Setting the Latest Standards in Room Cleaning and Disinfection

Critical care perspectives on TJC requirements

Wendy Simpson, MSN, RN, CCRN, FCCS, Infection Prevention, Lt. Col. Luke Weathers, Jr. VA Medical Center, commented on the critical care implications of the new and revised TJC requirements. She highlighted IC.07.01.01, a new standard that addresses preparedness for high-consequence infectious diseases or pathogens, stating:

“This standard was inspired by the recent outbreaks of Ebola and COVID-19. Though the standards leave decisions related to frequency and levels of disinfection up to the individual facilities, each facility should have a robust cleaning program in place, particularly in our ICUs.”³

Perioperative perspectives on TJC requirements

Karen deKay, MSN, RN, CNOR, CIC, FAPIC, senior perioperative practice specialist, AORN, offered her insights on how the new and revised TJC requirements impact cleaning and disinfection practices in the perioperative environment.

“The new and revised Joint Commission infection prevention and control standards are more streamlined and focus on the structures and processes that support a strong infection prevention and control program,” said deKay. “The reason for this restructuring is because infection prevention is not just about individual practices, but instead the overall framework in which infection prevention occurs.”

deKay highlighted these three elements of performance (EP) from TJC’s requirements that are particularly important to the perioperative space:³

IC.04.01.01 EP 2 recommends that hospitals foster a multi-disciplinary approach to infection prevention and control. “Communication and collaboration among various departments including infection prevention, nursing units, sterile processing, perioperative personnel, and environmental services are key,” deKay explained. “Personnel from perioperative services may be asked to serve on a multi-disciplinary team to discuss challenges, share insights, and implement best practices.”

IC 04.01.01 EP 4 clearly identifies key elements for cleaning, disinfecting, and sterilizing medical equipment and surgical instruments that should be included in a hospital’s policies and procedures. “As surgical instrumentation, as well as a variety of noncritical devices and equipment, are utilized in every surgical procedure, perioperative personnel should review these elements carefully,” said deKay. 

“Some elements include following manufacturer’s instructions for use (IFU), using U.S. Environmental Protection Agency (EPA) registered disinfectants and U.S. Food and Drug Administration (FDA) approved liquid chemical sterilants, developing criteria for immediate-use steam sterilization, and documentation of device reprocessing cycles,” she added.

IC.07.01.01 EP 1 states facilities should have a protocol in place for recognizing, responding, and containing potential high-consequence infectious diseases or special pathogen outbreaks. “This is important for perioperative personnel because surgery for a patient with a confirmed or suspected infection with one of these pathogens may be necessary,” deKay commented. 

“Protocols should include not only room preparation and PPE, but also how cleaning and disinfecting of the patient care area, surfaces, and equipment, as well as handling of waste and linen will occur,” she continued. “Education and training on the new protocols should be developed for all personnel, along with demonstration of those skills and tasks specific to their roles (e.g., cleaning operating rooms, sterilizing instruments).”

The importance of collaboration

As TJC’s requirements demonstrate, collaboration among EVS, IP, perioperative, and critical care teams (and other clinical department teams as well) is critical in room cleaning and disinfection efforts.

“EVS is a profession and it’s a very important profession,” said Marci Butts, director of Environmental Services, West Hospital, Mercy Health, Cincinnati. “That’s why we must have a seat at the table and a strong connection and relationship with our IPs and other teams responsible for patient care and safety. None of us can be on an island. We must work together and all be speaking the same language.”

Janet Flynn Mulroy, DNP, ACNP, CCNS, CCRN, Acute Care Nurse Practitioner, Threlkeld, Threlkeld, and Omer Infectious Disease Associates, spoke to the importance of this collaboration in critical care environments. She served on the national board for the AACN.

“Our critical care patients are at a much higher risk of infection than the average acute care patient, so maintaining a clean, anti-infective environment is essential to protect patients, family members, and staff,” said Mulroy. “The EVS team plays a crucial role in shaping the patient experience within a hospital setting. Even though EVS staff follow rigorous cleaning protocols with daily disinfection of high-touch surfaces in high acuity areas, the high traffic flow and the additional equipment found in critical care units create challenges unique to the ICU environment.”

“Utilization of AACN’s Healthy Work Environment (HWE) standards of skilled communication, true collaboration, and effective decision making with EVS, IP, and critical care clinicians is crucial to prevent spread of infection in the ICU,” Mulroy added.

Commenting on the impact of this collaboration in the perioperative environment, deKay stated:

“Explicit communication and collaboration between different departments (e.g., EVS, IP, perioperative services) within a healthcare organization can significantly improve both patient and healthcare worker safety. The collaboration can play a crucial role in ensuring proper cleaning and disinfection of perioperative areas, as when everyone is on the same page, all work to make sure infection control protocols are followed consistently.”

“My own interpretation of TJC’s changes is that infection prevention must be integrated into all hospital departments and functions, including EVS, nursing and engineering,” said Marie Moss, MPH, RN, CIC, APIC Communications Committee Member. “Specific to EVS, consistent and timely communication around room contamination between IP and EVS leaders helps ensure EVS workflows remain in alignment with IP protocols.”

