Environmental Services During COVID-19: No Longer ‘Unsung’ Heroes

Napoleon said (supposedly), “An army marches on its stomach.” In other words, they can’t fight if they aren’t fed. In a sort of twist, it could be said that a hospital—fighting a deadly pandemic—depends vitally on the people who clean the floors and baseboards, curtains, mattresses, elevator buttons, and handrails.

The frontline healthcare workers rely on that “other” frontline. In the Lompoc Valley Medical Center newsletter, Environmental Services Director Deanna Hall called her staff “behind-the-scenes heroes protecting our physicians, nurses, respiratory therapists, patients, and employees by stopping the spread of infectious disease.”¹

Not just any old infectious disease, either. It may have taken many in the general public a long while to grasp the size of the viral tidal wave heading their way, but back in January hospitals were already anticipating the need to batten down the hatches. When the disaster did begin to hit, though, it was more like isolated hurricanes and tornados—massive disruption in some places, nearly nonexistent in others. Washington, New York, and California were among those that took the initial brunt, but few would be spared.

The US Centers for Disease Control and Prevention (CDC), the American Hospital Association, and state hospital associations have issued guidelines for dealing with the pandemic, but as the Occupational Safety and Health Administration’s (OSHA’s) Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers says, “Although a pandemic will be a nationwide event, it will be experienced on a local level.”² That is, individual hospitals would have to work out what was best for them, their staff, and their patients.

As the virus began its devastating sweep, hospital associations and other groups began updating protocols that were generally intended for influenza outbreaks or less common events like Ebola and severe acute respiratory syndrome (SARS). Then it became more and more evident that coronavirus disease 2019 (COVID-19) was not like influenza. It couldn’t even rightly be compared to SARS, even though they’re related.

“I’ve been in environmental services for 17 years and I have never seen anything like this,” Glen Rogers, assistant director of environmental services at the University of Iowa Healthcare, tells Infection Control Today®.

“The coronavirus is changing all of our lives,” said the California Hospital Association’s Coronavirus Response page.³ The California Department of Public Health “All Facilities Letters” revealed the changing focus: From application processes and notices of stakeholder meetings on January 17 to health updates and interim guidance on COVID-19 beginning January 23.⁴

Some hospital associations adapted others’ existing protocols. The COVID-19 updates from the California Department of Public Health, for instance, direct healthcare providers to the “Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV) in Wuhan, China,” distributed by the CDC Health Alert Network.⁴

Still, the swiftness and severity of the virus spread meant some hospitals were scrambling to adjust. “The entire pandemic came on too quickly, so we were initially slow to get going,” Sharon Ward-Fore, MS, MT(ASCP), CIC, a Chicago infection prevention consultant and member of Infection Control Today®’s Editorial Advisory Board, said.

The Missouri Hospital Association released A Framework for Managing the 2020 COVID-19 Pandemic Response—in April.⁵ “Ideally,” the authors said, “this document would have been developed through a deliberative process involving many stakeholders and reviews. However, the need for established guidance at this critical time necessitated the expedited development of a framework for Missouri Hospitals.” They based their guidance on other “well-established plans such as the Utah Crisis Standards of Care.”

The University of Iowa Healthcare started to modify its plan in early March. “We started proactively adapting to the situation in many ways to keep providing a clean safe environment,” says Rogers. “We immediately put in place a conservation protocol for our disinfectants to reduce end-of-the-day waste and changed how we distributed them. We researched and found alternatives to our current disinfectants and secured those products. We retrained all our staff on cleaning protocols to keep them safe. And we worked with epidemiology to sequence our cleaning to reduce risk to other patients.”

Rebecca Leach, RN, BSN, MPH, CIC, the infection prevention coordinator at HonorHealth in Scottsdale, Arizona, says her hospital started preparing in late January, and has been “going ever since. We’ve had incident command at our organization since mid-March,” when they had their first COVID-positive patients.

Environmental services (EVS) staff were limited from going into the rooms, Leach says, to conserve PPE and limit staff member potential exposures. “We have one dedicated EVS person for the cohort units who focuses on cleaning the shared spaces, nursing station, med room, and so on, as well as performing the terminal and discharge cleaning.”

But Leach’s hospital also had some extra staff members at the ready. “We already had a fleet of UV disinfection robots that we were utilizing prior to the pandemic,” says Leach, who is also a member of ICT®’s Editorial Advisory Board. “We had assigned those robots to specific departments or areas based on healthcare-acquired infection [HAI] levels or service line.” When the pandemic took hold, the hospital expanded and shifted the UV robots to COVID cohort units or rooms where COVID patients had been discharged or transferred from, widening the scope of the program.

The adjustment to a more intensive protocol, on top of the daily strain of dealing with quarantines and cutbacks, adds to the stress of long hours. “In the beginning, 16-hour days were the norm,” Ward-Fore says. “As we worked through things, 12 hours seems to be the new norm.”

Overall, Leach says, “Dealing with the pandemic for my infection prevention department has been tiring, inspiring, challenging, and collaborative. The demands on our time have been extreme, as most IPs would likely agree. The preparation and training before our patients arrived was very consuming, and once we started getting patients and our first wave, that was all we worked on. We were on call 24/7, working 12- to 14-hour days in the hospital, and then working from home at night and sometimes through the night and through weekends. The days all blended together.”

Support and collaboration help, though. “I feel supported by my hospital,” Leach says. “Other members from other departments help with some of our tasks and duties to ease the burden. I think for IPs, we are the subject matter experts in a pandemic, so we will be relied on heavily, and since you typically have a limited number of IP staff, you feel stretched.”

Rogers also emphasizes the importance of a supportive and collaborative environment. Hours fluctuate constantly in EVS, he says, but he cites the amount of time spent focusing on the pandemic. “Luckily we have a great management team here that we could rely on to keep the day-to-day operations going as we worked on pandemic-specific issues.”

