May 2012 HEALTHCARE White Paper ENVIRONMENTAL SERVICES

Specialized. Proven. Exceptional. Guaranteed.SM

White Paper

Crothall Healthcare’s Strategic Initiatives for Reducing Healthcare-Associated InfectionsRich Feczko

Tim Polizzi

Steven J. Schweon

Mark Shamash

Teri Alameda

C R O T H A L L H E A L T H C A R E

E N V I R O N M E N T A L S E R V I C E S

Very few people … have any idea of the exquisite cleanliness required in a sick room!

– Florence Nightingale, 1859

EXECUTIVE SUMMARY Crothall Healthcare’s Environmental Services program focuses on the challenges healthcare personnel (HCP) face in reducing healthcare-associated infections (HAIs) while meeting regulatory compliance, maximizing limited financial and human resources—all while meeting expectations of improved operational efficiency and maintaining a competitive edge.

Crothall’s effective, synergistic and proven approach managing environmental hygiene and the impact on patient safety sets the industry standard for efficiency and

effectiveness. By using a thorough,

integrated, best-practice approach that

requires standardized processes, outcomes

measurement, ongoing training and

innovative technologies, Crothall is able to

reduce environmental contamination and

pathogen transmission that lead to reduced

HAIs and favorable patient outcomes.

This white paper:

• Discusses the association among

hospital environmental contamination,

pathogen transmission and patient

safety

• Describes Crothall’s strategic initiatives

with reducing environmental

contamination and promoting improved

patient outcomes

May 2012

TABLE OF CONTENTS

1 Executive Summary

2 Introduction

2 Background

4 The Crothall Healthcare Solution

10 Mt. Sinai Hospital Case Study

11 Summary

12 References

13 Contact Information

2 | Crothall Healthcare

INTRODUCTIONThe rising cost of HAIs

There are an estimated 35 million admissions to acute care facilities annually,(1) with 1.7 million patients being affected by a secondary healthcare-associated infection,(2) and 99,000 associated deaths.(2) Thirty-two percent of the infections originate from the urinary tract; 22% of the infections are a result of surgery; 15% of the infections are pneumonia; and 14% are bloodstream infections (fig. 1).(2) HAI medical costs range from $28.4 to $45 billion dollars annually; infection prevention interventions can result in savings of $5.7 to $31.5 billion dollars annually.(3)

The rising costs of treating infection coupled with the knowledge that certain infections can be prevented has led the Center for Medicare and Medicaid’s (CMS) Inpatient Prospective Payment System and some private insurers to no longer reimburse for several preventable HAIs, e.g., catheter-associated urinary tract infections, surgical site infections after coronary artery bypass surgery. Clearly, HAIs result in a mounting personal, medical and economic toll, especially impacting patients who are immuno-compromised.

Patients are routinely exposed to microorganisms that are ubiquitous in the healthcare environment. Increasingly resilient and opportunistic bacteria, spores and viruses are shed from patients and staff, and these pathogens:

• Can contaminate the hospital environment

• May be transmitted between patients and the healthcare provider

• May lead to potential infection with significant morbidity and/or mortality

Microorganisms are progressively more adept at sur- viving and reproducing on environmental surfaces(4) while also developing increasing resistance to available treatments,(5) thus posing a challenge to the infection prevention and medical teams.

Healthcare leaders need to consider new management strategies to achieve operational efficiency. Crothall Healthcare’s proactive and vigorous response to environmental hygiene is focused on a commitment to patient safety coupled with innovative and strategic initiatives. Our proactive, proven approach to disinfection cleaning processes sets the industry standard for thoroughness and effectiveness with reducing potential infection risk and resulting in improved patient outcomes and satisfaction. These strategic

initiatives and positive outcomes can be found in

the Mt. Sinai Hospital case study beginning on p. 10.

