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May 2012 CROTHALL HEALTHCARE ENVIRONMENTAL SERVICES White Paper Specialized. Proven. Exceptional. Guaranteed. SM Crothall Healthcare s Strategic Initiatives for Reducing Healthcare-Associated Infections
May 2012 CROTHALL HEALTHCARE ENVIRONMENTAL SERVICES White Paper Specialized. Proven. Exceptional. Guaranteed. SM Crothall Healthcare s Strategic Initiatives for Reducing Healthcare-Associated Infections TABLE OF CONTENTS 1 Executive Summary 2 Introduction 2 Background 4 The Crothall Healthcare Solution 10 Mt. Sinai Hospital Case Study 11 Summary 12 References 13 Contact Information Rich Feczko Tim Polizzi Steven J. Schweon Mark Shamash Teri Alameda Very few people have any idea of the exquisite cleanliness required in a sick room! Florence Nightingale, 1859 EXECUTIVE SUMMARY Crothall Healthcare s Environmental Services program focuses on the challenges healthcare personnel (HCP) face in reducing healthcare-associated infections (HAIs) while meeting regulatory compliance, maximizing limited financial and human resources all while meeting expectations of improved operational efficiency and maintaining a competitive edge. Crothall s effective, synergistic and proven approach managing environmental hygiene and the impact on patient safety sets the industry standard for efficiency and effectiveness. By using a thorough, integrated, best-practice approach that requires standardized processes, outcomes measurement, ongoing training and innovative technologies, Crothall is able to reduce environmental contamination and pathogen transmission that lead to reduced HAIs and favorable patient outcomes. This white paper: Discusses the association among hospital environmental contamination, pathogen transmission and patient safety Describes Crothall s strategic initiatives with reducing environmental contamination and promoting improved patient outcomes 14% bloodstream 17% other 15% pneumonia 22% surgical Fig. 1: Healthcare-associated infections (HAIs) reported at acute care facilities annually. 2 32% urinary tract INTRODUCTION The rising cost of HAIs There are an estimated 35 million admissions to acute care facilities annually, (1) with 1.7 million patients being affected by a secondary healthcare-associated infection, (2) and 99,000 associated deaths. (2) Thirty-two percent of the infections originate from the urinary tract; 22% of the infections are a result of surgery; 15% of the infections are pneumonia; and 14% are bloodstream infections (fig. 1). (2) HAI medical costs range from $28.4 to $45 billion dollars annually; infection prevention interventions can result in savings of $5.7 to $31.5 billion dollars annually. (3) The rising costs of treating infection coupled with the knowledge that certain infections can be prevented has led the Center for Medicare and Medicaid s (CMS) Inpatient Prospective Payment System and some private insurers to no longer reimburse for several preventable HAIs, e.g., catheter-associated urinary tract infections, surgical site infections after coronary artery bypass surgery. Clearly, HAIs result in a mounting personal, medical and economic toll, especially impacting patients who are immuno-compromised. Patients are routinely exposed to microorganisms that are ubiquitous in the healthcare environment. Increasingly resilient and opportunistic bacteria, spores and viruses are shed from patients and staff, and these pathogens: Can contaminate the hospital environment May be transmitted between patients and the healthcare provider May lead to potential infection with significant morbidity and/or mortality Microorganisms are progressively more adept at surviving and reproducing on environmental surfaces (4) while also developing increasing resistance to available treatments, (5) thus posing a challenge to the infection prevention and medical teams. Healthcare leaders need to consider new management strategies to achieve operational efficiency. Crothall Healthcare s proactive and vigorous response to environmental hygiene is focused on a commitment to patient safety coupled with innovative and strategic initiatives. Our proactive, proven approach to disinfection cleaning processes sets the industry standard for thoroughness and effectiveness with reducing potential infection risk and resulting in improved patient outcomes and satisfaction. These strategic initiatives and positive outcomes can be found in the Mt. Sinai Hospital case study beginning on p. 10. BACKGROUND Patients Perspective Patients expect their hospital room to be clean; (6) it s critical the hospital room is meticulously cleaned and disinfected prior to their admission and on a daily basis during their stay. Additionally, they anticipate a satisfactory and uneventful outcome and do not want to become ill with an HAI, potentially resulting in additional morbidity, extended hospital admission and possible mortality. Many variables impacting pathogen transmission are associated with infection prevention practice