Simpson noted how TJC and several other advisory groups, such as APIC, recommend a system wide multidisciplinary approach to maintaining a safe and clean environment.

“It is beneficial to schedule regular multidisciplinary Environment of Care Rounds between EVS, IP, and critical care clinicians to evaluate current processes,” she stated. “The Environment of Care team members can discuss new and emerging diseases, assess knowledge gaps, provide needed education, and assure appropriate staffing and resources to provide a safe environment for everyone.”

Katelyn Harms, MPH, CIC, APIC Communications Committee member, Infection Prevention program manager, Performance Improvement Dept., UnityPoint Health, Meriter, Madison, Wis., spoke to the close relationship between EVS and IP leaders in her health system, stating:

“Our EVS workers are really our right hand in infection prevention. Acquisition of HAIs from environmental contamination is incredibly common; therefore, we know routine disinfection practices are essential to providing safe patient environments. EVS workers partner with us to identify problem areas, often serving as our eyes and ears.”

UnityPoint Health’s EVS supervisors participate in the health system’s IP committees and annual risk assessments. They also routinely receive IP data around HAIs. Additionally, IP professionals participate in new EVS employee onboarding, orientation, and training. 

“I love having face-to-face time with new EVS orientees so they know the IP team and understand we’ll have an ongoing collaboration throughout their employment,” she stated. 

Harms and team review EVS competencies and training materials and infuse IP principles into EVS practices so, in Harms’ words, “they know not only how to clean a room but why their work is so important to break the chain of infection.” 

In conclusion, Harms stated: “Our message to EVS staff is clear - they have the power to impact patient safety.” 

Tips for collaboration

Butts, deKay, Harms, Moss, and Mulroy offered tips for fostering effective collaboration among EVS, IP, and perioperative services and critical care teams. 

Acknowledging individual team members

“We mentioned using HWE standards of skilled communication, true collaboration, and effective decision making while engaging a multidisciplinary team for monitoring the ICU environment,” Mulroy commented. “We can also use AACN’s HWE standards of ensuring appropriate staffing and meaningful recognition in nurturing this initiative. A collaborative approach allows each individual to focus on their particular specialty and identify potential issues before they reach the patient. This approach also recognizes each team member for the value they bring to the organization and engages all levels of staff members in development and maintenance of a strong, effective disinfection program.”

Documentation

Butts emphasized the importance of documentation, not only to guide cleaning and disinfection efforts but also to demonstrate to TJC and other agencies specific protocols a facility has in place and who is responsible and accountable for performing specific tasks. According to Butts, a critical piece of documentation assists in tracking “who cleans what.”

“It's very important to have a document of who cleans what, not only in the specialty areas, but throughout the house,” said Butts. “An anesthesia cart has multiple instruments on it, for example, so it’s important to know exactly who is responsible for each item to ensure high quality and safety controls. We need that documented so everyone knows where the responsibility lies and how we go about making improvements there.”

Butts says she meets every week with perioperative department leadership to review the “who cleans what” document, and to discuss issues and improvements related to it. She and her team also regularly don surgical personal protective equipment (PPE) and enter the operating rooms (OR) to conduct inspections and speak with perioperative services staff members on cleaning and disinfection topics.

Gap analysis or Gemba walk

deKay said one approach to “help all disciplines get on the same page” is to complete a gap analysis of environmental cleaning processes to compare actual performance with potential or desired performance.

She noted how AORN provides members with a gap analysis tool, which lists all the recommendations from the AORN Environmental Cleaning guideline.⁴ 

“This document can be used for direct observation of cleaning processes in their facility,” deKay explained. 

Another option is to perform a Gemba walk, said deKay, which is a process that involves interviewing and walking side by side with those individuals responsible for cleaning to understand their issues and opportunities. 

“It is recommended that these reviews be completed by an independent observer, such as an infection preventionist, as this removes those closest to the source and provides a more objective view,” deKay commented. “Once the gap analysis or Gemba walk is completed, a summary of what was found should be compiled and shared with perioperative and environmental cleaning personnel, to help with buy-in and to focus on what needs to be improved.”⁵

Environmental monitoring

Harms says her team uses environmental monitoring as a strategy for onboarding new EVS employees in alignment with IP protocols. For example, they employ florescent markers on high touch surfaces to evaluate disinfection practices and train EVS professionals on how to improve cleaning effectiveness.

Moss spoke to room turnaround time pressures that EVS professionals face, which she says are always there and can impact thorough cleaning of a room.

“Managing the time to clean and disinfect a room between cases must be a coordinated effort between nursing and EVS staff so there is timely notification of when that room is no longer occupied and ready for turnover,” said Moss. 

Moss acknowledged how turnaround time pressures can lead to missed steps in room cleaning and decontamination processes. She also made the distinction between different protocols for different patient types – occupied and discharged rooms for standard patients versus those infected with one or more multi drug resistant organisms (MDRO), such as methicillin-resistant Staphylococcus aureus (MRSA).