BACKGROUNDPatients’ PerspectivePatients expect their hospital room to be clean;(6)

it’s critical the hospital room is meticulously

cleaned and disinfected prior to their admission

and on a daily basis during their stay. Additionally,

they anticipate a satisfactory and uneventful

outcome and do not want to become ill with

an HAI, potentially resulting in additional

morbidity, extended hospital admission and

possible mortality. Many variables impacting

pathogen transmission are associated with

infection prevention practice compliance;

environmental cleaning, hand hygiene, staffing

challenges, antibiotic policies, disinfection/

sterilization practices, employee vaccination

compliance, hospital census, patient acuity and

facility design may all affect total outcomes. All

of these variables must be proactively addressed

to be able to meet patient expectations in today’s

competitive marketplace.

Contaminated Environmental SurfacesAn estimated 20% to 40% of HAIs have been

attributed to transmission by the hands of HCP who

have become contaminated from direct patient

contact or by indirect contact with contaminated

environmental surfaces.(7) While hand hygiene

is the most important way to reduce pathogen

transmission in the healthcare environment, it is

exceptionally challenging to measure adherence,

with varying compliance rates across studies.(8)

The evidence that pathogens responsible for

healthcare-associated infections can be widely

found in the hospital environment(9–12) and

hence readily acquired on the hand by touching

surfaces(13) does demonstrate the importance

of decontaminating hands before every patient

contact.(14)

Patients are the prime source for environmental

contamination; surfaces within the patient’s

vicinity, also known as the “patient zone”(15)

that are frequently touched by the patient and

HCP have an increased contamination frequency

than other sites.(17) Environmental surfaces and

equipment can harbor pathogens (fig. 2). This

contamination may contribute to the spread of

disease-causing, multidrug-resistant organisms

(MDROs), such as MRSA (Methicillin resistant

Fig. 1: Healthcare-associated infections (HAIs) reported at acute care facilities annually.2

32%urinary tract17%

other

22%surgical

15%pneumonia

14%bloodstream


Staphylococcus aureus), VRE (Vancomycin resistant

Enterococcus), and C. diff. (Clostridium difficile).(16,17)

MRSA Surface Contamination

Epidemiological studies have shown that patients

admitted to rooms previously occupied and

contaminated by patients with these pathogens

are at significant risk of acquiring these organisms

from contaminated environmental surfaces that

were not properly disinfected and cleaned upon

discharge of the previous patient.(17)

Microorganism Transmission

Patients—and sometimes HCP—will shed bacteria,

spores and viruses into the hospital environment,

creating potential threats to other staff members,

patients and visitors.(17) Microorganisms may be

attached to droplets, skin scales or other particles

and disperse through the hospital environment,

where they have the ability to survive for hours

to days to months (fig. 3). Transmission of many

healthcare-associated pathogens is related

to contamination of near-patient surfaces and

equipment.(10, 20) Environmental contamination

depends on the following:(17)

• The ability to culture the organism

• The degree of patient shedding; infected

patients shed more than those colonized

• The number of culture-positive body sites

• Sampling methodology

• Difficulty of cleaning the environment

• Presence of an ongoing outbreak

• Diarrhea, with widespread contamination

• Type of patient

In addition, horizontal surfaces have a greater

amount of microorganisms and contamination

than vertical surfaces, ceilings, and intact walls.

Importance of Cleaning and Disinfection

Cleaning, the removal of soil and contaminants

from surfaces, is recognized as a vital component

of the intervention package required to reduce

hospital infection.(21) Disinfection results

in destroying pathogens. Friction is also used

to remove surface contamination. The type of

materials used in environmental surfaces and the

design/amount of equipment in a patient’s room

will impact cleaning effectiveness.

