By John Scherberger FAHE, T-CSCT, VPEI
“The time has come,” the Walrus said,
“To talk of many things:
Of shoes—and ships—and sealing-wax—
Of cabbages—and kings—
And why the sea is boiling hot—
And whether pigs have wings.”
Source: “The Walrus and the Carpenter” by Lewis Carroll
What a strange way to start an article about value and science-based healthcare evaluation product purchasing. What does the poem have to do with product evaluation and purchasing?
Recognize this: When considering all the essential elements needed to purchase critical healthcare essentials, many people bypass the science, safety, efficacy, value, and cost (not just the price) of crucial products. It’s as if some people become the Walrus and concentrate on too many nonsensical issues such as shoes, ships, sealing-wax, cabbages, and kings. Their minds take flight in search of the unrealizable, and yes, the impossible, such as if pigs have wings.
But when it comes to needs, product assessments, and desired outcomes, it often appears those decision-makers take flights of fancy like the Walrus or ignore the fundamental goals of all healthcare products -- safety for staff, patients, and visitors, the efficacy of the products to accomplish the intended outcomes, and the lifetime costs involved in using the products. Cost is not the same as price, and expenses must include life-cycle issues. The training involved in using the right products, the time needed to use the products, the physiological stress tools and equipment have on staff, and the potential for workers’ compensation claims, the ecological effects products have on the environment, and so many other costs involved during the lifetime of the products. Be mindful that if the price is the determining factor in a purchase, that is when everyone should expect to see pigs fly. Because pigs will never fly, and in value-based and science-based purchasing, the price will never be the fundamental reason for buying anything. The old axiom of getting what one pays for is so true.
For example, when a hospital purchases disposable items that have reusable counterparts based upon the word of a company representative, an offered price, or a rebate not based on scientific evidence, one must ask questions, and others must provide scientific answers. If reusable items are purchased, yet disposable products offer safer, science-based desired outcomes, the purchasing department should choose the disposable products.
The patient cannot be the “oh, yeah” part of the equation when considering infection prevention and environmental services tools. In this context, tools are liquid cleaners and disinfectants whether they are concentrated or ready-to-use (RTU), wipers, mops, dusters, toilet mops, mop handles, EVS carts, and other tools of the trade. Not following value and science-backed purchasing decisions can have a detrimental impact on patient health and outcomes.
There are no preternatural measures needed for infection prevention to be effective. Infection prevention may be strictly clinical by nurses, physicians, phlebotomists, or quasi clinical EVS professionals tasked with rendering healthcare environments hygienic. Whether tackling the effects of a Clostridioides difficile outbreak or the COVID-19 pandemic, infections cost $40 billion in the United States each year. Healthcare-associated infections (HAIs) cost the average 500-bed hospital $5.5 million in lost revenue.
Conditional reasoning and logical equivalence (“If-Then”) should dictate that healthcare professionals’ reason if the $40 billion in lost revenue has one source, HAIs, then many tributaries that contribute to the source. If clinicians do their utmost to prevent central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), surgical site infections (SSIs), and methicillin-resistant Staphylococcus aureus (MRSA) bloodstream events, then contaminated healthcare environmental surfaces remain as a significant contributor to other HAIs. And who is tasked with disinfecting healthcare environmental surfaces and rendering them hygienic? Environmental services (EVS) is. Yes, hands are the biggest spreaders of germs, but the germs are transferred to and contracted from surfaces, other people, uniforms and scrubs.
Questions must be asked: “Why are scientific and value-based processes not part of the “DNA” of procurement decision-making when considering EVS tools?” “Why is scientific and value-based product evaluation bypassed when considering or purchasing EVS tools (remember what EVS tools are) for infection prevention processing of the environment?” “Why are EVS departments excused from scientific and value-based product evaluation for the most important infection prevention trap-capture-remove tools are purchased or services contracted? “Why is scientific and value-based training for EVS technicians ignored or limited?”
In 2020, the Centers for Disease Control and Prevention (CDC) released an informative and ground-breaking resource that highlighted core components of environmental cleaning disinfection in hospitals. The CDC recognizes the risk of infection from surfaces and provided descriptions and examples of each of the six core components to ensure a hygienic environment. Here are the six core components:
- Integrate environmental services into the hospital’s safety culture.
