Environmental Services Workers Need to be Certified

COVID-19 highlighted the crucial role that environmental services (EVS) teams play in thwarting the spread of infection in hospitals and other health care settings. Darrel Hicks, a past president of the Healthcare Services Institute, tells Infection Control Today^® that it’s time to create a certification process for these health care professionals. “And if we certify them, then we need to pay them better than we do,” says Hicks, who will be a presenter at the ISSA Show North America 2021, which will be held in Las Vegas from November 15 to November 18. “They’re the lowest paid people in the hospital and they have such an important role in patient care.” The title of Hicks’s presentation is “Safe/Clean/Disinfected Procedures in Health Care.” ISSA has existed under several different names for 94 years. One of those names was the International Sanitary Supply Association. In 2005, when the association branched out to include cleaning service providers, the name was officially changed to ISSA—The Worldwide Cleaning Industry Association. One of the things Hicks would like any certification to pin down is exactly what we mean when we say that an area is clean. In fact, he argues that maybe we should get rid of “clean” as a designation because “it means different things to different people. And ultimately, the person that’s doing the cleaning and disinfection needs to understand that it’s two separate operations. And too often, we interchange those terms.”

Infection Control Today^®: What were some of the changes caused by COVID-19 when it comes to procedures for safe and clean disinfection in health care that you think will last after the pandemic?

Darrel Hicks: Well, it changed a lot of things. It was a time of shortages, with the supply chain shortages of disinfectants. Certainly shortages of personal protective equipment. It was a very difficult time for the first few months. It seemed to level out after that. But because there wasn’t PPE for those who weren’t doing direct patient care, they’re trying to reserve what they have. They’re burning through isolation gowns and masks so quickly that the environmental services team was in many cases not involved with cleaning that patient’s room unless it was a terminal [discharge] cleaning. One of the things that I think the COVID-19 brought out was the need for educating environmental services about how things get transmitted. Initially, we thought it was being transmitted on surfaces and the air droplets that fall on high touch-surfaces, especially in

and around the patient bed. I call that patient bed the hot zone in the patient’s room. It’s more contaminated than the restroom is. And so that patient bed and the 36 inches around it… Just think about the shedding of these organisms. That was the hot zone. And in many cases the nurses were expected to maintain that environment. And only on discharge or terminal cleaning was EVS [environmental services] brought into the picture. So, that was different at first. And I think a lot of that leveled off later on. I think it really brought to fore the essential workers that EVS are in health care. What I have said for many years is that when this pandemic would come, that we need to have people who are environmental services workers who are certified to some level of knowledge about the transmission of disease, and their role in breaking that chain of infection. Too often, we just told them you use the pink stuff on this and here’s the color-coded microfiber wipes and here’s how you do it. And it was the how-tos without the why behind it. I think that we still need to certify that these workers that now we’re short of…. It used to be that they would come to work from a quick food service drive-through. And now they’re going to be cleaning patient rooms or possibly even the operating room this week when they were stuffing hamburgers into a bag last week. What has prepared them to protect the patients and the staff if we don’t have some level of certification for those workers?

ICT^®: When you say certification for EVS, what do you mean by that?

Hicks: I believe that they should be certified to a certain level of knowledge. In order to be certified, they need to be well trained. They need to be equipped with the necessary tools and equipment to do the job. They need to be allotted the right amount of time to do the task. And you can’t rush the process. They need to be…. We need to be measuring clean in those areas. So that we know that the products and the process and the person doing the job are validated. We audit the cleanliness of the area. And finally, that they’re being educated about the prevention and transmission of disease. That we are not just cleaning toilets and mopping floors. We have to be infection prevention on that frontline. Because it’s so important that we break that chain of infection. And you know that terminal cleaning is probably the one opportunity, but yet we find that wherever we scientifically measure the room after it’s been terminally cleaned, in many cases, fewer than 50% of those surfaces that are points of transmission were properly cleaned and disinfected. We have a long way to go to get to the point where we’re confident that [pathogens] don’t get passed from the previous patient to the next patient. But beyond COVID-19, we know that just with Clostridioides difficile…. That if we don’t break that chain of infection with that terminal clean that the next patients are put in much greater risk, sometimes 100% more risk of getting C diff, if we don’t do a proper job of removing the spores and then disinfecting with the right disinfectants. And during COVID-19 I think we were so focused on getting products that were on EPA’s [Environmental Protection Agency’s] List N…. There are 576 products on that list. And manufacturers are rushing to get their products tested and certified to make the list. But as we know, this envelope virus [SARS-CoV-2] is the lowest rung of the difficult-to-hard-to-kill organisms. The disinfectants that were effective against COVID-19 may not necessarily … probably aren’t registered for killing C diff spores, and even MRSA [Methicillin-resistant Staphylococcus aureus]. We saw MRSA rebound during this time. And from what I’ve seen, MRSA in hospitals jumped 32%, just in the last quarter of 2020 from the previous 2019. All the previous five years of gains of reducing MRSA in that environment [were lost and] now it’s a problem again. And then Candida auris is really more difficult to kill in the environment. But while we were watching COVID-19 and making sure that we have COVID-19 disinfectants, we took our eye off of some of these other organisms that proliferate in the hospital environment.