Effective cleaning and disinfection will decrease

the number of environmental pathogens, reduce

the risk of transmission and potential infection,

and be an integral part of a hospital’s infection

prevention and control plan. It is highly likely that

cleaning practice plays a larger role in positive

outcomes than does the product used.(22)

Daily Cleaning and Disinfection Challenges

Numerous clinical studies indicate thoroughness

of disinfection cleaning may be suboptimal and

can be significantly improved.(20) Environmental

surface contamination may contribute to the

spread of disease(16) and potential infection by

contaminating HCP hands, gloves, uniforms,

gowns and equipment. Several significant

pathogens, including MRSA, VRE, C. diff. spores

and Acinetobacter baumannii can survive, under

certain conditions, for four to five months or

more.(17) Norovirus can survive for a week or

more.(17)

The number of microorganisms on a surface is

impacted by:

• Amount of surface moisture

• Amount and type of activity taking place

in the immediate vicinity

• Amount of air flow

• Prevailing ambient temperature

• Number of people interacting with

the environment

• Type of environmental surface and its ability

to foster microbial growth

• Biofilm development on equipment

and furnishings

0 10 20 30 40 50 60 70 80 90 100

Floor

Bed linen

Patient gown

BP cu�

Overbed table

Side rails

Bath door handle

Infusion pump button

Room door handle

Percent Positive for MRSA

Fig. 2: Percentage of environmental cultures positive for MRSA, by direct plating and by broth enrichment, by item cultured.(11)

Pathogen Length of Survival

Acinetobacter 3 days–5 months

Clostridium difficile 5 months

Enteroccocus, including VSE1 and VRE

5 days–4 months

Klebsiella2 hours–>30

months

Staphylococcus aureus, including MRSA

7 days–7 months

Lingering Contamination

Fig. 3: Length of Pathogen Survival on Environmental Surfaces(4)


Hospital environments are complex and may result

in disinfection cleaning challenges. A surface may

appear “clean” but still harbor pathogens. Frequent

environmental contamination has been implicated

as a contributing factor during protracted outbreaks

of MRSA, C. diff., VRE, Acinetobacter baumannii,

and norovirus.(17) Evidence exists that improved

cleaning regimens are associated with the control

of outbreaks(9, 18) and bacterial transmission.(10)

Environmental surface contamination with

pathogens can be transmitted onto the hands of

HCP and may spread disease-causing organisms

like MRSA, VRE and C. diff. to the patient.(17)

Regulatory and Governmental Agencies’ Perspectives

Regulatory agencies, including The Joint

Commission (standards and National Patient

Safety Goals) and the Centers for Medicare and

Medicaid Services (CMS), in conjunction with the

United States Department of Health and Human

Services (HHS) and the Centers for Disease

Control and Prevention (CDC), recognize the

importance of environmental hygiene to reduce

infection. These organizations are increasing their

recommendations and standards to improve

environmental hygiene. The regulatory agencies

are requiring documentation demonstrating

that hospitals are focused on reducing HAIs. The

evolving regulatory and governmental healthcare

emphasis is to supervise, inspect, analyze and

optimize the thoroughness of disinfection cleaning

to ensure safe patient care.

Importance of a Clean Environment

There is generalized agreement that a clean

environment is necessary to provide both good

standards of hygiene and maintain patient and

staff confidence.(25) Patient satisfaction surveys

also question the hospital’s cleanliness. Patients

may subjectively consider hospitals “dirty” and

will associate this with a general lack of care.(25)

The media also have a heightened interest with

environmental hygiene and reporting on “dirty

hospitals.” Many states now have public reporting

of hospital infection rates, with diminished

reimbursement in some situations, for having

higher-than-expected infection rates. The hospital

must strive to meet community standards and

exceed expectations to avoid negative outcomes.

The impact of negative media coverage can

adversely affect the bottom line.

A clean, disinfected environment may promote

a healthier workforce. HCP who work in close

proximity to patients, including those who

provide either direct or indirect patient

care, need to stay healthy to come to work,

reduce infection risk to their families, and

minimize the potential of spreading illness

to patients.

Meeting the Challenges

Healthcare providers must align their operations

to more efficiently meet HAI challenges.

Effective administration and management of

environmental services resources are critical for

improving processes and maintaining a safe and

clean environment for patients and healthcare

personnel.

In the markets we serve, we will be recognized as the premier provider of the highest quality, customer-focused support services.

