EvSOP: Time for Quality Outcomes

By Aaron Jett

A sticky floor, dirty bathroom, unemptied trashcan, dusty ledge, or missed surface getting wiped -- when you hear about these things, what goes through your thoughts? As your mind races to explain the "why," could one of those reasons perhaps be that the person responsible for cleaning didn't have enough time?

In last month's article in this series, “A Better Way to Understand Your Microbial Jungle: What's in There and How to Know When It's Gone,” authors Paul Pearce and John Scherberger made an insightful comment that goes to the very heart of this article: "EVS teams must have with the knowledge, proper cleaning tools including Healthcare Grade Ultrafine Microfiber© (HGUM©), EPA-registered hospital-grade disinfectants, and sufficient time to incorporate them. All four of these essential factors must be in place."

William Rutala has also consistently said, "Good Products + Good Processes (Training) + Good Processing = Good Patient Outcomes."

This fundamental truth that sufficient time is needed to clean and disinfect properly exists in all areas of our lives, especially in healthcare, and now with the COVID-19 pandemic, we have increased awareness as to the essential need for proper cleaning and disinfection.

If soil, dust, dirt and debris are visible, one can count on what can't be seen there too -- the pathogens that can make us sick within that microbial jungle.

So why devote an entire article to sufficient time to incorporate best practices, tools and training?

There are many reasons why sufficient time to incorporate best practices for cleaning and disinfecting are negatively affected. These may include unexpected increase in census levels, negatively affected staffing levels, call-offs, inaccurate estimation on needed resources, and scope creep as other tasks and areas added without increased headcount. More massive soil areas such as OR, ED, L&D, and inadequate quality tools such as non-healthcare grade ultrafine microfiber are also contributors. Too often, tasking environmental services (EVS) personnel to use disposable wipes designed for clinical staff to address small area spot cleaning impedes their productivity and raises their frustration level due to time constraints. EVS faces complications of processing (cleaning and disinfecting) various pieces of medical equipment, having to choose which two-step disinfectant to use, and knowing which leaves residue and haze is a common impediment for them. When people with the best intentions choose which chemicals EVS is to use will often require EVS double their best efforts go back to polish or clean not to give the appearance of a soiled surface. EVS is the one department that tends to encounter too many EVS supervisors providing "direction." The question of "who cleans what, when, and how" is a great time waster and results in less than optimal results. Perhaps a more excellent way of saying that "too many cooks spoil the broth."

A good friend likes to use an analogy about a football field. If tasked to vacuum an empty football field (yes, crazy, and Astroturf, of course), it will take a pre-determined amount of time using specialized equipment. Now, if that same football field had furniture, waste cans and people occupying each cubicle, would one expect it would take the same amount of time? Now, let's add an office party, and the occupants of these cubicles decided to have cake and punch. And, oh yes, the special occasion included streamers, decorations, and poppers that sent confetti everywhere. Let's not forget glitter that sticks to everything! With each change in circumstance or added equipment, assets, and people, not to mention their behavior in what they do in that space, cleaning time is significantly affected. Combining all of the above with an understaffed EVS department that does not have sufficient time, training, proper tools, and processes, the result is a minimally effective department.

When questions remain about what will be done by EVS as part of the multidisciplinary team (MDT) or how to fulfill swim lanes or the responsibility matrix, unrealized expectations, disappointment, and frequent anger arises. Stressed partners on an MDT often pressure the technicians to turn the rooms faster for them, which causes a demoralizing effect, a sense of not being understood or appreciated. There are times when an OR theatre may have just been used for a joint replacement or a very messy trauma case. There needs to be time allowed for proper processing of these surfaces, often involving significant scrubbing. Turning over a room also requires sufficient disinfectant dwell-time for bacteria and potential pathogens to be destroyed. Disinfectants need a clean surface to be effective, and there is no short-cut. EVS cannot make time go faster. To ask EVS to reduce dwell time to speed up a process can be equated to asking a surgeon to close an incision with three stitches rather than the requisite 10 stitches; it is not appropriate or safe to do so; the patient will suffer.

All of this equates to a successful recipe, one in which each ingredient or step is essential. The human element of the formula is just as necessary to ensure the message of quality, cost and outcome (CQO) must always factor into decisions made and actions taken for the best possible patient outcome. Communicating this importance of each member's role and mutual respect for the individuals and their responsibilities on the MDT is vital.

Every year, the Association for the Healthcare Environment (AHE) conducts a trends and data survey to keep a finger on the industry's metaphorical pulse. And each year, most facilities included in this survey allocate between 30 and 44 minutes for discharge cleaning of rooms, with the minority allotting 60 minutes. The timeframes reflect the individuality of each hospital and the size of their "football fields." Occupied rooms are more likely to be given about half that time for cleaning, but this is not a hard and fast rule. There are multiple factors each facility and MDT must consider. Slightly less than 50 percent of the respondents say they do not disinfect floors for occupied or terminal (discharge) cleaning of patient rooms.

Almost all sites allocate 30 minutes or more for the end of the day or terminal cleaning of each OR. Between cases, the OR is more likely to be given 10 to 20 minutes. These time limits should give a pause for reflection, especially if remembering the football field analogy. EVS must receive information regarding the type of surgery conducted and the potential bioburden level in each OR, mainly if it was a messy procedure or a patient on isolation required surgery. This essential information can only come from OR MDT members when handing ORs over to EVS for processing.

Now more than ever, awareness of the opportunities to deliver industry best practices for OR between-case cleaning such as zone cleaning and implementing the training, along with a substantial responsibility matrix. Organizations like AHE offer a Train-the-Trainer program for the perioperative areas called CSCT – Certified Surgical Cleaning Technician to help in this endeavor, for the rest of EVS CHEST – Certified Healthcare Environmental Services Technician. Programs like these offer rock-solid advice and ensure everyone is in harmony, efficient and effective in conducting their duties.