She commented on ways her team engages in constructive and collegial communication and collaboration with the EVS team when addressing hygiene gaps. One methodology they employ to simulate germs is a cream product which contains fluorescence particles that sparkle when exposed to a black light. 

“It is a great technique for training EVS to see if they have cleaned and disinfected all high touch areas in a room,” Moss explained. “We use it to make handprints on surfaces like doorknobs, sinks, toilet flushers, and bed rails before cleaning is performed. If the handprints are visible under the blacklight following a cleaning, the IP and EVS supervisors work with the EVS staff member on re-training.”

Additionally, Moss noted how clinical teams are responsible for removing potentially dangerous items from a room, such as medications and sharps, before EVS staff enter the space to disinfect and clean.

“We are all responsible for keeping patients safe, but we must also ensure that spaces are safe for EVS to perform that work,” Moss commented. 

The VHA sets standard processes for UV-C radiation

Alongside standards are technologies IP and EVS teams can employ to help optimize room cleaning and disinfection practices.

Ben Guerrero, Deputy Director, Environmental Programs Service, Department of Veterans Affairs (VA) and his colleague Trina Zabarsky presented a session entitled “Advancements in Cleaning and Disinfection Technology“ during the AHE Exchange24 Summit, which was held July 22-24, 2024, in Phoenix.

Guerrero and Zabarsky focused not only on the technologies themselves, but also strategic implementation, stakeholder satisfaction, and related continuous improvement initiatives. Guerrero spoke to HPN regarding the VA’s use of UV-C technology as an adjunct to manual room cleaning and disinfection throughout its 162 medical centers. 

“Use of UV-C disinfection skyrocketed with the COVID-19 pandemic, to the point where VA Medical Center usage of the technology is somewhere around 88% today,” said Guerrero. “When performing on-site visits and reviews of cleaning and decontamination practices, we found there were no standardized processes around UV-C usage. EVS technicians would roll the UV-C machine into a room and run it without considering positioning of the device.”

To help ensure VA Medical Centers were getting the most out of their UV-C technology investments, Environmental Programs Service collaborated with CARRIAGE II VA Quality Enhancement Research Initiative (QUERI) Program researchers as well as UV-C equipment manufacturers to establish standardized best practices that EVS technicians could employ. This served as the foundation for a toolkit that includes chapters on ultraviolet light, disinfection, the benefits of UV-C processes for disinfection, quality assurance and validation, and frequently asked questions. 

As Guerrero pointed out, simply rolling a UV-C machine into a room and running it does not equate to effective use of the technology; therefore, the toolkit goes in-depth into the processes that maximize its efficacy. This includes consideration and practices ensuring target surfaces are exposed to the ultraviolet light for the amount of time recommended by the manufacturer. 

“We worked with UV manufacturers to determine the best processes for deployment, such as pulling out tray tables, opening drawers, facing monitors downward, and lowering operating room (OR) booms so they are exposed to the UV-C light,” Guerrero explained. 

Guerrero and his team piloted this toolkit at six VA Medical Centers alongside education and training of EVS technicians. He commented on this work, stating:

“It’s important to gain front-line employee buy-in for UV-C because when they understand it, they are more likely to use it. We conducted a pre-test to assess EVS technician knowledge of UV-C prior to the toolkit education and a post-test to determine whether our training was effective.”

They employed UV dosimeter cards as a training and verification tool, incorporating their use into the VA’s sanitation procedure guide. When exposed to UV-C light, the cards reveal a checkmark. On initial set-up of the UV-C equipment in a room, EVS technicians are instructed to place the cards in high touch/target areas to confirm the required amount of ultraviolet light is reaching them. 

“That way, EVS technicians have a standardized practice where they are bringing the UV-C machine into a room and placing it where it will provide the maximum efficacy,” said Guerrero. “As the UV-C machines age and their bulbs start to lose effectiveness, we instruct EVS technicians to use the dosimeters to make sure they are still achieving the required efficacy.”

“We don’t mandate usage of the dosimeter cards, but we do tell the field, ‘If you're going to use UV-C, the cards will be a best practice for you,’” Guerrero added. “We are very clear that UV-C machines will never replace manual cleaning and disinfection because ultraviolet light will not remove bioburden on surfaces. If faced with the choice of using either manual cleaning and disinfection or UV-C, the best practice is to go with the manual methods.”

Guerrero and his team have also worked on standard practices for the use of other technologies for disinfection. This includes electrostatic sprayers, which VA Medical Centers recently added to its contracts. 

“Obviously, there are concerns when it comes to electrostatic sprayers,” said Guerrero. “For example, they are not to be used in spaces where you cannot disturb the air, including pharmacy compounding areas. There are also considerations about the personal protective equipment (PPE) required to use them. We are approaching 13,000 EVS technicians nationally. We want to make sure that they're safe and we're doing the right thing by them.”