Crothall Healthcare Mission Statement

THE CROTHALL HEALTHC ARE SOLUTION

Strategic Initiatives for Improved Outcomes

The Centers for Disease Control and Prevention

(CDC) divides housekeeping surfaces into two

distinct groups: those with minimal hand contact

(e.g., floors and ceilings) and those with frequent

hand contact (also known as “high touch

surfaces”),(26) which have the potential to become

reservoirs for infection. High-touch surfaces

can quickly become contaminated; pathogen

transmission is related to the contamination of

near-patient surfaces and equipment.(20)

High-touch housekeeping surfaces include:(26)

• doorknobs

• bedrails

• light switches

• wall areas around the toilet in the patient’s room

• edges of privacy curtains

and(27)

• sink

• bedside table

• side rail

• call box

• telephone

§482.42 Condition of Participation: Infection Control(23)

“… The hospital must provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases. ”

Standard EC.02.06.01

“Areas used by patients are clean and

free of offensive odors” (The Joint

Commission. Accreditation Program:

Hospitals)(24)


The CDC recommends that high-touch house-

keeping surfaces should be cleaned and/or

disinfected more frequently than surfaces with

minimal hand contact(26) and that programs be

developed that optimize cleaning thoroughness.(20)

The Human Factor

Every day, HCP perform thousands of

interventions and actions that have the potential

to transmit infection and/or cause environmental

contamination. To address the problem, there is

a focus on technical solutions—re-engineering

protocols, adopting new products and

researching new technology. But what cannot

be overlooked is the human factor: the front-line

housekeeping staff, whose daily cleaning and

disinfecting activities help to protect the patient.

The cultural divide between the environmental

services and clinical staff is a resultant theme

impeding hospital cleanliness.(19) Optimal

performance barriers include:(19)

• Gaps in training, education and

understanding of their role

• Separation from traditional hospital clinical

team

• Potential for language or understanding

barriers

• Pressure from nursing and admitting staff to

clean a room under the allotted time

• Feeling of disempowerment to challenge

hospital staff

This results in hospital equipment and furniture

not being appropriately cleaned and an increase

in pathogen transmission risk to patients

and HCP.

Crothall’s Environmental Services program,

respected as an integral part of a facility’s

infection prevention program, is designed to

go beyond basic cleaning to disinfect surfaces

by implementing specially designed protocols

that consist of best practices to protect patients,

staff and visitors from acquiring pathogens. To

be healing environments, hospitals must not

only look visibly clean; they must also be free of

microbial contamination.

Crothall’s thorough, integrative environmental

cleaning and disinfection approach (fig. 4) that

reduces HAIs and leads to positive patient

outcomes is accomplished through multiple

systems and processes.

Crothall proactively responds to these human

factor challenges by:

• Ongoing and direct employee coaching,

training, engagement, partnership,

accountability and empowerment of staff

members to ensure they are clear about

their individual responsibility for promoting

environmental hygiene through correct

cleaning/disinfection processes and proper

personal protective equipment (PPE) use

Fig. 4 Integrated Infection Prevention Approach

Continuing employee education

aNew hire orientation

aWeekly “Minders”

aMonthly in-service CHAT sessions

aAnnual refresher training

aTraining, including hand hygiene,

PPE, C. difficile modules, VRE, MRSA,

isolation room cleaning, and safe

work practices


• Educating the environmental services

and healthcare teams in the proper use of

hospital-grade chemical agents

• Designing comprehensive, specific and

integrative protocols and strategies, including

a 10-step process that focuses on disinfecting

and cleaning of high-touch points in the

patient zone

• Auditing staff to ensure strict adherence to

standard protocols that have a high-touch-

point focus

• Diligently using the Clean-TraceTM performance

improvement technology for immediate

employee feedback to ensure service quality

and monitoring long-term trending

• Using checklists to ensure all procedures are

being followed

• Competency testing to assess worker

performance

Crothall recognizes that a successful environmental services program depends upon:

