Infection Preventionists, Environmental Services Need to Work More Closely Together

COVID-19 forced infection preventionists (IPs) and environmental services (EVS) teams to improvise during the surge. That often meant that the two departments had

to collaborate in ways they didn’t before. That’s not a bad idea even as COVID-19 recedes, says Sharon Ward-Fore, MS, MT(ASCP), CIC. Ward-Fore, a member of Infection Control Today®’s Editorial Advisory Board, recently sat down with ICT® to discuss how crucial IP-EVS collaboration is for infection control and prevention in healthcare settings, the importance of following donning and doffing protocols for personal protective equipment, and the need for IP expertise in long-term care facilities.

Infection Control Today®: What should the relationship between infection preventionists (IPs) and environmental services (EVS) look like?

Sharon Ward-Fore: It should be a collaborative type of relationship. The hospital I worked at, I was the IP liaison for EVS, and I worked very closely with the managers and the boots on the ground; the EVS workers cleaning the areas. And I think it’s really, really important for IP to be part of the EVS team and EVS to be part of the IP team because we’re so intimately connected. We should be included in discussions about cleaners and disinfectants that are used in various areas of the hospitals. We should be involved in the training, so that we’re knowledgeable about how they’re trained so that when we’re up on the units rounding and auditing, we know that they’re following their own processes. Where I came from infection prevention monitored the rooms using ATP [adenosine triphosphate]. We were required to do two rooms a month just to make sure that we were following our own cleaning practices. And we had a cut-off point with ATP light units so that we knew that the room was clean or not clean. So, besides a visual, we were actually monitoring for level of bioburden, too. Which is really important. Now, EVS was also doing the same thing, but there is sort of the rub. If that’s your department and you’re monitoring your own results, there’s the potential for bias. I’ll just put it that way. I think when there’s another system of checks and balances that’s outside of the department, but has that department’s best interests in mind, it provides another level of scrutiny that’s not biased. When I would monitor a room and I’d find something wrong, you would just let EVS know when they would come and reclean the room. But we were also tracking data—both EVS and IP—and we would notice trends. So then working together, you would kind of dig down into what’s happening and figure out if there’s retraining that’s needed. Are people not using cleaners appropriately? It is a collaboration, and I think the most successful environmental services department has an infection preventionist who really enjoys working with EVS.

ICT®: Did you notice a change in how EVS cleaned because of COVID-19? Did they wear more personal protective equipment, or different PPE?

Ward-Fore: I think during COVID-19, EVS—probably the only thing that changed was the volume of room turnovers. I’m thinking specifically like in an ED. And that they really needed to wear PPE in the general areas as opposed to when they just enter the patient room. So EVS for example, in an ED would go from bay to bay to bay cleaning. They would be reusing their PPE just like staff members. Probably cleaning more frequently and wearing PPE that maybe they’re not the most comfortable with. That’s a point where, moving forward, I’m a firm believer in hands-on PPE training. Not just a video where you click through some boxes and you watch someone don and doff. I think training on PPE so that people are comfortable—EVS and everybody else—will probably be something we should do moving forward. In general, I think, EVS; their processes won’t change. There are all kinds of new disinfectants out there now with maybe quicker dwell times. Maybe that will change, but how they clean won’t change. Now, you’re right. CDC did recommend that for COVID rooms, if the nurse is in the room, the nurse should do the cleaning. And that’ll work when maybe there’s a couple of patients, but I think in general EVS rose to the occasion and went in these rooms and cleaned them when patients were in there. Of course, wearing the appropriate PPE. For facilities that had the luxury of not having to have EVS go in there, I think that’s the best-case scenario. Just like with our Ebola training, if the nurse is already in the room caring for the patient, you’re looking at fewer possibilities of contamination down the road.

ICT®: Many of infection prevention protocols had to be adjusted when COVID-19 surged? Where do you see that going?

Ward-Fore: I think, as IPs, we’re going to get some pushback. Because staff to put PPE on day in and day out, they get tired of it. And now that we’ve shown that we can successfully manage patients without it, it’s going to be a tough sell to get us back to our regular policies. Now, having said that, I think before we throw everything to the wind, we need to go back to our procedures using PPE if we’re able to without using up our PPE. But in the meantime, I’m hoping someone is looking at data from this period of time where we haven’t used that PPE. And where we’ve done environmental sampling, and where we’ve been continuing to do very immersive surveillance on our patients and finding out: Did we have an uptick in these organisms when we weren’t using PPE? I’m a big advocate of PPE because I think it does prevent horizontal transmissions. But as I’ve been reading more and more in the literature, that’s one thing we can do. There’s a whole bag of tricks out there that we probably should be trying to do a little harder. And one of them is also discontinuing precautions for people. You know, people sometimes are on lifetime precautions for MDROs, but they may not need to be on for MRSA or VRE. There are criteria that can be followed to remove that precaution. And maybe we don’t do that enough. Something to look at as we move forward so that we can reserve PPE for our worst case scenarios and maybe spend more time getting patients off of lifetime precautions, if there’s the ability to do that safely.

ICT®: Do you see the infection preventionist role expanding?

Ward-Fore: I do and one area that’s been woefully underserved is long-term care. And I think you’re going to see a big change in how long-term care is handled. IPs don’t have any oversight over that. Typically, in long-term care, they have their pseudo infection control person. Usually it’s a nurse that’s been assigned that job as well as 100 others. But I think now with this pandemic, there are more eyes on long-term care and congregate facilities. Even jails, where we’re going to have to have maybe IP consultants help people figure out what to do. And I don’t think you need a full-time IP. But you need someone you can call and say: “Hey, I think I have a problem,” and that person can come in and help guide you through what needs to be done. Someone needs to be keeping track of PPE for these types of facilities. Someone needs to be training staff on the importance of PPE and these facilities. And I just don’t think they’ve had the manpower to do that. And because of it, we’ve seen tragically that long-term care is where we’ve seen the majority of deaths. So yes, I think that there will be a need for IPs to step into areas they haven’t touched before. Even the dental industry has risen to the occasion. There are all kinds of areas that will need some guidance by IPs. I think there’s a lot of opportunities for IPs to stretch their legs a little bit and become knowledgeable in areas outside of acute-care facilities.

ICT®: Any final advice for your fellow IPs?

Ward-Fore: I’m hoping that hospital administrators will realize the value of IPs and of having an infection prevention and control department. Pandemics are one thing we do. But patient safety is first and foremost in an IP’s mind. And it touches areas that no one even thinks about. It’s construction and renovation. It’s EVS, it’s food services, the laboratory. I think IPs are stretched pretty thin in most healthcare settings and maybe moving forward, systems will realize they need more specialists to be able to handle the many areas IPs touch. And I think a lot of people don’t know all the areas that IPs touch. So maybe now they’ll understand. We’re not just the cops with our white gloves making sure you wash your hands and tie your gown. We do way, way more. And in a pandemic, you’ll see how important it is to have good IPs who are able to be flexible and learn and educate the boots on the ground.

This interview was edited for clarity and length.