ICT^®: When you talk about certifying EDS teams, are you saying that each hospital system should basically educate them better? Are you thinking about some kind of national certification process?

Hicks: I think that we first of all need to agree on what that education should consist of. There are some good education programs out there, whether APIC [Association for Professionals in Infection Control and Epidemiology] put them out. But even when I see CDC’s…. Wherever I watched their information videos on COVID-19 cleaning and disinfection, I find that…. First of all, the terminology. It’s important that we agree on the terminology. And that we first get rid of the term clean or cleaning, because it means different things to different people. And ultimately, the person that’s doing the cleaning and disinfection needs to understand that it’s two separate operations. And too often, we interchange those terms. We have to come to an agreement—whatever certification program there is—about terminology. And we have to agree that these terms have gotten to be used in the education of the frontline workers doing that task. I think that we need to bring the stakeholders to the table. And I think that APIC, and AHE, which is the American Hospital Association’s Environmental Services Group, would need to collaborate and come up with a certification program. EVS teams work around professionals who are certified—whether it’s respiratory therapists, physical therapists, the RNs, the doctors—and I think if we ever hoped to elevate their status that we need to certify environmental services workers to a certain level of knowledge before they even start cleaning patient rooms. They might clean offices. They might clean public areas. Unless EVS workers are certified, I don’t think they should be cleaning and disinfecting patient care areas. We need to certify their knowledge of disease transmission. How things get passed around, and that we don’t clean just for appearance sakes, but we clean for health. And that health is the health of the staff, as well as the visitors. Anyone who comes into that hospital environment, whether it’s even an ambulatory surgery center. We are educating and certifying those workers so that the confidence of those who work around them and the patient in the bed is that they are certified. And if we certify them, then we need to pay them better than we do. They’re the lowest paid people in the hospital and they have such an important role in patient care. And they should be educated and certified in order to perform that task to a level that makes those surfaces safe, clean, and disinfected.

ICT^®: Do you think infection preventionists should monitor EVS departments?

Hicks: I do. And I think that [IPs should audit] that surfaces are indeed safe for patients. And I’m not going to say disinfected, because disinfection takes a great deal more effort. And to get surfaces to that level, then it’s going to take more time in that room to do that. Right now, the EVS person on a regular daily cleaning, if it’s a semi-private room and a restroom, they’re allotted 12 to 15 minutes in that room to do the daily cleaning and disinfecting. And on a terminal cleaning, it’s maybe 30 minutes, but that 30 minutes includes stripping the bed, washing the bed, cleaning all the surfaces in the room and making the bed. Depending on the length of stay of that patient—some of these patients during COVID-19 were in there for 30 to 60 to 180 days. And so I guarantee that environment in that patient room is going to take longer than 30 minutes to do a terminal cleaning. But I think that those two groups, the AHE and APIC, they’re the stakeholders. I believe that infection preventionists do need to be involved in auditing of the rooms. And that there is a way of tracking all of that. So, you know, ATP is one of those methods. But you have to realize that there are things that affect ATP readings, and we haven’t come to an agreement about what constitutes a safe surface. We haven’t even agreed on the RLUs [relative light units] that are acceptable in a patient care environment. There are no national standards for auditing. And we need to come to that some say no more than, you know, one Cfu [colony forming unit] per centimeter or centimeter squared. That’s what’s been used in the food production industry for years. And if it’s good enough for food production, it ought to be the standard for operating theatres and for patient rooms as well. One Cfu per centimeter squared is attainable, but it takes time and effort and education of those EVS workers to attain that. I seem to be out there on the edge of the frontier. And I think that we have made this whole thing way more complicated than it ought to be. And too often we depend on these room disinfecting systems—[such as] UV light—to take care of the human error part of things. Anytime you introduce a human into the process, then there are opportunities for failures. And I think that what we have in this country right now is a situation where patients are going back and forth to the nursing homes. The CDC says that 99,000 …. Americans die every year [from HAIs]. I think the numbers are much higher, because what we’re counting is just while they’re in the hospital. But they go back and forth to nursing homes, they go home, and they’re discharged. And then we have people walking around with MRSA and some of these MDROs [multidrug resistant organisms] that will be with them for the rest of their lives. And they’re shedding these organisms as they’re out there in the public. It’s a much bigger problem than what we’re conveying, but we need to get better at what we’re doing. I feel like I’m out there on the edge of the frontier trying to educate anyone who will listen. We need to do better in order to prevent these MDROs. They are going to be a much bigger problem for longer term. And since there are no new antibiotics really being developed, then proper cleaning and disinfection of surfaces in the future may be one of the only things that saves mankind.

This interview has been edited for clarity and length.