• Acknowledging the Environmental Services

(EVS) Department as a key player in

infection prevention

• Clinically involving the EVS staff

• Viewing EVS as full-fledged health care

team members

• Team cooperation breeding empowerment

• Partnering with the hospital’s Infection

Prevention Team, serving on the Infection

Prevention and Control Committee, and

participating in regular environmental rounds

performed with Environment of Care and

Infection Prevention colleagues

• Using appropriate one-step EPA-registered

hospital disinfectants for cleaning and

disinfecting high-touch, environmental

surfaces

• Cleaning/disinfecting C. difficile rooms with

CDC recommended Environmental Protection

Agency (EPA) registered disinfectants with a

C. difficile sporocidal label claim

• Implementing microfiber products, H2O2

liquid products, ultraviolet (UV) technology,

and H2O2 vapor technology

• Conducting periodic independent consultant

assessment surveys

• Scientific testing of emerging antimicrobial

product technology for reducing

environmental contamination in the

patient zone

• Partnering with a manufacturer and hospital

to perform a clinical evaluation with a

new disinfectant that will have a C. difficile

sporocidal label claim

• Using High Efficiency Particulate Air (HEPA)

filtration in selected clinical situations

• Allocating significant resources for piloting

and studying the results of emerging

innovative technologies

• Researching optimally constructed hospital

furniture and equipment surfaces to reduce

environmental contamination

• Staying current with emerging chemicals

and technology

• Implementing and ensuring compliance

with evidence-based policies and procedures

based on:

– The Centers for Disease Control and

Prevention (CDC), World Health

Organization (WHO), Canadian and British

infection prevention guidelines and

recommendations

– Regulatory agencies (e.g., OSHA,

Department of Public Health, CMS)

– Accrediting agencies (e.g., The Joint

Commission, Healthcare Facilities

Accreditation Program (HFAP), National

Integrated Accreditation for Healthcare

Organizations (NIAHO)

• Incorporating well-designed research from

medical literature

• Implementing industry studies and

recommendations

• Adopting best practices from other leading

organizations (e.g., AORN, APIC)

• Understanding that the implementation of

newer technologies will always complement

basic environmental cleaning and disinfection

• Evaluating an organization’s specific and

unique needs when recommending proper

cleaning procedures, products and new

technologies

• Embracing Crothall’s research and scientific

experience


The “Clean-TraceTM” Performance Improvement Tool for Reducing ContaminationSome hospitals use visual inspections, which are

subjective, inaccurate and unreliable indicators

of environmental cleanliness and invisible

microbial contamination.(29) Based on the CDC’s

recommendation(20, 28) to monitor cleaning

performance, Crothall relies on the 3MTM Clean-

TraceTM Surface ATP test, with its proven high

sensitivity and repeatability, as an objective

indicator of high-touch surface cleanliness

in seconds. Clean-Trace detects adenosine

triphosphate (ATP), an enzyme present in all

living cells. This ATP monitoring system detects

the amount of organic matter that remains after

cleaning an environmental surface. In one study,

after the implementation of an intervention

program, ATP readings provided quantitative

evidence of improved cleanliness of high-touch

surfaces.(30) A second study noted ATP testing can

provide instant feedback on surface cleanliness

and is an effective tool for demonstrating

deficiencies in cleaning protocols to the staff.(31)

The use of Clean-Trace, with its standardized

methodology, is an integral component of

monitoring a hospital’s sanitation efficacy.

Measuring and documenting right after cleaning

allows for specific, timely and constructive feedback

to the front-line employees, leading to remarkable

cleaning efficacy and patient satisfaction results.

Employees feel more motivated and engaged

with their roles. Crothall quickly realized the value

of Clean-Trace and offered this performance

improvement technology to its customers.

Clean-Trace is superior in that it provides:• Rapid surrogate test for assessing

surface hygiene

• Objective, quantifiable verification for

monitoring and evaluating surface cleanliness

and contamination

• Optimization and enhancement of cleaning

practices to verify the efficacy of current

methods

• Assessment of the hygienic status of

high-risk surfaces in 30 seconds, enabling

immediate feedback to staff members and the

opportunity to take quick corrective action

• Reduction in the risk of cross-contamination

due to inadequate cleaning

• An automated, performance-improvement

tool to trend, benchmark and continually

improve environmental hygiene cleaning

performance while acceptable, national

scientific standards reflecting cleanliness and

safety continue to be studied

• Assistance in protecting the client’s integrity

due to the inability to manipulate or falsify

findings

Crothall managers collaborate with a hospital’s

Infection Prevention and Control Department to

determine the high-touch surfaces that will be

measured. Ongoing target goals are established

with the client, infection prevention and control,

and appropriate Crothall regional leadership.