Other things to factor in are computer workstations on wheels, respiratory and anesthesiology equipment, and others processed (cleaned and disinfected) by those who typically use them. Those users have the training, tools, and proper resources to follow manufacturers’ instructions for use (IFU). When a MDT ensures the equipment in the room is cleaned by the designated professional, this ensures that the place is ready as soon as possible. However, if any one of these vital components is disrupted, missed, completed out of order, or late, it may fall to EVS to pick up the slack. The disruption causes an already strapped and burdened EVS department to get the job done with limited resources and often limited success. We must distinguish between room turnaround time (wheels out to wheels in), a phrase that typically means the time a patient leaves the space, and another arrives. This time frame incorporates all activities and disciplines involved in cleaning and disinfecting the environment, which encompasses the physical surfaces and the assets or equipment in the room. This is not to be confused with room turnover time (when EVS receives the call and begins processing the space to the time the room is completed by EVS, which may or may not include bed make-up).

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Variables that may impact standard benchmark times:
• Room type and size
• Age of the facility
• Facility design
• Weather and other elements
• Activity in the room
• Clutter
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According to the AHE trends and data survey, more than half of all EVS directors say they do not have enough staff for their current workload and need more full-time employees (FTEs). Unfortunately, EVS is historically the first department to receive the C-suite's notice to tighten the belt. Most of the EVS budget is labor, followed by equipment and expendable supplies impacted by the facility census. Unfortunately, since EVS is not a direct revenue-generating department, it is considered an expense department. One day, hopefully soon, administrations across the world will recognize EVS for what it truly is -- an investment in quality patient outcomes.

During this COVID-19 pandemic, many industries, not just healthcare, are redistributing labor, investing in more personnel, allocating additional resources including funding for hand sanitizer, cleaning chemicals and disinfectants, awareness and training. It appears that this is the "new normal." Rather than just placing a new moniker to a different way of doing things, it should be a wake-up call for healthcare organizations, especially post-acute facilities. Just because the rest of the world is so focused on one enveloped virus, does that mean that the U.S. should follow suit and lose the focus on the rest of the microbial jungle out there? Pathogens much deadlier and more resistant than SARS-CoV-2 are still present and emerging. Healthcare professionals, including infection preventionists (IPs) and EVS, must not become myopic or be as horses with blinders to keep their focus only on one thing. Preventing the spread of COVID-19 is essential, but so is addressing multidrug-resistant organisms and superbugs.

Fortunately, many world-class organizations and health systems they are doing just that. Also, programs like Doctors Without Borders are working on domestic (U.S.) soil in the much flailing post-acute care systems for the first time in their history. Their task force is providing vital resources, boots-on-the-ground, to help construct infection prevention and control programs. They've seen firsthand in Detroit and now Houston, where many facilities receive a deplorable CMS survey because they are without hand sanitizer, proper tools, chemicals and equipment. They have also seen dedicated employees ready to learn and do what it takes to protect our most tender and at-risk generation of loved ones. In an upcoming article in the EvSOP series, Dr. Buffy Lloyd-Krejci will provide a first-person account of what she has witnessed and the steps needed in long-term care facilities. Alicia Cole will share her experiences and feelings as a multiple HAI patient and her patient experience perspective.

Alicia Cole may not be the first to tell that a patient needs a knowledgeable advocate. She will not be the first to say that patients need to use and demand that healthcare professionals incorporate effective hand hygiene. Cole is not the first to know the need for EPA-registered, hospital-grade disinfectants or the need to use healthcare-grade ultra-microfiber wipe or mop. But she is probably one of the first non-healthcare people to advocate on a nation-wide basis to the public the necessity of ensuring the healthcare environment is hygienic. Cole is one of the few non-EVS populations that knows the proper sequence of processing patient rooms and ORs. She advocates that EVS and their MDT use those tools from top to bottom, cleanest to dirtiest, clockwise or counterclockwise (unidirectional wiping). She will address the inconsistencies personally seen between shifts and technicians, and careless nurses that bump a bedpan that spills everywhere. She can effectively and personally address instances when a nurse or assistant does not have time to clean up urine or feces, even in a bed. She will speak of the EVS technician who feels for the patient and asks, "Do you mind if I come to clean your room later so I can take the time to do a good job and change my mop bucket water, so it's not dirty for your room?”

Over the next few months, the EvSOP series will address each component of a successful process and program that speaks to the heart of every element that is vital for best patient and healthcare worker outcomes.

Until next month, utilize the tools available on how to calculate cleaning times through ISSA 612 that has taken 612 frequent tasks and benchmarked the appropriate time required to accomplish them adequately. The list has expanded with items added since the previous 540 list.

Implement the EvSOP playbook to ensure the whole MDT is on the same page with service level agreements for each MDT member and department. The purpose of a Service Level Agreement (SLA) is threefold:
• Clearly represents the capabilities of the service.
• Establish a shared set of expectations regarding the operation and support of the service;
• Provide performance measurements of the service

Let’s not forget, September is EVS Week; please let the environmental services technicians, custodians, housekeeping staff in whatever facility you frequent or manage, and let them know just how important they are to you and the clients they serve. After all, EVS isn’t just mopping floors, but saving lives.

Aaron Jett is an EvSOP researcher for the Pearce Foundation for Scientific Endeavors, as well as clinical solutions manager for Cintas Corporation, where he is focused on Joint Commission National Patient Safety Goals and achieving the triple aim (CQO). Jett has a clinical background and is certified in infection prevention and control, as well as serves as an OSHA walkway auditor. He is also a trainer for the AHA/AHE.