PREVENTIVE MEDICINE

Ask most facilities management (FM) professionals to list the top three things that keep them awake at night and you’re likely to hear: safeguarding occupant health and safety, safeguarding occupant health and safety and, yes, safeguarding occupant health and safety. In many ways this FM fixation is a mere manifestation of a global Zeitgeist that has made us all — in recent times — more alert to and wary of myriad manmade and natural threats to our well-being.

Nowhere are these modern-day facility management challenges more crystallized than in the medical facility market. And, arguably, nowhere is there more urgency — and sophistication — associated with keeping clients, employees and the public from harm’s way.

A recent Chicago Tribune investigative report alleges that in the United States in 2000, an estimated 103,000 patients’ deaths were linked to nosocomial (hospital-acquired) infections and that the causes of 75 percent of these deadly infections (unsanitary facilities, unwashed hands and unsanitary instruments) were preventable. The Tribune also cites a U.S. Centers for Disease Control and Prevention (CDC) report that deaths linked to hospital infections represent the fourth-leading cause for mortality among Americans.

More recently, the emergence of severe acute respiratory syndrome (SARS) has raised the bar on hospital readiness. Medical facilities find themselves battling new and exotic pathogens and also worrying about the safety of caregivers.

While medical facility housekeepers share many of the same health priorities as their counterparts in other building markets, there is one critical task unique to the former: fighting lethal infections and combating the spread of infection.

And, depending on the size of the health-care facility, methods of managing infection control may vary. Smaller organizations might rely on vendors and outsourced expertise to keep on top of products and procedures for fighting infection. Larger, more established medical facilities might boast a relatively elaborate in-house infection control operation.

The role of infection control departments
An infection control department usually provides specific information on proper cleaning processes and the appropriate products to use for each hospital or clinic area. The department keeps track of infectious diseases within the hospital, including infections people might have coming in — and what they might contract at a hospital.

“Our primary focus is to prevent nosocomial infections,” says Debbie Ellis, infection control coordinator at St. Elizabeth’s Medical Center in Edgewood, Ky. “We also look for [infection] trends and similarities among areas, people and departments.”

Ellis says she creates baseline rates for infections based on hospital data and works to maintain those rates.

“When we see a change in infection rates, we work to find the cause of that infection,” she says.
Sonny Wyatt, director of environmental services at Anderson Area Medical Center in Anderson, S.C., says he relies on an infection control staff to answer questions, give advice and approve cleaning products.

“We give them all of the data on our supplies and they review our procedures for all areas, including patient areas and operating room suites cleaning and disinfecting,” Wyatt says.

Risk assessment
In addition to regularly scheduled meetings, environmental services and infection control meet informally as often as needed.

One of the most important projects shared by the two departments is developing a facility risk assessment.

Every organization is different. The group conducting the risk assessment considers the type of medical facility and the type of patients inside. The group might take into account the number of patients and the kinds of diseases treated in the facility, among other things. Documented risk levels help determine what cleaning procedures are best for a particular facility.

“[The group] develops policies in each department — for ORs, exam rooms, patient rooms, ERs. There is a need for a different level of cleaning in different areas,” says Carl Solomon, senior maintenance operations consultant for Kaiser Permanente hospitals in Oakland, Calif.

Contaminated areas
Staffs should work together to determine the role various surfaces and objects, also known as fomites, play in the spread of infection. A fomite is defined as an inanimate object that serves to transmit an infectious agent from person to person. Fomites serve as a reservoir for pathogens, which are spread from the inanimate object to an animate object (person) via hands.

Although most nosocomial infections usually result from patient contact&Mac226; poor hand hygiene and person-to-person transmission, contaminated surfaces also have been linked to infection spread.

Interior surfaces within patient areas — including exam rooms, operating rooms, emergency rooms and isolation rooms — may be contaminated with human pathogens, bloodborne pathogens, respiratory and intestinal viruses and other harmful microorganisms.

Although microorganisms may be present on walls and floors, unless visibly soiled, they are infrequently associated with the transmission of infection. However, walls, blinds and curtains should be washed periodically.

“Housekeeping staff should be trained in the major areas of transfer — vertical surfaces, hand contacts on doors and so on,” says David Frank, consultant to the cleaning industry.

Environmental services managers identify what surfaces get contaminated and when contamination is likely to occur. They evaluate the potential for direct patient contact, likelihood that the surface is contaminated with bodily substances, the degree and frequency of hand contact and the patient risk of infection.

For example, housekeepers change the curtains in rooms of patients who have been placed on contact/droplet precautions, like a patient with SARS.

