Science-based health care cleaning

A meeting of Loma Linda University Health System’s multidisciplinary CMIP project team.

Image courtesy of LLUH

The Certificate of Mastery in Infection Prevention (CMIP) program for environmental services (EVS) professionals developed by the Association for the Health Care Environment (AHE) of the American Hospital Association (AHA) cultivates and validates the knowledge required to coordinate efforts across the care team to implement infection prevention strategies and improve outcomes.

It is a unique program that translates the requisite knowledge of an infection preventionist into real-world, day-to-day environment of care operations.

This comprehensive program explores the most critical topics in infection prevention, including microbiology and epidemiology, patient and health care worker safety, surveillance, outbreak risk assessment, antimicrobial stewardship, evidence-based cleaning practices, environmental monitoring, and prevention of infection during construction and emergencies.

Responsibility and goal

Infection prevention is everyone’s responsibility and goal. It takes a trained multidisciplinary team implementing multimodal interventions to fulfill the goal.

A health care facility will never be germ-free because bacteria, viruses, molds and fungi outside the facility are always carried inside. Infiltration into health care facilities is extremely easy for contaminants and pathogens. They can be carried by air currents, clothing, supplies, carts, emergency services stretchers and, of course, inside and on the skin of every person entering a facility.

Despite the variety of viruses and bacteria, germs spread from person to person through everyday interactions. Therefore, to prevent germ transference, everyone must work to break the chain of infection. The CMIP program trains professionals on how to identify and break, or interrupt, the six points of the chain. At whatever point the chain breaks, the potential for infection stops.

The six links in the chain include the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry and susceptible host.

Recently, the Centers for Disease Control and Prevention (CDC) released a report titled “Antibiotic resistance threats in the United States 2019,” updating the state of infection prevalence and antibiotic resistance. Most of the attention focused on the revelation that more people have died from antibiotic-resistant infections than was previously believed.

The CDC categorizes pathogenic infection threats as “concerning,” “serious” and “urgent.” The “urgent” category is expanded to include the fungus Candida auris and Carbapenem-resistant Acinetobacter. The group is now five, having joined C. difficile, the deadliest antibiotic-resistant germ on the CDC’s urgent list; Carbapenem-resistant Enterobacteriaceae; and drug-resistant Neisseria gonorrhoeae.

With the increase, hospital administrators, infection preventionists, nursing services, physicians and EVS professionals face an increase in surveillance reporting and efforts needed to ensure hygienic health care environments.

One system’s journey

Successful completion of the CMIP course requires each participant to complete a capstone project to demonstrate competence in addressing an infection prevention challenge. One recipient of the designation is Allen LaFramboise, EVS director for Loma Linda University Health System (LLUH) in California.

“After 38 years of working in health care, and now leading a forward-thinking, innovative health system EVS department, it became clear to me that the AHE was the best partner for LLUH,” LaFramboise says. “Our capstone project focused on enhancing infection prevention processes here at LLUH. We based it on the guiding principles of the AHE and the mission of LLUH. The route included utilizing industry partnerships with AHE corporate champions that have the same level of commitment to patient care and supporting sustaining gains toward common objectives as we do.“ 

The project started with a vision to be the leader in health care, becoming a benchmark organization for others to emulate and finding innovative approaches to common challenges. “Infection prevention was already working with a very robust multidisciplinary advisory council on the environmental services optimization playbook," LaFramboise says. 

Also known as ESOP, the playbook is being developed by the Environmental Services Optimization Project Advisory Council to enhance EVS and infection prevention efforts, and improve communication, cooperation, collaboration, consistency and sustaining gains. The council consists of AHE members, a former AHE Board member and past president of the Healthcare Laundry Accreditation Council, EVS directors and managers, hospital operations directors, infection preventionists, doctorates in health care research, laboratories, professionals from other scientific fields, registered nurses, allied health care industries and laundering operations, fiber researchers and others. 

“Seeing AHE rooted in these efforts, and the shared commitment, we agreed to be a study site,” LaFramboise says.

“The gap analysis from all levels of our organization showed results that were insightful and thought-provoking,” LaFramboise says. “Overall, the theme was to continue to improve knowledge and competency — consistent application of best practices, enhanced training, and proper equipment and tools. 

“Our team immediately embraced all five signature certification programs from AHE,” LaFramboise says. “As a director of EVS, I completed the CMIP and value-based product evaluation and implementation (VPEI) courses, and am now working toward my Certified Health Care Environmental Services Professional designation. 

LaFramboise adds, “One of the greatest highlights of my training was attending these two courses with industry partners. I found all of AHE’s training to be phenomenal, but CMIP took my career to the next level, allowing me to see the science behind cleaning and disinfecting — to be able to communicate with infection preventionists as partners, not just peers.” 

One highlight for LaFramboise was taking the CMIP class at the AHA offices in Chicago. “I was able to meet with Ruth Carrico, Ph.D., instructor for CMIP, and associate professor at the University of Louisville,” he says. 

“How we care for health care environmental surfaces and the disinfectant we use to kill the pathogens is important,” Carrico said. “However, the correct types of wipes and microfiber mops appropriate to use in a health care environment that is used to scrub and remove the biofilm, endotoxins and the bioburden are just as essential.”

