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Based on the results of studies dating back to 2006, Philip Carling, M.D., believes he has found a key element for helping hospitals reduce infection and transmission rates of pathogens, such as C. difficile and methicillin-resistant Staphylococcus aureus (MRSA). The professor of clinical medicine at the Boston University School of Medicine advocates renewed attention to environmental cleanliness and the education of environmental services (ES) staff to go along with hand hygiene efforts. Carling says hospitals have seen sometimes dramatic reductions in surface contaminations after working with ES personnel to apply basic education and feedback. “The ES line staff are sometimes viewed as invisible people—they don’t seem to have a role in anything except keeping the floor shiny,” Carling says. “But they’re part of infection control and what they do is important. With our program we’ve given them a way of being recognized.”
Q Why should hospitals take a fresh look at environmental cleanliness?
When it comes to combating hospital infections and transmissions, three intervention points are particularly practical. You enhance patient isolation, you enhance hand hygiene, or you enhance environmental hygiene. Isolation is hard to do and hard to comply with. For the last 12 years, the whole hand-hygiene juggernaut has rolled along and a lot of work is being done to improve compliance. But it still is a problem area. Compliance isn’t what we want in most hospitals. There’s also the whole problem that with hand hygiene, you can’t do it at the most critical times. When you move between a patient and machinery then back to the patient, then back to the machinery, you can’t perform hand hygiene between every patient contact even if you were really conscientious.
Q Given that, do you think the whole environmental aspect has been overlooked?
Yes, it’s been overlooked. This goes back to the 1950s when staph infections became rampant in hospitals because of the Asian Flu. The first intensive care units were developed at that time, [so was] the first resistance [in staph] to penicillin. Everybody became very concerned, and that’s when isolation really took off. When people started culturing the environment they found staph, so they started focusing on environmental hygiene. But after the epidemic quieted down, they kept culturing the environment. Nurses would go around and culture once a week—the surface of this and that, and they kept coming back with non-Aureus staphylococcus. Just skin staph. The CDC saw all the effort being put into this culturing and monitoring with nothing coming of it, so they started saying in the 1970s to stop culturing the environment.
So now we have hundreds of thousands of environmental services folks working hard and doing what they think they’re supposed to do with regard to disinfectant cleaning. But it turns out that on the basis of what we’ve discovered over the past couple of years, things aren’t being ideally cared for in terms of environmental hygiene in most hospitals.
Q How big a factor is this in hospital infection rates?
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We’ve learned in the last few years that the environment plays a role in infections of C. difficile (which is by far the most important in terms of the environment and transmission), MRSA, VRE, Acinetobacter, norovirus, and others. It’s not an insignificant role, but is it a gigantic role? That’s hard to say.
Good studies haven’t been done yet to fully assess how much of a role exactly because it’s difficult to separate whether it was the hand hygiene that failed when the nurse touched the doorknob that was contaminated with MRSA and then touched the patient. Or was it environmental hygiene that failed because the doorknob hadn’t been cleaned in a month?
Q You started being involved in environmental cleanliness studies in 2006. What has your research found?
In 2006, those were the preliminary studies I did with an evaluation system I developed called the direct targeting method. We were just looking at [terminal room cleaning]: disinfecting a room upon a patient’s discharge.
In the first three hospitals we looked at, the environmental hygiene was an average of about 50 percent clean. In other words, 50 percent of the 14 things that should be cleaned according to what the CDC and past research studies suggested were actually cleaned. You can view that in two ways—the glass is half full or half empty. The phrase I use is there’s “opportunity for improvement.” On the basis of that, I recruited other hospitals. We gave each of the 36 hospitals a kit to do an environmental sampling covertly without environmental services being involved. They found where their baseline was in terms of terminal cleaning. Then we gave them a kit with educational materials and some advice about how to begin to change environmental service’s view of what they were doing, which is a critical aspect of this method. All of a sudden, through the education and performance feedback [for ES staff] we saw moderately good improvement in most hospitals—up to about 80 percent thoroughness from roughly 50 percent.
Q What are some of the techniques that you suggest, not only for training and raising awareness for ES staff members, but also for getting them to feel more involved with hospital operations?
We found that in most hospitals (but not necessarily every one) over time they do better when there’s performance feedback [for ES staff]. Once they start doing better, the infection control personnel have the opportunity to say, “Look at what a great job these folks are doing.” And this is the first time that anybody’s ever been able to give positive feedback to ES folks. Think about it, what’s the feedback loop when you’re an ES person? It’s “The floor isn’t shiny, there’s dirt in that corner, what’s that red spot on the wall over there?”
Q All negative feedback...
Exactly. If all of a sudden they’re getting positive feedback, the response becomes very nice. It’s true that to some degree APIC [Association for Professionals in Infection Control and Epidemiology] has been trying to put together better educational materials for environmental services. But my personal bias is that there has to be a system that provides feedback to the [ES] folks.