Managers test 50 surfaces per week, equaling 10

surfaces per patient room; this ensures thorough

and accurate results. Outcomes scoring outside

the pre-determined acceptable range of 0 to

499 will require immediate associate re-training.

Perc

enta

ge o

f Res

ults

with

RLU

≤ 4

99

Crothall’s Clean-Trace ImplementationOverall Score

84 Hospitals 164,561 High Touch Points Inspected

Feb ’11 Mar ‘11 Apr ’11 May ’11 Jun ’11 Jul ’11 Aug ’11 Sep ’11 Oct ‘11 Nov ’11 Dec ’11 Jan ’12

Overall Score

Target

Goal

95

90

85

80

75

70

Fig 5: Clean-Trace implementation, February 2011 through January 2012

CLEAN-TRACE TESTIMONIALS“By using standard testing protocols and empirical data, we can prove that the environment has been cleaned and sanitized properly, thereby eliminating patient contamination by contact surfaces.”

Peter Duffy, VP of Operations Hospital of Saint Raphael New Haven, Connecticut

“We had a successful Clean-Trace EVS/ICP to JCAHO in which they remarked that this was the first time they had seen the program in practice and asked for a demonstration—and they were immensely impressed!”

Dayan Sangha, EVS Operations Manager Inova Fair Oaks Hospital

Fairfax, Virginia

“We implemented the 3M Clean-Trace in the first quarter of CY 2011. Initially, we used the target of achieving 80% pass rate for each of the 10 high-touch surfaces. Within a few months, each one of these tough points was exceeding this target. Instead of just staying with this metric, we decided to move the target to 90% pass. Once again, within a few months, we were able to consistently achieve this new and higher target.”

Patrick Cassese, Resident Regional Manager, Environmental Services and

Patient Transportation Departments Allegheny General Hospital and Suburban

Campus Pittsburgh, Pennsylvania

“The Clean-Trace tool provides us with an effective means of producing data that our cleaning practices are effective and helps us deliver a product that is state-of-the-art to our customers.”

Newlson Darrow, Unit Director EVS Hahnemann University Hospital

Philadelphia, Pennsylvania

“Infection control and the nurse managers have been very supportive with our testing. Their only request has actually been to increase the number of swabs we are conducting weekly.”

Alan Rothstein, Director of Housekeeping Hebrew Rehabilitation Center

Dedham, Massachusetts


Follow-up testing occurs within 24 hours for

all deficient surfaces. Surfaces that reveal no

improvement will result in additional training

as well as performance counseling. Outcomes

are reported during quarterly management and

joint review committee meetings for assessment;

data may also be reported through the Infection

Prevention and Control Committee.

Crothall’s Senior Leadership Team is fully engaged

with reinforcing quality inspections of high-

touch patient surfaces in a systematic manner.

The operations manager, assistant director

and unit manager/resident regional manager

conduct quality inspections. Any deficiencies

are investigated within 24 hours. Findings and

outcomes are additionally reviewed by the team

during documented bi-weekly management and

joint review meetings. Action plans are created for

deficiencies related to project work. Additionally,

data is inputted daily to meet weekly guidelines

and company expectations.

Crothall’s Clean-Trace Implementation

During February 2011, Clean-Trace was

implemented at Crothall accounts, with an initial

target of 80% compliance (fig.5). High-touch

points inspected included the following:

• telephone

• remote control

• light switches

• sink faucets

• toilet and flusher

• bed hand rail

• shower handle rail

• call button

• restroom door handle

• bedside table

The initial goal of 80% was met and exceeded.