On the other hand, the hospital staff are prey to the same things the general public are: anxiety and fear of contracting the virus. Ward-Fore says the pandemic “caused a drain on staffing, by illness and fear. All the education in the world could not help those that refused to work due to fear.” But she adds, “Having enough PPE and using it as we normally would have helped alleviate the fear.”

It also helps to have flexibility. As Rogers recalls, “Some of the new protocols presented challenges for staff, but we then used them as learning opportunities.”

Months of long days without let-up take a double toll: both professional and personal. Leach says, “At first I didn’t even have time to think about how the pandemic was affecting me, my kids, my family, my friends. It was exhausting, I had moments of total meltdown and times when I was so proud of what I do for a living. I think it finally hit me that my personal life has changed and my kids and family were experiencing this in a totally different way than I was about 2 months into the pandemic. I realized how much loss I was feeling and how much stress and grief I was holding in, just to get through the days and be supportive and effective in my work. I was totally compartmentalizing my own personal experience so that I could do my job. I think I’m still figuring out how I feel about things and sorting through my emotions. I think those of us working in IP right now have a unique perspective on resiliency during a pandemic.”

“A sustained crisis” is how OSHA describes an influenza pandemic.² It contrasts such a pandemic with mass casualty and weapons of mass destruction events, which are “typically a surprise.” By contrast, a pandemic may come and go in waves, taxing morale and mental health of the people who must face it again and again. As of this writing, many parts of the country are still on the uphill part of the climb in the crisis, and others are relapsing after beginning to reopen. Arizona, where Leach is located, saw an alarming surge in cases and hospitalizations in mid-June.⁶ Chicago, where Ward-Fore is, was not out of the woods as it “cautiously” reopened around the same time: The chart of daily COVID-19 deaths was admittedly heading down, but in a very spiky way.⁷ And Rogers’ home, Iowa, despite a downward trajectory, has ongoing virus hotspots.⁸

And a second, perhaps even harder, wave is expected to hit in the fall. The more intensive protocols may not be needed forever, but certainly their time is not done. “At this point,” Leach says, “we know that this work will continue through the year, so we have to think about burnout of the IP staff and how we can sustain our work through other methods that are not dependent on us being there at all times.”

Every disaster brings lessons. Hard-won though they may be, they can inform the way forward. In May, the Association for the Health Care Environment held a webinar to provide guidance in “transitioning back to normal, albeit a new normal.” On the discussion list: What to do with rooms outfitted with special equipment, or the space that’s been converted to COVID care? What do environmental services leaders need to do to ensure facilities return to their “pre-crisis state”?⁹

“We’ll continue with this process now, likely until we get to a place where we can stand down our COVID cohort units,” Leach says. “We also have enhanced cleaning procedures within our public areas as we re-opened for elective surgery and procedure to ensure more frequent disinfection of countertops, door handles, and other high-touch places in those common spaces where patients and visitors are coming through. We’ll likely keep up the UV disinfection protocol for COVID patients after the pandemic is over. I hope we sustain the frequent cleaning of shared spaces and waiting rooms as well, but that will depend on staffing.”

“Some of the new protocols were temporary, like using alternative products,” says Rogers, “and they will go away as the availability stabilizes. Others, like enhanced training, will stay because it has proven to be a valuable tool.”

Draining and demoralizing as the battle has been at times, there has been an upside, he feels. “It took the whole department coming together to make sure that we were prepared and, most importantly, safe through this. I feel like we have learned to be nimble and adapt much quicker than was required in the past. Overall, I feel our department will only be stronger because of this experience.”

Not only that: “Our department has gotten tremendous support from our hospital and from the community as well,” Rogers says. “I feel that the need to keep things clean and safe has helped to elevate environmental services.”

JAN DYER is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

REFERENCES:

1. Wallace N. Environmental Services Fighting COVID-19. LVMC News. https://lompocvmc.com/blog/125-press-releases/1308-environmental. 04-22-20.
2. Occupational Safety and Health Administration. U.S. Department of Labor. Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers. https://www.osha.gov/Publications/OSHA_pandemic_health.pdf. OSHA 3328-05R. 2009.
3. California Hospital Association. Coronavirus Response. https://www.calhospital.org/coronavirus. Accessed 06-11-20.
4. California Department of Public Health. Licensing and Certification Program. All Facilities Letters-2020. https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/LNCAFL20.aspx.Accessed 06-11/20.
5. Missouri Hospital Association. A framework for managing the 2020 COVID-19 pandemic response and implementing crisis standards of care. 04-20-20. https://www.mhanet.com/mhaimages/COVID-19/A%20Framework%20for%20Managing%20the%202020%20COVID.pdf. Accessed 06-11-20.
6. Leingang R. Arizona Republic. Arizona COVID-19 spread is increasing and action is needed, experts warn. 06-09-20. https://www.azcentral.com/story/news/local/arizona-health/2020/06/09/number-covid-19-going-up-arizona-increased-hospitalization/5328560002/. Accessed 06-11-20.
7. Coronavirus in Illinois updates: Here’s what’s happening Thursday with COVID-19 in the Chicago area. Chicago Tribune. 06-11-20. https://www.chicagotribune.com/coronavirus/ct-viz-coronavirus-case/. Accessed 06-11-20.
8. Iowa Coronavirus Map and Case Count. New York Times. 06-11-20. https://www.nytimes.com/interactive/2020/us/iowa-coronavirus-cases.html. Accessed 06-11-20.
9. Association for the Health Care Environment. Post-COVID-19: Transitioning environmental services to a new normal. 05-21-20. AHE website.https://www.ahe.org/education-events/post-covid-19-transitioning-environmental-services-new-normal