Environmental services line staff in general are very conscientious people [even though] they are doing a rather mundane job that nobody gives them much credit for. It’s just that they’ve never been told what to do completely enough.
Think about how a lot of folks get trained. They come to a hospital without any specific health care training. So Mary teaches Joe exactly what she has been doing [for terminal room cleaning], which means she does a very good job of cleaning tray tables, sinks and bedside tables, but never thought about cleaning the grab rail next to the toilet or the toilet room door handle because nobody ever really asked her to do that.
Q In the hospitals that see improvement, how long does it usually take?
[In some,] it’s instantaneous, just with education. It can get up to more than 90 percent with just education. That happens in about a third of hospitals. In about a third of hospitals, it takes a couple of cycles of feedback to exceed more than 85 percent. That means about six months’ worth of interventions. Then some hospitals just don’t improve too much.
For some, that’s because the hospitals are already doing well, relatively speaking. They’re already at around 75 percent or 80 percent, which is about the best we’ve seen pre-intervention. They don’t make the effort that somebody would if they found they were at 20 percent, let’s say. And then there are these other hospitals that just have a hard time.
I think data is going to come out from our work in the next year or so that will probably suggest that it is a more common problem with larger hospitals than it is with smaller hospitals. If you have an ES staff of two and a supervisor who also works as a line person, you can get improvement pretty quickly. But if you have a staff of 200 ES folks, it might not be as quick. A lot of it depends upon administrative commitment.
Q Have you been able to correlate improvements in environmental cleanliness to the rate of hospital infections?
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The answer is that we’re getting there. There is good evidence with C. diff, VRE and MRSA that using a structured program can certainly decrease environmental contamination. That’s been pretty nicely shown in several studies. There’s little doubt, as you might expect, that improved environmental hygiene and disinfectant cleaning decreases environmental contamination. But the next step is determining where there is proof that improved cleaning and decreased environmental contamination leads to decreased transmission of pathogens.
The answer is coming along. This is such a new thing. There are some folks talking to me from the CDC and the VA system to develop research projects to answer that question. I’m pretty sure we will be able to show something [positive], but it’s not easy because it gets into epidemiology and the problems of trying to do epidemiology in acute care settings. There are so many variables. If you improve environmental hygiene and at the same time hand hygiene is improved, then which one caused the decrease [in infections]? The only way to answer this question is with a multisite project that uses 20, 30, 40 hospitals so so-called “confounding variables” cancel each other out and you can statistically look more clearly at your intervention.
Q You mentioned that some of these training techniques don’t work for all hospitals. Why not?
Many factors that account for that, and I’ve been learning about this over the past five years by talking to infection control professionals and ES managers. Sometimes the ES leadership doesn’t feel the [cleanliness] data is useful to them.
They’re used to doing things their own way and a new evaluation of what their staff is doing isn’t, let’s say, what they’ve wished for. And when they see not-so-good results, rather than do something about it, they maybe will stonewall it a little bit.
Q Let me ask you about two practical considerations related to the ES staff. One is that in a lot of hospitals there’s a fairly high turnover rate in this area. If training and awareness is important, how can hospitals accomplish this when there’s a steady stream of new ES personnel?
You’re right, some hospitals have taken longer to improve for that reason. What happens is they improve dramatically and then a couple of months later they recheck and all of a sudden things are much worse. Not as bad as the baseline, but they’ve fallen off perhaps 20 percent to 30 percent.
That helps these hospitals then say, “We have to incorporate this whole educational piece right away when new employees come to the hospital. Not once a year.” [High turnover] has not been a problem once the structure for what we’ve been doing has been put into place.
Q What about ES staff members who speak English as their second language? How does that complicate the incorporation of these procedures?
I haven’t really been able to study that area much yet, but I’m working with a group of hospitals in California, and I’m translating some of the materials into Spanish. That’s an important issue and one that needs to be addressed.
Q Have you heard any anecdotal comments about how significant the language barrier may be?
It’s not something that I’ve heard complaints about yet, but maybe I haven’t sampled the right patient population group.
Q In addition to staff turnover, are there any other factors related to recidivism?
The major one is not the turnover of personnel, it’s [the lack of] administrative recognition and support for the program. There are some hospitals where this approach has been just a little research tool. There just hasn’t been any support for the infection control folks to continue with the project.
Infection control practitioners or preventionists are being stretched so far and so thin. We’ve had many hospitals withdraw from the research projects because the infection control professionals didn’t have enough time. We’ve worked this project in the hospitals that have done the research primarily through infection control, and then brought environmental services on board very early on to help support it. That’s been a very positive thing for that relationship [between the two staffs], which is one that is sometimes a bit tenuous. Again, what feedback do environmental services people ever get from infection control except negative feedback? In some hospitals there’s not a, let’s say, pre-existing working relationship.