compliance; environmental cleaning, hand hygiene, staffing challenges, antibiotic policies, disinfection/ sterilization practices, employee vaccination compliance, hospital census, patient acuity and facility design may all affect total outcomes. All of these variables must be proactively addressed to be able to meet patient expectations in today s competitive marketplace. Contaminated Environmental Surfaces An estimated 20% to 40% of HAIs have been attributed to transmission by the hands of HCP who have become contaminated from direct patient contact or by indirect contact with contaminated environmental surfaces. (7) While hand hygiene is the most important way to reduce pathogen transmission in the healthcare environment, it is exceptionally challenging to measure adherence, with varying compliance rates across studies. (8) The evidence that pathogens responsible for healthcare-associated infections can be widely found in the hospital environment (9 12) and hence readily acquired on the hand by touching surfaces (13) does demonstrate the importance of decontaminating hands before every patient contact. (14) Patients are the prime source for environmental contamination; surfaces within the patient s vicinity, also known as the patient zone (15) that are frequently touched by the patient and HCP have an increased contamination frequency than other sites. (17) Environmental surfaces and equipment can harbor pathogens (fig. 2). This contamination may contribute to the spread of disease-causing, multidrug-resistant organisms (MDROs), such as MRSA (Methicillin resistant 2 Crothall Healthcare Pathogen Acinetobacter Clostridium difficile Enteroccocus, including VSE 1 and VRE Klebsiella Lingering Contamination Staphylococcus aureus, including MRSA Floor Bed linen Patient gown Overbed table BP cuff Side rails Bath door handle Infusion pump button Room door handle Length of Survival 3 days 5 months 5 months 5 days 4 months 2 hours 30 months 7 days 7 months Fig. 3: Length of Pathogen Survival on Environmental Surfaces (4) Staphylococcus aureus), VRE (Vancomycin resistant Enterococcus), and C. diff. (Clostridium difficile). (16,17) MRSA Surface Contamination Epidemiological studies have shown that patients admitted to rooms previously occupied and contaminated by patients with these pathogens are at significant risk of acquiring these organisms from contaminated environmental surfaces that were not properly disinfected and cleaned upon discharge of the previous patient. (17) Microorganism Transmission Patients and sometimes HCP will shed bacteria, spores and viruses into the hospital environment, creating potential threats to other staff members, patients and visitors. (17) Microorganisms may be attached to droplets, skin scales or other particles and disperse through the hospital environment, where they have the ability to survive for hours to days to months (fig. 3). Transmission of many healthcare-associated pathogens is related to contamination of near-patient surfaces and equipment. (10, 20) Environmental contamination depends on the following: (17) The ability to culture the organism The degree of patient shedding; infected patients shed more than those colonized The number of culture-positive body sites Sampling methodology Difficulty of cleaning the environment Presence of an ongoing outbreak Diarrhea, with widespread contamination Type of patient Percent Positive for MRSA Fig. 2: Percentage of environmental cultures positive for MRSA, by direct plating and by broth enrichment, by item cultured. (11) In addition, horizontal surfaces have a greater amount of microorganisms and contamination than vertical surfaces, ceilings, and intact walls. Importance of Cleaning and Disinfection Cleaning, the removal of soil and contaminants from surfaces, is recognized as a vital component of the intervention package required to reduce hospital infection. (21) Disinfection results in destroying pathogens. Friction is also used to remove surface contamination. The type of materials used in environmental surfaces and the design/amount of equipment in a patient s room will impact cleaning effectiveness. Effective cleaning and disinfection will decrease the number of environmental pathogens, reduce the risk of transmission and potential infection, and be an integral part of a hospital s infection prevention and control plan. It is highly likely that cleaning practice plays a larger role in positive outcomes than does the product used. (22) Daily Cleaning and Disinfection Challenges Numerous clinical studies indicate thoroughness of disinfection cleaning may be suboptimal and can be significantly improved. (20) Environmental surface contamination may contribute to the spread of disease (16) and potential infection by contaminating HCP hands, gloves, uniforms, gowns and equipment. Several significant pathogens, including MRSA, VRE, C. diff. spores and Acinetobacter baumannii can survive, under certain conditions, for four to five months or more. (17) Norovirus can