- Educate and train all HCP responsible for cleaning and disinfecting patient care areas.
- Select appropriate cleaning and disinfection technologies and products.
- Standardize setting-specific cleaning and disinfection protocols.
- Monitor effectiveness and adherence to cleaning and disinfection protocols.
- Provide feedback on adequacy and effectiveness of cleaning and disinfection to staff and stakeholders.
Those components are the bedrock upon which hospitals must build all EVS departments, and the Environmental Services Optimization Playbook (EvSOP©) is the blueprint of how to build upon the foundation.
The CDC resource is groundbreaking because it definitively states, “Therefore, cleaning and disinfection of environmental surfaces is fundamental to reduce potential contribution to healthcare-associated infections. Inadvertent exposures to environmental opportunistic pathogens may result in infections with significant morbidity and/or mortality.” Until this resource was published, there was no definitive “stake in the ground” by a government agency making such a clear-voiced declaration.
Point No. 3 above, “Select appropriate cleaning and disinfection technologies and products” cannot be overlooked or minimized. For far too long, EVS has been the “department in the basement,” and following science and value-backed purchasing discussions or decisions rarely were initiated with infection prevention departments, materials management, quality control/management/measurement, chief operating officers, or other C-suite executives. EVS budgets and staffing are first on the chopping block without any “If-Then” consideration of conditional reasoning and logical equivalence. Rarely is regard shown to the critical aspect of EVS personnel maintaining hygienic conditions and reducing HAIs. Too often, maintaining a winsome appearance or following a “looks clean, I know clean when I see it” is the prevailing attitude. It is that attitude that needs replacing with science and value-based decisions. EVS personnel save lives, and they must be empowered and required to incorporate value and science-backed purchasing decisions.
Now, more than ever before, in the business of healthcare environmental services, science-based resources are available for EVS departments to be a professional, life-saving, critical and science-based collaborative department. Recognized authorities such as EvSOP©, CDC, the Healthcare Infection Control Practices Advisory Committee (HICPAC), the Association for the Healthcare Environment (AHE), the Association for Professionals in Infection Control and Epidemiology (APIC), Infection Prevention and Control Canada (ipac), Public Health Ontario, the Provincial Infectious Diseases Advisory Committee (PIDAC), the Centers for Medicare and Medicaid Services (CMS), the Association for periOperative Registered Nurses (AORN), the Joint Commission (TJC) and numerous other deeming authorities are all calling for a science-based approach in EVS departments.
For decades, if not longer, too many facility power brokers held on to the antiquated “It looks clean, I know clean when I see it” position. Thank science that this retrograde philosophy is no longer the predominant driving force behind infection prevention and environmental services. All of the aforementioned authorities are recommending the American National Standards Institute (ANSI) and Association for the Advancement of Medical Instrumentation (AAMI) definition of hygienically clean: “Free of pathogens in sufficient numbers to cause human illness (20 colony-forming units per 10 cm2 = 20 CFU/dm2).” Note: a dm is a decimeter. The decimeter is a unit of length in the metric system, equal to one-tenth of a meter, ten centimeters or 3.937 inches.
As there is an accepted definition for hygienically clean, how is it achieved through testing? That depends upon the surface tested. If a soft surface such as EVS healthcare-grade ultra-microfiber (HGUM©) infection prevention textile products, healthcare textiles used by patients, or uniforms, scrubs, or lab coats, destructive testing occurs on a textile sample. When testing a solid surface, the most common method is laboratory sterile swabs and agar/RODAC plates.
Before hygienically clean can be achieved and tested for, there must be a science and value-based process in place to select appropriate infection prevention tools. How is that accomplished? One way is through the use of the CDC/HICPAC Infection Prevention Product Review Worksheet. A worksheet is a tool for assessing products for infection prevention in healthcare settings. It is a variation of the conditional reasoning, and logical equivalence (“If-Then”) process mentioned previously.
