At the SHEA Spring 2017 Conference on March 30, 2017, David P. Calfee, MD, MS, discussed the role that the environment plays in transmission of healthcare-associated infections, and why cleaning and disinfection measures need to be improved to reduce these infections.
A reoccurring theme discussed throughout the Society for Healthcare Epidemiology of America (SHEA) Spring 2017 Conference was finding ways to prevent the transmission of healthcare-associated infections in healthcare facilities. On March, 30, 2017, David P. Calfee, MD, MS, associate professor of Medicine and Health Policy & Research, Weill Cornell Medicine, talked about the role that the environment plays in transmission, and why cleaning and disinfection measures need to be improved to reduce these infections.
The hospital environment frequently harbors a variety of pathogens. For example, investigators have shown that 42% of rooms holding patients with Acinetobacter baumannii infection were contaminated with that organism, and in methicillin-resistant Staphylococcus aureus (MRSA) patient rooms, that number rises to 73%. Even more unsettling is that some investigators have reported 100% environmental contamination of rooms housing patients with Clostridium difficile.
“Now you might say, of course, that’s not a surprise, but it might not be that important because these rooms are being cleaned on a daily basis, and again, even more thoroughly at the time of discharge. However, a lot of evidence is out there that suggests these pathogens are frequently recoverable from the environment after cleaning has occurred,” Dr. Calfee said.
To this end, Dr. Calfee cited a recent three-year long study of nine hospitals and two long-term health facilities that found that even after daily cleaning was performed in “multidrug-resistant organism (MDRO) contact isolation rooms,” in 34% of the rooms, MDROs were recoverable from the environment. Even more unsettling is that, even after terminal or discharge cleaning, which is arguably more laborious, investigators were still able to recover MDROs in 18% of the rooms.
So, why aren’t current cleaning and disinfection practices getting rid of these harmful pathogens?
Dr. Calfee postulates, “I think a very simple and probably basic explanation for all of this is that these services just aren’t being cleaned reliably.”
Another study conducted in 2006 found that one out of every two high-touch surfaces within hospital rooms are not cleaned at time of discharge. “This persistent frequent contamination of the environment is a real problem,” said Dr. Calfee.
Contamination of the environment can lead to the contamination of healthcare workers (HCWs), which could lead to the transmission of pathogens to other patients and more areas within the environment. One study Dr. Calfee highlighted detailed how they had a HCW perform hand hygiene and then go into a patient room and put their hands on a bedrail and the bedside table for five seconds each. After these acts, hand cultures were then performed on the HCW. The findings were startling. After just five seconds of contact, the hand cultures tested positive for several pathogens (such as Staphylococcus aureus, vancomycin-resistant Enterococci (VRE), gram-negative bacilli, and C. difficile) in 53% of the occupied rooms and, even more unsettling, 24% of the rooms that were not occupied, or the “clean rooms.”
The process of achieving and maintaining a safe, clean environment is incredibly “complex,” said Dr. Calfee, “[And,] perhaps even more importantly, this relies on individual human behavior and effective communication.” Success in this goal depends on the cooperation of several groups, not just environmental service workers; doctors, nurses, and techs also need to clean equipment from time to time. In addition, these complex cleaning tasks need to be carried out frequently, sometimes even daily.
Similar to what plenary speaker Matthew Kreuter, PhD, MPH, discussed in his presentation, Dr. Calfee also touched on behavior change techniques and the importance of understanding the drivers of human behavior in order to drive the change that is needed to improve cleaning and disinfection strategies.
After asking conference attendees to start thinking about how their own institutions or facilities go about improving quality in Environmental Services, Dr. Calfee shared the approach that he and his colleagues came up with to improve cleaning and disinfection practices to reduce HAI transmission. This approach is being used in five acute campuses of the New York Presbyterian Hospital which range in size from community hospitals to academic medical centers.
The first step? To “get a full picture of the current state of cleaning and disinfection in all of the hospitals,” he said; this includes looking at policies, procedures, and products and seeing if they fall in line with current evidence and guidelines. In addition, this means looking at the visual appearance of the hospital (if the floors are shiny, if it looks clean), doing objective assessments, checking adherence to current policies and protocols, looking at Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores related to environmental cleanliness, as well as looking at patient outcomes that may be related to environmental cleaning. However, Dr. Calfee added, “I would argue that none of these [actions] by themselves really give you that full picture. I think you really need to look at it from multiple avenues in order to really understand what’s going on in your hospital.”
Dr. Calfee continued, “We needed to step back and critically look at our systems and understand what it was about them that was preventing us from receiving or achieving the results that we wanted, and identify what we needed to do differently in order to get our desired results.” To do this, his team used a non-judgmental, objective, impartial observer and had the individual shadow the Environmental Services (EVS) team to learn from them and observe their activities and interactions.
To get an even bigger picture, they also created and implemented a knowledge, attitudes, and practices (KAP) survey “so we can get a more representative understanding of what some of the barriers were and really start to quantify and even prioritize some of the barriers that exist,” said Dr. Calfee.
A total of 45% of the EVS workers completed the survey, and it yielded a wealth of important information, according to Dr. Calfee. “We found some opportunities for education, personal safety concerns (such as toxicity of the disinfectants and concern about getting infected by being near patients),” he said, adding, “There was opportunity to increase their understanding of the important role that they play in preventing infection transmission, and basics about hospital-acquired infections, and infection prevention strategies.” Based on the results of the survey, they also found that the workers desired more constructive feedback regarding their performance.
Furthermore, Dr. Calfee and his colleagues were able to quantify some barriers that the workers were up against, which included “pushback from patients regarding cleaning in their immediate vicinity and clutter in the environment,—both of which inhibited daily cleaning activities—interruptions, lack of clarity regarding cleaning responsibilities, and some larger cultural issues such as perceived lack of appreciation and respect from other HCWs, and a concern about not wanting to get near patients for cleaning because they world disturb and interrupt them and interfere with their healing process.”
Dr. Calfee then shared a project that they have been carrying out to “address more of those adaptive issues that we’ve identified.” The project entails an interactive educational series consisting of five sessions, as follows:
So, has the program effective? To evaluate this, Dr. Calfee and his team used the Kirkpatrick Model for evaluating the effectiveness of training, which consists of four levels: 1) Reaction; 2) Learning; 3) Behavior; 4) Results.
Because the last sessions of the project were just conducted last week, the only available data at this time pertain to the first two levels, which seem to show some “pretty good outcomes.” Dr. Calfee reported, “[A total of] 92% [of participants thought] the material was definitely useful; 90% [said] that they would recommend it to their coworkers; 72% [learned] something new; and 94% felt that the suggestions related to those common barriers would be useful, which was particularly encouraging to us.”
Dr. Calfee concluded, “Throughout this project, [we’ve learned that] improving is hard, and sustaining improvement can be even harder. Why does this happen? For me, I think about it through the character Doug, from the movie, Up. Doug gets very excited about things and he focuses a lot of attention and love on something when he first sees it, but then a squirrel goes by, and he’s totally forgotten what he was so in love with.” He added, “I think that’s kind of what we often do. We’re very involved in a project and then a squirrel goes by, [or] The Joint Commission comes to see you, or some new problem comes along, or the grant funding runs out, and we’re distracted. So, I think we need to think about how we can’t be a Doug, and how we can [instead] maintain our focus and continue to improve what we’re doing.”
SHEA Spring 2017 Conference
Environmental Services as a Patient Safety Initiative