This reminded LaFramboise of what was said by the Healthcare Infection Control Practices Advisory Committee in the CDC “Guidelines for Environmental Infection Control in Health-Care Facilities” under cleaning housekeeping surfaces: “Disinfectant/detergent formulations registered by EPA are used for environmental surface cleaning, but the physical removal of microorganisms and soil by wiping or scrubbing is probably as important, if not more so, than any antimicrobial effect of the cleaning agent used.” 

The necessary communication between departments to maintain and watch for anything that could pose a threat to the harmonious balance of a facility is essential, LaFramboise adds. The CMIP experience and the interaction with AHE professionals led LaFramboise to embrace the ESOP project report template that helps keep the lines of communication open between these critical departments and to realize that infection prevention is everyone’s responsibility. 

Another vital area identified in the capstone project was the standardization of cleaning processes and procedures, including cleaning accountability by discipline: Who is responsible for cleaning? When is an object or surface to be cleaned? What needs cleaning and how to do it? Why is a specific product or process required? 

“We’ve always thought that microfiber was microfiber; however, we heard many conflicting reports, and white papers that left us with more questions than answers,” LaFramboise says. “Hospitals need evidence-based, unbiased information, from which to evaluate, so utilizing the VPEI principles from AHE’s program, and ESOP resources, we staffed an intern to work with the laboratories and test the numerous disposable and reusable wipes and mops in the actual areas of the medical center. 

“We measured efficacy for EVS by the products’ ability to clean and disinfect, microbial removal, absorption and dilution of chemicals as well as the recommended disinfection time needed to attain the required dwell or kill time on environmental surfaces,” he adds.

Additionally, the VPEI course stresses the life-cycle engineering steps to ensure that EVS incorporates the life-cycle costs of all products and processes involved in choosing products of quality, sustainability, and with the smallest environmentally negative impact possible. 

His team soon learned that not all disposables are the same, and neither are reusable microfiber products. 

“We were fortunate to be working with a team from ESOP and AHE that connected us with another industry standards group that defined health care-grade ultra microfiber as an infection prevention textile, and differentiated the proper use of disposables and reprocessed textiles,” LaFramboise says.

EVS needs wipes and mops that have validated removal ratings from third party-certified labs against common and opportunistic pathogens, or MDROs, according to ongoing research from Nova Biologicals Inc., Conroe, Texas. 

“[We need to see] consistent test criteria and, if the product is to be reprocessed, it must follow the definition of health care-grade ultra microfiber that can be laundered to the CDC/Centers for Medicare & Medicaid Services (CMS) guidelines (washing at 160 F for 25 minutes with 125-150 parts per million of bleach and appropriate drying temperature until completely dry) or those of the authorities having jurisdiction,” says Paul J. Pearce, Ph.D, of Nova Biologicals.

The most intense CMS survey will show the importance of following manufacturer instructions for use (IFU) and proper risk assessments if there are any gray areas in applying the IFU. Unfortunately, most microfiber IFU used in health care today cannot comply with CDC guidelines. Even CMS guidelines for low-temperature laundering required the use of bleach and complete drying at the appropriate temperature until completely dry. Just as important to having good products, is good processing, followed by application.

“We found that if it’s in the hands of EVS, it should be ‘health care-grade ultra microfiber’ to achieve the highest quality outcomes and aforementioned goals, so proper cleaning and disinfection can take place,” LaFramboise says. “With the least amount of worker exertion, reduced room turnover times, decreased chemical cost and smaller environmental footprint, we’ve seen patient experience scores increase and, at the same time, decreased supply cost.

“However, we still need disposable wipes for clinical staff and patients to disinfect sensitive or mobile equipment, in between EVS cleaning, quick turns in the ED, and items that may fall to the floor and should be wiped before coming in contact with the hands of workers, visitors, patients or their environment,” LaFramboise says. “All tools are necessary; we just need to make sure that we are putting the right tools in the hands of the technicians to accomplish the right outcomes, with appropriate cost and quality.”

Other health care organizations also have faced this challenge.

“When evaluating products and services, utilizing AHE’s evidence-based process as taught in the VPEI certification class is critical,” says Robert Tussey, an EVS director with another health care organization.

“We did something similar to Allen [LaFramboise],” Tussey continues. “After attending VPEI together, we evaluated the same performance characteristics of health care-grade microfiber over disposables utilizing AHE’s principles taught, along with on-site support from Pearce and Michael Overcash, Ph.D., and support from our chemical partners, and proved what AHE taught in the Certified Health Care Environmental Services Technician training program: the superiority of health care-grade ultra microfiber over cotton and cellulosic fibers in both conventional cotton loop mops and disposable wipes and flat pads.

“We reduced room turn times by almost 10 minutes, had full efficacy of our quaternary chemicals — with no binding utilizing the dip-and-wipe method, validated by both manufacturer and lab, and reduced costs, while improving outcomes,” Tussey says.

Through this project, Tussey also clearly identified with the work of Lynne Sehulster, Ph.D., on the laundry accreditation/certification crosswalk to compare and contrast best-in-class laundry accreditation and certifications.

“Timing couldn’t be better as we now face legislation in California to comply with the state’s AB-2679 bill on health facility linen laundry processing , which went into effect on Jan. 1,” Tussey says. “We are excited to see this study published in future academic journals.”

John Scherberger, FAHE, T-CSCT, is president and founder of Healthcare Risk Mitigation, Spartanburg, S.C. He can be reached at jfscherberger@me.com.