survive for a week or more. (17) The number of microorganisms on a surface is impacted by: Amount of surface moisture Amount and type of activity taking place in the immediate vicinity Amount of air flow Prevailing ambient temperature Number of people interacting with the environment Type of environmental surface and its ability to foster microbial growth Biofilm development on equipment and furnishings 3 Crothall Healthcare Condition of Participation: Infection Control (23) The hospital must provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases. Standard EC Areas used by patients are clean and free of offensive odors (The Joint Commission. Accreditation Program: Hospitals) (24) Hospital environments are complex and may result in disinfection cleaning challenges. A surface may appear clean but still harbor pathogens. Frequent environmental contamination has been implicated as a contributing factor during protracted outbreaks of MRSA, C. diff., VRE, Acinetobacter baumannii, and norovirus. (17) Evidence exists that improved cleaning regimens are associated with the control of outbreaks (9, 18) and bacterial transmission. (10) Environmental surface contamination with pathogens can be transmitted onto the hands of HCP and may spread disease-causing organisms like MRSA, VRE and C. diff. to the patient. (17) Regulatory and Governmental Agencies Perspectives Regulatory agencies, including The Joint Commission (standards and National Patient Safety Goals) and the Centers for Medicare and Medicaid Services (CMS), in conjunction with the United States Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC), recognize the importance of environmental hygiene to reduce infection. These organizations are increasing their recommendations and standards to improve environmental hygiene. The regulatory agencies are requiring documentation demonstrating that hospitals are focused on reducing HAIs. The evolving regulatory and governmental healthcare emphasis is to supervise, inspect, analyze and optimize the thoroughness of disinfection cleaning to ensure safe patient care. Importance of a Clean Environment There is generalized agreement that a clean environment is necessary to provide both good standards of hygiene and maintain patient and staff confidence. (25) Patient satisfaction surveys also question the hospital s cleanliness. Patients may subjectively consider hospitals dirty and will associate this with a general lack of care. (25) The media also have a heightened interest with environmental hygiene and reporting on dirty hospitals. Many states now have public reporting of hospital infection rates, with diminished reimbursement in some situations, for having higher-than-expected infection rates. The hospital must strive to meet community standards and exceed expectations to avoid negative outcomes. The impact of negative media coverage can adversely affect the bottom line. A clean, disinfected environment may promote a healthier workforce. HCP who work in close proximity to patients, including those who provide either direct or indirect patient care, need to stay healthy to come to work, reduce infection risk to their families, and minimize the potential of spreading illness to patients. Meeting the Challenges Healthcare providers must align their operations to more efficiently meet HAI challenges. Effective administration and management of environmental services resources are critical for improving processes and maintaining a safe and clean environment for patients and healthcare personnel. In the markets we serve, we will be recognized as the premier provider of the highest quality, customer-focused support services. Crothall Healthcare Mission Statement THE CROTHALL HEALTHCARE SOLUTION Strategic Initiatives for Improved Outcomes The Centers for Disease Control and Prevention (CDC) divides housekeeping surfaces into two distinct groups: those with minimal hand contact (e.g., floors and ceilings) and those with frequent hand contact (also known as high touch surfaces ), (26) which have the potential to become reservoirs for infection. High-touch surfaces can quickly become contaminated; pathogen transmission is related to the contamination of near-patient surfaces and equipment. (20) High-touch housekeeping surfaces include: (26) doorknobs bedrails light switches wall areas around the toilet in the patient s room edges of privacy curtains and (27) sink bedside table side rail call box telephone 4 Crothall Healthcare Continuing employee education a New hire orientation a Weekly Minders a Monthly in-service CHAT sessions a Annual refresher training a Training, including hand hygiene, PPE, C. difficile modules, VRE, MRSA, isolation room cleaning, and safe work practices The CDC recommends that high-touch housekeeping surfaces should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact (26) and that programs be developed that optimize cleaning thoroughness. (20) The Human Factor Every day, HCP perform thousands of interventions and actions that have