The problem

The Centers for Disease Control estimate that 300 patients die every day in U.S. hospitals from the C. difficile bacteria, which can remain infectious on a surface for several months.

The biggest culprits are those most frequently touched areas and fixtures in a clinical setting such as door handles and light switches. Cleaning those surfaces to reduce patient exposure was never more important: Recent studies have shown that the risk of developing the infection doubles if a patient occupies a room previously occupied by a patient with C diff.

What’s being done

Last fall, Southern California’s quality and risk management group launched a pilot project in environmental services departments throughout the region to focus on “high-touch” areas and cut down on potential infections. The Northwest region was not far behind in establishing similar training and procedures at its Sunnyside Medical Center.

“It’s so important because of the risk for transmitting resistant organisms,” said Enid Eck, Southern California’s regional director of Infection Prevention and Control. “And two ways those bugs get transported is when the environment gets contaminated and if a health care worker doesn’t wash their hands.”

Both regions are making use of a sophisticated reactive gel, which is applied to the high-touch areas before cleaning. After cleaning, a UV light reveals whether the surfaces have been cleaned sufficiently.

How Riverside achieved its turnaround in performance

When the Southern California program began, the first step was to get a sense of how often and how many of the high touch points were being cleaned effectively.

Riverside EVS manager Cora McCarthy was crushed when she learned her department’s results. Initial testing found that staff was cleaning 3% of the touch-spots. The goal is to have over 90% of those surfaces be clean.

And Riverside was not alone. Most medical centers in Southern California showed troubling baseline results, making clear this was an area needing improvement in many in-patient settings across Southern California.

“I almost died when I saw that,” McCarthy said, adding that there was a gap of nearly 25 percentage points to the next closest facility.

Once McCarthy got past the initial shock of the scores, she produced a laminated list of the high-touch areas for each employee—even before official training and education began.

“I thought, ‘You know, we need to start getting busy on this,’” McCarthy said.

By the second testing, the department had jumped to 50%.

Eventually, with labor co-lead Sandra Pena, the Riverside EVS unit-based team rolled out extensive education and training offered by the region, including the use of the gel. Environmental services workers were educated on the 14 high-touch areas that harbor the highest concentration of infectious organisms.

The results are impressive: As of June, nearly 80% of the touch spots were showing up clean. Other Southern California inpatient medical centers have exceeded the 90% goal, including South Bay, Panorama City, West LA, Irvine and San Diego. Many others are close behind.

Collaborative approach

From the start, the project received support and input from Southern California's LMP leaders and union representatives, making sure that both management and staff understood that the process wasn't meant to be disciplinary in any way.

Instead, it was stressed from the outset that the tests and findings were an opportunity for learning and performance improvement. If areas are missed, supervisors and managers coach staff to ensure that everyone provides the same standard of cleaning.

"At first, people were afraid they were going to lose their job," Pena said. "Then they realized it was something everyone is doing."

Northwest UBT tackles the problem too

The EVS department at Northwest region’s Sunnyside Medical Center is doing related work. The local UBT there has developed visual display of the procedures, and a quality assessment program similar to the one in place at Riverside. The team also uses the gel method of assessing the cleanliness of a room after a staff member has cleaned it. They identified 18 frequently touched areas.

“This is work the team can be proud of. Keeping our patients healthier is what it's all about,” says Ladonna Sullivan, the EVS manager at Sunnyside.

Breaking down the procedure

To measure the cleanliness of the hot spots, EVS managers are alerted when a patient is discharged. Before any cleaning begins in the room, the manager applies the gel on all 14 high-touch points. The manager is alerted again when the room’s cleaning has been completed, and returns with a UV light to shine over each touch point. If anything lights up, there's more cleaning to be done.

“They were things they were already doing, but they needed to do more detailing,” Pena, a member of Steelworkers Local 7600, said. “They’re glad they got that. I think everybody’s learned something different. It helps them. Now they think about those things.

“Some people,” she added, “say they’re even doing it at home now.”

Patients like the effort

And patients feel more confident too. When McCarthy needs to conduct the “black light” test in a room already occupied by a patient, she explains that it’s for their safety in preventing infections, and it gives them peace of mind.

“’I say ‘I’m here do to some quality testing,’ and explain it to them,” she said. “They think it’s great, that’s wonderful.”

“The teams have experienced fabulous improvements,” Eck said. “That has been a huge source of pride for EVS staff. EVS are really partners in infection control.”

Taking it national

Acknowledging the success seen in Southern California, the effort is now part of a larger push across Kaiser Permanente to reduce hospital-acquired infections through surface contamination.

A national EVS work group this year created standard policies and procedures, quality assessment tools, training and contract language—all based on the Southern California work—to ensure the same standard of service for the ROC regions where environmental services is outsourced.