Lessons from the Frontline

Lessons from the Frontline

In 1742, Sir John Pringle, a physician, was tasked with logging the problems associated with the military life. It resulted in the book, Observations on the Diseases of the Army.

Pringle stated that there were two fundamental issues related to infection. The first was that inadvertent contact between medical professionals, the sick, and the instruments and surfaces they touched led to more instances of the same illness. The second was that the cause was not some mysterious ethereal phenomenon but rather an unseen one.

He was certain that infections were microbial in nature and that he could stop their spread with the use of a combination of chemicals, which he termed “antiseptic.” The solution was straightforward: keep hands, clothing and environmental surfaces clean and infections would be prevented.

Despite being over 250 years old, Sir Pringle’s efforts are still the theoretical basis of current infection prevention measures. Yet the relative simplicity of infection prevention principles is unfortunately not as easy to accomplish.

Today, healthcare facilities are an assemblage of departments each of which is responsible for carrying out certain roles. To prevent Healthcare-Associated Infections (HAIs) from occurring, there are usually two departments involved on the frontlines of the battle.

The first is the infection prevention and control department (IPC), which is staffed with academically-trained professionals. The other is the Environmental Services Department (ES), which is comprised of professionals who do the actual cleaning of the institution. Their job is to work together towards a similar goal, reduce the risk of infectious disease.

Unfortunately, as history has shown, this is where the problems start.

When hospitals want to compete in their market, leaders often look to the latest 128-slice, 3D CT scanner, a Divinci robot to perform intricate surgeries, recruit the best surgeon, or begin a new service line with the best ROI. While these capital expenditures and improvements might attract publicity for a fleeting moment, the Board of Directors needs to consider a different, low cost option that provides the best chance to improve patient satisfaction, reduce HAIs and improve the bottom line: the Environmental Services Department.

The literature is replete with articles and studies in infection prevention annals extolling the virtues of various environmental hygiene Products, Processes and Programs to reduce HAIs in healthcare. The one missing “P” is the People who work hard, do a dirty (sometimes disgusting) and repetitive job and make less than $15 an hour providing a safe, clean and disinfected environment for patients and staff, the People of the Environmental Services Department.

In an article titled, “Clean Sweep: Hospitals Bring Janitors to the Front Lines of Infection Control”, 8/15/12 Scientific American, Marilyn McKenna wrote, “It hasn’t been that long ago the poster bug for nasty bacteria that attack patients in hospitals was MRSA. Because MRSA clings to the skin, the chief strategy for limiting ist spread was thorough hand washing. Now, however, the most dangerous bacteria are the ones that survive on inorganic surfaces such as keyboards, bed rails and privacy curtains. To get rid of these germs, hospitals must rely on the staff members who know every nook and cranny in each room, as well as which cleaning products contain which chemical compounds.”

When it comes to keeping pathogenic organisms at a safe level on environmental surfaces, the least educated and lowest paid people in the hospital must eliminate those dangerous bacteria. “This is the level in the hospital hierarchy where you have the least investment, the least status and the least respect,” says Jan Patterson, MD, past president of the Society for Healthcare Epidemiology of America (SHEA).

To a hospital or health system, the risks and financial burdens are not trivial. In fact, on a larger scale, it has been estimated that HAIs arising in U.S. acute care hospitals cost America as much as $147 billion annually, according to data published in the Journal of Medical Economics (Dec. 2013).

The impact of HAIs implies prolonged hospital stays, long-term disability, increased resistance of microorganisms to antimicrobials, a massive additional financial burden for health systems, high cost for patients and their families, and excess deaths. In Europe, HAIs cause 16 million extra days of hospital stay, cause 37,000 attributable deaths, and contribute to an additional 110,000 every year.

In Canada, rising infection rates in hospitals are causing unnecessary suffering and death and are taxing the healthcare system as well as patients and families.

  • Each year in Canada, more than 220,000 HAIs result in 8,500-12,000 deaths, and the rates are rising.
  • One in nine hospital patients in Canada get a healthcare associated infection.
  • Infections are the fourth leading cause of death in Canada

Many hospitals and healthcare organizations have consistently held a low regard for the ES department. Too often, housekeeping or environmental services workers are thought to be expendable (anyone knows how to clean a toilet and mop a floor, right?) and difficult to educate because English is not their first language. To those organizations, the thought is, “What if I educate them and they leave?” But, far worse than that, what if you don’t educate them and they stay?”

Simple cleaning of the environmental surfaces may be one of our key defenses in the future battle against infectious disease. With antibiotic-resistant organisms proliferating on common touch-points for up to 56 or more days, the time has come to turn cleaning professionals into a Certified Environmental Services Technician (CEST). Moreover, infection prevention will only become a reality when the CEST is properly regarded, educated and equipped.

The CEST must be:

  • Well trained
  • Equipped with the necessary tools to clean, sanitize or disinfect
  • Allotted time to do the necessary tasks to process a room or item
  • Provided the tools to a scientifically validate the process, product and person performing the task
  • Educated about the prevention and transmission of disease.

In closing, the message from the frontline in the battle against HAIs is:

One well-trained, conscientious CEST given the right tools and enough time to perform the job to a standard will prevent more disease than a room full of doctors can cure.”

Prevention trumps a cure every time.



About Darrel Hicks

J. Darrel Hicks, B.A., is the author of Wiley Publishing's "Infection Prevention For Dummies", and is nationally recognized as one of the top experts in infection control. Darrel Hicks is also the Past President of the IEHA and is an active member in AHE where he holds the designation of CHESP. View all posts by Darrel Hicks

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