infect Control Hosp Epidemiol 2008;29:1035-41
Many pathogens can survive in the environment for long periods of time. Organism Duration of Survival Acinetobacter sp. 3 days-5 months Clostridium difficile spores 5 months E. coli 1.5 hours-16 months Enterococcus (e.g., VRE ) 5 days-4 months Klebsiella sp. 2 hours->30 months Proteus vulgaris 1-2 days Pseudomonas aeruginosa 6 hours-16 months Serratia marcescens 3 days-2 months S. aureus (including MRSA ) 7 days-7 months Kramer A. BMC Infect Dis 2006;6:130
C. difficile is one of the top 3 antibiotic resistance threats in the U.S. https://www.cdc.gov/drugresistance/threat-report-2013/
Environmental contamination can lead to patient infections. Did the last occupant of the hospital room have C. difficile infection? No Yes 1 in 25 patients gets 3 in 25 patients get C. difficile C. difficile A similar risk occurs with MRSA and other germs. Shaughnessy MK. Infect Control Hosp Epidemiol 2011;32:201-6
Environmental contamination can lead to patient infections. 1 out of every 5 hospital patients with C. difficile infection was infected by another hospital patient’s germs. Eyre DW. Clin Infect Dis 2017;65:433-441
Effective cleaning and disinfection of the environment can prevent germ transmission and infection among patients.
Proper cleaning and disinfection prevents infections and deaths. Fewer germs on surfaces Fewer germs on patients and health care workers Fewer infections
Improvements in cleaning and disinfection can prevent infections. MRSA infections in ICU patients Before discharge cleaning was improved: 305 infections After discharge cleaning was improved: - 182 infections _________________ 123 infections prevented! Datta R. Arch Intern Med. 2011; 171 (6): 491-494.
Is this room as clean and safe as it can be?
How do we know an elephant is an elephant?
How do we know if our health care facilities are optimally clean? Patient Visual surveys Policies, appearance products (HCAHPS scores) Adherence Objective Patient to policies and assessment outcomes protocols
“Every system is perfectly designed to get the results it gets.” - Paul Batalden, MD
Are we doing all that we can to make our hospitals and nursing homes clean and safe?
Do you think that there is room for improvement in cleaning and disinfection at your facility? A.Yes B.No
Maintaining a clean and safe environment is a very complex process. Detergent Other complicating factors Elbow Contact • Must be done frequently grease time • Occupied spaces • Differing expectations Teamwork • Competing priorities • Human behavior Disinfectant Communication Avoiding recontamination
Why do we do what we do? Why don’t we do what we don’t do? Attitude Behavior Do we think we What is “ok” can do it?
Why do we do what we do? Why don’t we do what we don’t do? Attitude Acceptance/awareness of responsibility Impact on patient outcomes Impact on the worker Behavior What is “ok?” Do we think we can do it?
Why do we do what we do? Why don’t we do what we don’t do? Attitude Behavior What is “ok?” Expectations of supervisor, colleagues Do we think we can do it? Institutional culture Feedback
Why do we do what we do? Why don’t we do what we don’t do? Attitude Behavior Do we think we can do it? Training/skills What is “ok?” Time, workflow barriers Tools, equipment, supplies
We need to identify, understand and eliminate barriers that prevent us from doing the right thing, EVERY TIME. Opportunities for education • Expectations and technique • Personal safety concerns (cleaning products, patients) • Role of the environment in infection transmission and infection prevention strategies Desire/need for constructive feedback Workflow barriers • Pushback from patients and residents • Clutter • Interruptions • Lack of clarity regarding cleaning responsibilities Culture • Lack of appreciation and respect • Concern about disturbing patients
Do you feel that you’ve been properly trained to perform your job effectively? A. Yes B. No
Do you get enough useful feedback about your quality of you work? A.Yes B.No
What is your biggest challenge during DAILY cleaning of patient rooms? A. Getting the necessary supplies B. Concern about your own safety (exposure to chemicals, patients) C. Clutter in the patient’s room D.Patients refuse to have their room cleaned E. Something else
What is your biggest challenge during DISCHARGE cleaning of patient rooms? A. Not enough time B. Interruptions C.Concern about your own safety (exposure to chemicals, patients) D.Uncertainty about what EVS cleans and what others clean E. Something else
Make interventions that address facility- specific needs. Optimize job-specific training • Topics: technique, protocols, expectations • Methods: hands-on training, return demonstration, assessment of competency Provide constructive feedback Educate • Rationale for and importance of the work Eliminate/reduce barriers • Make supplies available and easy to use • Provide communication tools and skills: patient refusals, clutter Enhance relationships • Intradepartmental • Interdepartmental
We can make a difference. Higher is better Ray AJ. Infect Control Hosp Epidemiol 2017;38:777-783
We can make a difference. Daily Cleaning Improvement Initiative 100% 90% 80% 70% Toilet Seat Items Clean (%) 60% Toilet Flush 50% Overbed Table Bed Rail 40% Call Bell/Remote 30% Visitor Chair 20% 10% 0% Before After Martin E. IDWeek 2017. San Diego CA. Abstract 501
Improvements in cleaning and disinfection can prevent infections. After Before 50 45 40 C difficile Infection Rate 85% 35 Lower 30 is lower better 25 20 15 10 5 0 Orenstein R. Infect Control Hosp Epidemiol 2011;32:1137-9
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