Emmert Wolf, apparently famous only for one long-lasting and actual quote, said, “A man is only as good as his tools.” In today’s vernacular, an acceptable version of that quote might be, “A person/worker/technician/human is only as good as the tools they use.” Regardless of the common noun used, the emphasis is on “tool.” There is not one particular tool that is most important for EVS technicians. Just as cleaning and disinfecting chemical decisions are science and value-based, associations and authorities having jurisdiction base their recommendations on science and recommend microfiber, particularly ultra-microfiber infection prevention textiles.
In their Practice Guidance for Healthcare Environmental Services, the AHE states, “Microfiber cleaning materials should be used,” and “Using the proper tools or equipment with the proper chemical products in the most effective and productive method of cleaning. The tools should always include microfiber.”
In a May 2016 webinar titled: Evidence for Easily Improving OR Environmental Hygiene, Linda Homan, RN, BSC, CIC, and Dawn Hughes, RN, MSN, MBA, CNOR, RNFA, said, “Half the environmental hygiene battle is using the proper tools to clean.” They also commented, “While not all microfiber products are equal, in general, microfiber boasts superior chemistry absorption and ability to release chemistry to the surface when compared to traditional cotton cleaning cloths. It is also lint-free, which is important in the OR.”
Another very informative and authoritative guide, Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Best practices for environmental cleaning for prevention and control of infections in all health care settings. 3rd ed. Toronto, ON: Queen’s Printer for Ontario; 2018, has a detailed and accurate description of microfiber and ultra-microfiber cleaning products and infection prevention ultra-microfiber tools in section 1.3.3 Microfiber and Ultramicrofiber Cleaning Products.
Unlike the agencies having jurisdiction and associations previously listed that came together to agree on an accepted definition of hygienically clean, the microfiber and ultra-microfiber manufacturers appear to have resisted a mutual definition to differentiate between various microfiber textiles. Due to the vast differences in manufacturer product construction, design, material selection, instructions for care and maintenance, EvSOP© decided to put itself out there to improve the provide an infection prevention textile definition. EvSOP© recognized the necessity of assisting EVS and IPs in choosing infection prevention healthcare textiles. Healthcare needed specific microfiber textile characteristics to define an HGUM©, which is not manufacturer- or brand-specific. Here are the factors that set HGUM© apart from other ultra-microfiber products:
- The individual fiber size (in denier) of less than .03, a required bicomponent composition of polyester (80 percent to 85 percent) and polyamide (15 percent to 20 percent)
- A minimum number of bicomponent splits
- A split percentage of the bicomponent of more than 90 percent
- High grams per square meter for the face fiber on flat mops
- Non-cellulosic composition of the mop interior (what makes up the “mop sandwich”)
- Compatible with all EPA-registered hospital-grade disinfectants
- Withstands CDC/CMS laundering guidelines through more than 120 reprocessing cycles
Ensuring hygienic results requires healthcare to use science-based decisions in choosing the correct ultra-microfiber. All aforementioned specifics are needed to ensure that EVS uses only effective infection prevention textiles incorporated into processing environmental surfaces. Because HGUM© is exceptional for trapping, capturing and removing surface, subsurface, and biofilm grime, mold, fungi, spores, microbes and potential pathogens, it is necessary that used HGUM© be laundered according to CDC parameters and by CMS guidelines.
One must point out that all healthcare and commercial laundries must launder products according to the textile manufacturer’s instructions for use (IFU). Only HGUM© ultra-microfiber products have laundering IFUs that meet the CDC and CMS laundering guidelines that ensure hygienic products leave the healthcare and commercial laundries. They will not introduce contamination into the healthcare facility as they are hygienically clean. There is no requirement for HGUM© to be sterile before use.
Healthcare facilities that launder their microfiber or ultra-microfiber products in non-commercial machines (washers and dryers) with limited cycles and temperatures cannot provide hygienic textiles. They significantly increase the contamination risks and potential HAIs and the resulting financial losses. When HGUM© infection prevention textiles are processed according to the CDC guidelines, the textiles should be hygienic.
Let’s return to the beginning with another look at the poem segment “The Walrus and the Carpenter,” and read it from a healthcare point of view:
“The time has come,” the IP said,
“To talk of many things:
Of microbes—and HAIs—and high-touch surfaces—
Of disinfectants—and cleaners—
And why healthcare ultra-microfiber is an essential tool for success—
Because pigs don’t have wings and EVS saves lives.”