A Critical Juncture: Infection Prevention and Environmental Services

A series of personnel changes and a few twists of fate landed Karen Martin, RN, BS, HPN, MPH, CIC, directly in the middle of the intersection where infection prevention and environmental services meet. Martin is director of infection control/epidemiology and environmental services (ES) at Christ Advocate Medical Center in Oak Law, Ill., a unique dichotomy that has allowed her to accomplish what no one before her had time to do — unite both departments in the shared mission of preventing healthcare-acquired infections (HAIs). Several departmental reorganizations at her facility allowed Martin to focus new time and energy on overhauling the ES department and place renewed emphasis on environmental cleaning.

As infection control director, Martin had already been working with ES staff from an education standpoint, but the reorganization allowed her to start making key changes, such as raising the bar on ES managers’ and supervisors’ professional credentials, empowering staff members to create positive change, and most importantly, retraining staff on the importance of making HAI prevention a priority.

“I wanted them to connect to purpose in everything they did,” Martin says. “I wanted them to understand it was not just a seven-step cleaning protocol they were following, but that there was specific reasoning behind it. I developed a presentation that I made at all of the staff meetings that connected the importance of their jobs to preventing infections, and it must have stuck with them because all of a sudden they were coming to me or my staff in infection prevention when they were up on the unit when they saw something that was wrong.”

It was a significant breakthrough not only because of that connection to purpose, but because so many hospitals are grappling with the fact that patient rooms are not cleaned thoroughly and that substandard cleaning has been shown by many studies to contribute to the increased opportunity for cross-contamination and infections. Martin also faced the additional challenges of chronic ES department problems such as high staff turnover, language barriers, ineffective training programs and lack of oversight. Martin says she started digging deeper and discovered that opportunities for cross-contamination were rampant, and that inappropriate cleaning tools, dispensing systems and other techniques hampered cleaning efforts. She says most facilities have ineffective cleaning measurement systems that are largely subjective and based on visual assessment.

All of that began to change when Martin launched a pilot project on one floor of the medical center consisting of several interventions, including establishing a partnership between ES personnel and nursing staff.

“ES was included in the morning nursing huddles regarding potential discharges to better manage the scheduling of patient room cleaning,” Martin explains. “And infection prevention worked with the nursing staff so that for example, when they were taking off isolation gowns they weren’t just tossing them open in a basket. We taught them how to roll them up properly so the garbage wasn’t overflowing and exposing everyone to pathogens. Because of this partnership, in just one month, our patient satisfaction scores on the unit went from 35 percent to 95 percent. We actually had nurses picking up things like newspapers and throwing them away, and there was the understanding that we are a cleaning service, we are not a maid service, and we need nursing’s help to maintain a clean environment — which in turn gives ES a better opportunity to do what they need to do. “

Around that time, Martin says, the facility teamed up with Ecolab for a comprehensive pilot program that encompassed a baseline assessment of current cleaning methods, the application of best practices and the leverage of tools and dispensers to improve cleaning outcomes, classroom and hands-on training for all ES staff and managers and nursing, and the performance of audits to measure program objectives.

“Ecolab’s program was phenomenal,” Martin says. “It succeeded by providing a comprehensive approach toward assessment, product adoption and equipment/process standardization, training and education, and quantitative measurement tools.” For example, the efficacy of patient room cleaning was checked using a fluorescing marking solution to check the total aerobic bacteria count. Martin reports that room hygiene was improved by as much as 32.8 percent, a huge victory given the tie between the environment and microbial transmission.

One of the most astonishing results of the pilot program was the improvement in room turnover. When Martin first took over the ES department, she says the average room cleaning took 67 minutes; in just a short time with the pilot program (and a refined cleaning process using microfiber mops and an improved ES cart) in action, the cleaning process time was reduced to 30 minutes or less — an imperative for a facility that sees 88,000 patients a year. Crucial to such a quick turnover is Christ Advocate’s bed-movement strategy that is overseen by ES; according to Martin, nursing staff moves “dirty” rental beds and other transient beds to a specified location where ES staff pick them up and bring up beds that are already cleaned and disinfected, made up, and covered. It keeps patient throughput up to speed and helps ES stay on top of its workload.

“While programs like this are not without their costs, our facility, like any other, is performing cost comparisons and cost-savings analyses to see how things such as the standardization of equipment and supplies is effective in getting rooms cleaned quickly and thoroughly,” Martin adds.

One critical component to the success of not only the Ecolab pilot program but also the improvements she has been able to achieve, Martin says, is support from facility administration and management. “They allowed our major restructuring, which was the core of all improvement,” she says. “It enabled us all to come out of our respective silos, making improved collaboration possible.”

Martin also emphasizes the importance of empowerment and self-esteem as a cornerstone of improved job performance: “Florence Nightingale realized if nurses were to be accepted in the early years, they had to do a very good job, and so when she was recruiting people to become nurses, she needed people who were suited to do their work and who wanted to do it. The philosophy is that everyone wants to be accepted and in order to be accepted, you have to do a good job. We need to like our jobs, we need to be trained to do our jobs, and we need the tools to do our jobs to make it work. And then you can begin to do great things like integrate infection prevention with ES. What’s really kind of cool is that obviously you have your ES management staff, but ES staff members also look to infection prevention as their mentors. They’re not threatened by them because they are not their supervisors, so they are more apt to go to them and say ‘Hey, this is what I’ve seen that needs to be addressed.’”

Martin says that the pilot program also changed a lot of minds. “People who were initially resistant to the program eventually became so engaged in it, almost turning it into a competition. It worked because people were connecting to purpose — they were able to proudly say, ‘I am doing my job, I am getting rid of the microorganisms and I am preventing infections.’ It brings them back to the reality of why they do what they do.”