the potential to transmit infection and/or cause environmental contamination. To address the problem, there is a focus on technical solutions re-engineering protocols, adopting new products and researching new technology. But what cannot be overlooked is the human factor: the front-line housekeeping staff, whose daily cleaning and disinfecting activities help to protect the patient. The cultural divide between the environmental services and clinical staff is a resultant theme impeding hospital cleanliness. (19) Optimal performance barriers include: (19) Gaps in training, education and understanding of their role Separation from traditional hospital clinical team Potential for language or understanding barriers Pressure from nursing and admitting staff to clean a room under the allotted time Feeling of disempowerment to challenge hospital staff This results in hospital equipment and furniture not being appropriately cleaned and an increase in pathogen transmission risk to patients and HCP. Crothall s Environmental Services program, respected as an integral part of a facility s infection prevention program, is designed to go beyond basic cleaning to disinfect surfaces by implementing specially designed protocols that consist of best practices to protect patients, staff and visitors from acquiring pathogens. To be healing environments, hospitals must not only look visibly clean; they must also be free of microbial contamination. Crothall s thorough, integrative environmental cleaning and disinfection approach (fig. 4) that reduces HAIs and leads to positive patient outcomes is accomplished through multiple systems and processes. Crothall proactively responds to these human factor challenges by: Ongoing and direct employee coaching, training, engagement, partnership, accountability and empowerment of staff members to ensure they are clear about their individual responsibility for promoting environmental hygiene through correct cleaning/disinfection processes and proper personal protective equipment (PPE) use Fig. 4 Integrated Infection Prevention Approach 5 Crothall Healthcare Educating the environmental services and healthcare teams in the proper use of hospital-grade chemical agents Designing comprehensive, specific and integrative protocols and strategies, including a 10-step process that focuses on disinfecting and cleaning of high-touch points in the patient zone Auditing staff to ensure strict adherence to standard protocols that have a high-touchpoint focus Diligently using the Clean-Trace TM performance improvement technology for immediate employee feedback to ensure service quality and monitoring long-term trending Using checklists to ensure all procedures are being followed Competency testing to assess worker performance Crothall recognizes that a successful environmental services program depends upon: Acknowledging the Environmental Services (EVS) Department as a key player in infection prevention Clinically involving the EVS staff Viewing EVS as full-fledged health care team members Team cooperation breeding empowerment Partnering with the hospital s Infection Prevention Team, serving on the Infection Prevention and Control Committee, and participating in regular environmental rounds performed with Environment of Care and Infection Prevention colleagues Using appropriate one-step EPA-registered hospital disinfectants for cleaning and disinfecting high-touch, environmental surfaces Cleaning/disinfecting C. difficile rooms with CDC recommended Environmental Protection Agency (EPA) registered disinfectants with a C. difficile sporocidal label claim Implementing microfiber products, H 2 O 2 liquid products, ultraviolet (UV) technology, and H 2 O 2 vapor technology Conducting periodic independent consultant assessment surveys Scientific testing of emerging antimicrobial product technology for reducing environmental contamination in the patient zone Partnering with a manufacturer and hospital to perform a clinical evaluation with a new disinfectant that will have a C. difficile sporocidal label claim Using High Efficiency Particulate Air (HEPA) filtration in selected clinical situations Allocating significant resources for piloting and studying the results of emerging innovative technologies Researching optimally constructed hospital furniture and equipment surfaces to reduce environmental contamination Staying current with emerging chemicals and technology Implementing and ensuring compliance with evidence-based policies and procedures based on: The Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), Canadian and British infection prevention guidelines and recommendations Regulatory agencies (e.g., OSHA, Department of Public Health, CMS) Accrediting agencies (e.g., The Joint Commission, Healthcare Facilities Accreditation Program (HFAP), National Integrated Accreditation for Healthcare Organizations (NIAHO) Incorporating well-designed research from medical literature Implementing indu
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