In addition, managers determine the frequency of cleaning for each surface and decide what methods should be used to clean the surfaces, including types of disinfectants, equipment and cleaning strategies.

Most importantly, housekeeping staff pay special attention to high-touch surfaces, such as bed rails, bedside tables, light switches, doorknobs and faucets.

“It’s easy to overlook light switches, the bottom of the handrail on the bed or a knob on a bedside table,” says Weston Thiss, CHESP, director of environmental services at Bon Secours Health System, Richmond Va., and president of the American Society for Healthcare Environmental Services (ASHES).

“[Managers] need to really think critically about the surfaces touched in the room, even the side of the television or a picture frame on a nightstand,” he says.

Using people, products and processes to stop the spread
Using the proper chemicals, equipment and cleaning process is key to preventing cross-contamination.

Frank likes to use the three terms “people, products and processes,” to describe the most important elements that round out the cleaning operation.

Specifying disinfectants and germicidal products depends on factors such as: the surface classification, resistance of the microorganism to the chemical germicide, cost, safety and ease of use.

“There are germicides that cover multiple bacteria and diseases,” Solomon says. “Managers should look for a germicide that doesn’t leave a film on the floor but covers a broad spectrum of germs and bacteria.”

Going along with Frank’s “products, people, process” philosophy, Solomon says managers should make sure housekeepers are using the disinfectants correctly.

“Housekeepers should follow the label instructions precisely,” Solomon says. “Some germicide [labels] say in order for the germicide to be effective, the end user needs to use distilled water [for mixing the solution]. Or, the label might say the floor needs to be wet for at least five minutes or longer.”

He also says it is important that workers use the right amount of solution and water, prevent the germicidal solution from mixing with other chemicals, and ensure buckets are rinsed out after each use.
“It doesn’t matter if a chemical is a phenolic or EPA-registered disinfectant,” Frank says. “It is the correct procedure and the distinct process that matters.”

Solomon recommends environmental services departments use microfiber mops because the mops are better at containing bacteria and require less germicide. The mop heads also are thin and lightweight, making it easier to keep many clean mop heads stacked on cleaning carts as housekeepers move from room to room.

Managers should be sure microfiber mops are washed at the recommended temperature and air-dried, he says.

“The old way, the housekeeper would use one mop and change it every three rooms,” he says. “Microfiber mops make it easier to use a fresh mop for every room, eliminating cross-contamination.”

Frank says other procedures for preventing cross-contamination include using divided mop buckets; using single buckets, as long as the water is changed frequently; using flat-mop systems that have peel-off mop heads, so a new mop is used in every room; and using bucketless mopping systems.

The right cleaning products are important, he says, but in order for the products to be effective, housekeepers need to be trained in using the product correctly.

“My concern is whether the person cleaning is using a succinct process,” Frank says. “Are they mopping with systematic, overlapping passes or just ‘swabbing the deck?’ Are they changing the mopping solution? Contamination begins immediately when you put a dirty mop back into the bucket of clean solution.”

The importance of clean hands
Hand hygiene is the single most effective means of preventing the spread of nosocomial infections among hospital patients and personnel.

According to hand-hygiene guidelines, workers should wash their hands before and after patient contact; immediately and thoroughly when the hands are contaminated with blood or body substances; after gloves are removed; after using the restroom; and after performing cleaning tasks.

Hand hygiene involves the traditional method of handwashing (soap and water) or the use of waterless alcohol-based hand cleaners which are formulated to remove or kill microorganisms.

Most health-care facilities have introduced alcohol-based hand cleaners. In October 2002, the CDC released guidelines that promote the use of alcohol-based hand rubs to protect patients in health care settings.

“We recently started using waterless hand cleaners in all patient rooms and care areas so everyone can clean their hands as they enter or leave a room,” Wyatt says. “It’s not to take the place of soap and water — when hands are visibly soiled we use soap and water.”

There are advantages to using an alcohol-based hand cleaner. First, the cleaner is waterless, so there is no need for a sink or paper towels. Second, the cleanser is fast-acting. According to reports, the cleanser decreases the amount of bacteria on hands 10,000-fold in 15 seconds. The killing action from an alcohol-based hand rub is twice as fast compared to traditional handwashing.

Finally, alcohol-based hand cleansers have been proven to be gentler on hands than soap and water.

But the waterless cleaners have become controversial because they are highly flammable.

