Environmental services' role in hospital construction

ES technicians must help to isolate work areas from the rest of the hospital during construction.

Environmental services (ES) technicians play a critical role in today’s hospitals. Their previous focus on keeping a health care facility clean is only a limited view of how important the ES team is to the mission of the entire facility.

With the emergence of drug-resistant organisms and the abundance of specialized products used in hospitals, an ES team needs to be highly educated and armed to help reduce health care-associated infections (HAIs) and improve patient satisfaction scores.

A team approach

The primary goal for infection preventionists in any facility is to prevent patient-to-patient transmission of infectious microorganisms as well as to keep visitors and colleagues safe. Frequent brainstorming of various strategies for environmental hygiene will ensure a safer facility for everyone.

Creating a multidisciplinary brainstorming team increases collaboration among all departments and is vital to improved patient care. In the past, each department in the hospital had its own mission; seldom did departments cross into other territories. However, under the Affordable Care Act, everyone must collaborate because federal reimbursement is being tied directly to the quality of care and the facility’s HCAHPS scores.

Education remains a key priority when explaining the need among departments of improving infection statistics. Collaboration also means gaining more diverse knowledge so that everyone on the floor can watch for improper or neglected practices. It should be everyone’s goal to prevent the spread of infectious diseases and to improve outcomes for all patients.

For example, meeting with the director of nursing or the nurse manager also is an important aspect of keeping the patient population safe. Nurse managers can explain any health situations, such as allergies or chronic conditions, which might preclude the use of some cleaning products. If there have been any changes in a patient’s health status that could be affected by chemicals or techniques, nurse managers and ES technicians must be aware of them.

Continual construction

ES technicians must remain flexible to constant changes within the facility. Keeping up with a 24/7 facility means that staff, visitors and outside vendors are always moving about the complex, creating different needs at different times.

To further complicate things, hospitals are continually undergoing renovations and maintenance work, meaning that areas normally scheduled for routine cleaning may be under construction or even isolated from the rest of the facility. ES technicians must keep the perimeters of working areas clean, watch for leaks and often enter the isolated areas to remove trash or prepare the area when opening to patients.

When construction contractors turn spaces over to the hospital for use before terminal cleaning and disinfection has occurred, ES staff members are called on to disinfect the renovated area and prepare it for patients with little time remaining before occupancy.

Daily cleaning routines become more intense due to renovation and maintenance work. As additional materials and equipment are transported throughout the facility, the supply carts can track microscopic debris, which requires cleaning and scrubbing despite not being part of the original daily work plan.

Boxes of construction-related supplies that were stored in unconditioned, damp warehouses and then transported and stored in the hospital can create unsafe conditions for immunocompromised patients with the potential for mold to become airborne.

Eight steps

As risks of HAIs increase due to construction and other external factors, ES technicians should have access to their infection control awareness training materials at all times to help them recognize potential dangers and know how to properly treat the items or isolate them from patients.

Environmental service technicians should keep these eight steps in mind to improve patient health during hospital construction or renovation projects:

1/ Implement facilitywide training programs. A hospitalwide training model that can be accessed 24/7 by all ES staff ensures that professionals will be educated to make a difference in HAI rates and improve patient care. Addressing issues that health care staff members encounter on a daily basis can help to eliminate recurrence of high-risk situations. Every ES employee and construction vendor who enters the hospital should complete the training courses and learn about his or her role in HAI prevention.

2/ Store materials in dry areas to prevent mold. Mold grows quickly in a moisture-filled environment and, when disturbed, easily travels through the air. Wet or damp cardboard, for example, is an absorbing material that allows mold to colonize quickly. Material transporters in the hospital should be kept in isolated areas, as patients who are exposed to mold can develop serious health issues. Before putting away construction materials, ES professionals should check the storage area for high humidity or water damage.

3/ Clean all equipment daily and thoroughly. Debris removal and dust control are extremely important in HAI prevention. ES professionals should be sure that all ventilation systems in a construction area are sealed securely to prevent bacteria from entering clean areas in the facility. The ES staff should monitor large disruptions and ensure that no debris is tracked through the facility unknowingly by vendors or staff.

4/ Ensure that workers who leave the site are clean. Before leaving a job site, all ES staff and construction vendors should remove debris from clothing and shoes. Exiting a construction area covered in the smallest amount of dust or other harmful, bacteria-laden debris can expose an immunocompromised patient to deadly HAIs.

5/ Transport all materials correctly. When vendors are transporting materials from one location to the next, make sure they are covered correctly with tight-fitting plastic or a dampened clean cloth to prevent airborne infections. The ES staff should train or remind vendors of the importance of moving parts and the role these small steps play in overall patient health.

6/ Hire educated and accountable vendors who are aware of Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services infection control requirements. Knowledge of recommended or required infection control training for vendors is essential in improving hospital efficiency. The CDC states that HAI prevention requires a multidisciplinary approach. The ES team should help vendors to see their impact on the entire facility.

7/ Integrate a waste management program. ES professionals should clearly define the recommended procedure for controlling and disposing biological, chemical and radiological materials and wastes to minimize the risk of HAIs and ensure compliance with all federal, state and local regulations.

8/ Record all construction and renovation work. Documenting maintenance projects will aid in fighting legal action if there is a construction-related problem. ES professionals should educate their staff on how their work helps both patients and the bottom line.

Monitoring progress

The ES team can measure cleanliness with three basic quality-assurance monitoring tools or methods. Each of these methods can benefit a health care facility before, during and after a construction project.

First, direct practice observation is a subjective approach where either the ES supervisor or infection control practitioner observes the ES staff cleaning a room or visually inspects the room after it has been completely cleaned. Cleanliness can be evaluated statistically by use of a visual checklist to quantify results. However, the ES supervisor and infection control practitioner may have different standards as to what they consider to be clean.

Second, adenosine triphosphate (ATP) bioluminescence systems have been used in the food service industry for 30 years and measure the amount of surface contamination present on objects. These ATP monitors express the amount of bioburden on a surface by taking a swab culture of environmental surfaces. To get a true picture of the level of cleaning, both pre- and post-cleaning readings must be taken. This method is good from a managerial point of view in that the level of cleanliness can be measured objectively. It takes the human factor out of the equation and can produce reliable, reproducible results under the right circumstances.

Fluorescent gel monitoring is the simplest approach and involves the application of an invisible fluorescent mark on surfaces prior to room cleaning. Then a post-cleaning check is done to see if the mark has been removed through a combination of the mechanical action and the chemical process of cleaning. If the mark has been removed, and the manager has varied the locations on which the marks are placed, the manager can be reasonably assured over time that the surface and the room have been cleaned thoroughly. Another option is ultraviolet powder [see sidebar, below].

Because most health care facilities must keep full-time equivalents to remain financially competitive, training time must be quick and effective to keep staff knowledgeable while remaining productive. To meet today’s diverse workforce, infection control training programs must be available in different languages and include testing to verify understanding.

More than cleaning

As in all situations, ES professionals should encourage feedback from patients to identify areas in need of improvement. They also should remind other staff to ask patients about their stays and have comment material available at check-out.

To leave a positive impression on patients, ES professionals should place visual cues like a tent card over the bed table for a patient to recognize that his or her room has been acknowledged and cleaned thoroughly. 

Thom Wellington is the co-founder of Infection Control University and CEO of Wellington Environmental, St. Louis. He can be reached at thom@infectioncontroluniversity.com.

Using fluorescent powder to track cleaning results

It is the environmental services (ES) department’s role to ensure that patient rooms are cleaned properly after discharge, and one of the most effective approaches to measuring the cleanliness of a room is by using a fluorescent powder, which is visible only under ultraviolet (UV) light.

Infection preventionists emphasize the importance of disinfecting all high-touch areas during a discharge cleaning to improve and monitor the cleaning process, and this powder is a great tool for training ES technicians on cleaning high-touch areas in the room, such as the door handles, IV poles and bed rails.

To use this method, ES professionals should apply the powder to several high-touch areas before their scheduled cleaning. Then, after the room has been cleaned by an ES technician, the room can be checked with a UV light. Rough or textured surfaces hold onto the powder more than smooth surfaces, making those areas more difficult to clean. ES managers can build a checklist of the areas that were tagged with powder and use it as a monitoring tool.

Once the room is examined, ES professionals can determine the staff’s efficacy rate. They can schedule weekly meetings with room checkers to review the progress using graphs of the cleaning results, compliance levels staff members have reached and recommendations to improve cleanliness.

To ensure that all ES staff are complying with these cleaning standards, managers should establish a threshold percentage score. Any ES technician below that percentage should be retrained in proper cleaning procedures. Scores should be posted so that staff can see how they did.

With proper training, ES staff will become efficient in cleaning patient rooms and take pride in their work and, most importantly, patients will be more satisfied.