“Our biggest challenge is to come up with an appropriate placement for the dispensers,” Ellis says. “It defeats the purpose to put them next to sinks and it makes the most sense to put them near the door. But light switches and outlets are usually near the door and that presents a risk of fire.”

Protective equipment
When faced with cleaning up blood and bodily fluids, CDC’s “standard precautions” will help management and staffs determine what personal protective equipment is needed.

“[Hospital staff] don’t always know what a patient could have,” Ellis says. “And [staff] can’t always rely on the signage on the door.”

Gloves provide an extra layer of protection. Housekeepers should wear non-sterile gloves for all cleaning procedures. Disposable gloves should be changed whenever they start to deteriorate, between cleaning each patient room or area, and following contact with visibly contaminated objects or surfaces. Gloves never should be washed or reused.

If cleaning staff have to enter an isolation room, they have to put on a pair of gloves before entering, Ellis says. “Before [cleaning staff] leave the room, they should remove the gloves and wash or decontaminate their hands. If a housekeeper doesn’t change his or her gloves, there is a risk there. We don’t allow people in hallways with gloves on.”

Workers should don protective gowns for any cleaning procedure involving large amounts of blood or body substances that may be difficult to properly contain or may splash or splatter.

Workers should wear masks for cleaning blood or bodily fluids that may accidentally contaminate the mucous membranes of the mouth and nose. Masks also should be worn in the rooms of patients on “airborne precautions” and “droplet precautions.” When entering rooms of pulmonary tuberculosis or SARS patients, workers must wear a N-95/HEPA respirator must be worn, according to the CDC.

Workers also should wear protective eyewear for cleaning blood or bodily fluids that may splash or splatter.

Handling new diseases
To stay up to date on new diseases, regulations and guidelines, environmental services managers should work with their infection control departments, check association Web sites and talk with their peers to stay informed on the proper cleaning procedures and precautions.

“[Infection control staff] cover the hot topic on the plate, just like a hepatitis-C outbreak or tuberculosis,” Solomon says.

“We rely heavily on the CDC to get out the information and tell us what they think the spread is, what they method of transmission is, and what to be aware of,” Ellis says.

Many managers have plans in place to prepare for the possibility of having a SARS patient in their facility.

“[When SARS appeared on the news] the infection control nurse and I sat down and looked at the available data and said, ‘OK, how are we going to handle this?’” Thiss says. “We decided we aren’t going to take any chances.”

His organization plans on going beyond CDC recommendations — taking extra precautions in some areas, such as personal protective equipment.

Planning for SARS
By checking CDC and other association Web sites, Thiss recently found out that SARS “does not like” acidic substances, for example. Such news is helpful in the pre-planning process for SARS patients.

“We might use a more acidic cleaner for handling SARS,” Thiss says. “Otherwise we try to stay with neutral pH cleaners because acidic cleaners tend to be too tough on surfaces and floors to be used all the time.”

Thiss still is looking for the right acidic cleaner.

“If [we got a SARS patient today] we’d use our phenolic cleaner and wipe down everything,” he says.

Thiss points out that most hospital infections require staffs to follow CDC’s “contact precautions,” but SARS appears to fall under both “droplet” and “contact precautions.”

SARS patients are placed in negative-pressure isolation rooms. “There are four to six changes in air pressure in the room before anyone goes inside,” he says.

The housekeeper cleaning a negative-pressure room would wait one hour from the time a patient leaves before entering the room, Thiss explains. Upon entering in full garb, the staff would assume all linen is infectious. One person would clean the room while another would wait outside holding a bag for linens. The staff would double-bag and seal all linens.

In addition, Thiss says staff will give chemicals a longer dwell time before wiping down the surfaces.

When completely finished disinfecting the room, the housekeeper would take off all garb and hand it through the doorway, putting everything in an infectious medical waste bag.

“Nothing that goes into the room will be saved,” Thiss says. “Even the plastic spray bottle for the cleaning chemical will be thrown away.”

Although Thiss has a plan in place for handling SARS patients, he is waiting to train the entire staff on the proper cleaning procedures.

“We don’t want to create a panic,” Thiss says. “When a SARS patient is admitted, we’re not expecting 50 patients in the first day. We have supervisors, our most qualified and experienced people, who have been trained to handle [cleaning around] SARS. It would be a little overkill right now to train environmental services staff after just going through smallpox, anthrax and dirty-bomb training.”

Thiss is mostly concerned about how and where SARS patients might enter the hospital.

“The first point of admission is very critical,” he says. “We’ll have to find out exactly where that person has been in the hospital. But once the person is in the facility, we are pretty much ready to handle it.”

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