Compliance started to increase due to the

leadership team’s ability to assess and refine the

process and ongoing, immediate staff feedback.

The target goal was then raised to 90% with

consistent performance.

Ultraviolet Sterilization Technology; Reducing Unwanted Microbes

Crothall partnered with American Ultraviolet

(AUV) and became an early adopter of ultraviolet

(UV) technology as an innovation to destroy

microorganisms and fight HAIs. Ultraviolet

germicidal irradiation (UVGI) destroys airborne

organisms or inactivates microorganisms on

surfaces.(32) Its advantages include:(33, 34)

• Biocidal activity against a wide range by

destroying pathogen DNA

• Environmental surface and equipment

decontamination

• Rapid vegetative bacteria decontamination,

including activity against C. difficile spores

• No requirement to seal room

• Ability to keep the heating, ventilation and air

conditioning systems fully functioning

• Residual-free process

• Well-distributed UV energy in a room

Fig. 6: Automatically Reliably Targeting Zero (ARTZ)

Mobile Room UVC Germicidal Solution

First, as part of the hospital patient room or

operating room terminal disinfection process,

the room is manually cleaned and disinfected.

Then, the Automatically Reliably Targeting Zero

(ARTZ) Mobile Room UVC Germicidal Solution

is activated (fig. 6). This technology uses high-

intensity UVC lamps to deliver a critical dose to

all room surfaces to quickly, safely and effectively

reduce harmful pathogens in patient rooms and

surgical suites. This process is more efficient than

conventional disinfection. The ARTZ uses reflected

energy to reach shadowed areas and increase

overall intensity in the treated space. A touch-


screen tablet acts as a remote controller and

transmits reportable data to an SD memory device.

Infrared sensors provide a 360-degree field of

view, preventing the unit from turning on and

even extinguishing the lamps should anyone enter

the room from an unsecured door. ARTZ releases

no ozone and has proven effectiveness against

C. diff. spores.(35)

Crothall managers proactively introduce UV

technology specifics and outcome data to the

Infection Prevention and Control Representative,

key client and key other related hospital customers.

During the implementation period, initial test

specifics are established for a pre-determined

period of time including controlled specialty

areas (OR, Burn Unit, isolation precaution rooms,

etc.) and testing methods (typically, hospital

microbiology or designated resource). The

appropriate application locations are then chosen.

The manufacturer’s recommendations for training,

safety, product handling, device maintenance and

usage are followed. Ongoing product training

and education is included during orientation and

annual refresher sessions. An outcomes report in

partnership with Infection Prevention and Control

is given during joint review meetings.

Clostridium difficile (C. difficile) Room Cleaning

The CDC recognizes the importance of the

Environmental Services Department with

having a key role in reducing C. difficile

contamination that can directly be transmitted

to patients or contaminate the hands of HCP.(36)

C. difficile spores resist destruction by the usual

hospital disinfectants, e.g., quaternary ammonium

compounds. Resultantly, the CDC recommends

using an EPA-registered disinfectant with a

C. difficile sporicidal label claim in conjunction

with thorough physical cleaning.(36) Crothall

was using EPA-registered disinfectants with a

C. difficile sporocidal label claim prior to the

formal CDC recommendation.

Return on Investment

The Mount Sinai Hospital case study on page 10

clearly demonstrates how the implementation of

Crothall’s work procedures, including Clean-

Trace and UV technology, dramatically reduced

infection with improved patient outcomes.

Crothall Healthcare’s long-term investment in and

commitment to patient safety and standardization,

coupled with innovative and strategic approaches,

such as the ability to rapidly embrace innovative

emerging technologies, raises HCAHPS scores,

improves revenue streams and maximizes

staff productivity.

Ongoing Commitment to Providing a Safe Environment

Over the years, countless new technologies

have emerged. As part of our ongoing

journey to continually improve and expand

our support services, Crothall has put

significant resources into piloting and

studying the results of each new technology

or innovation.

Clinical testing is always done in conjunction with

our clients as well as third-party infectious disease

and infection prevention experts. And, it is an

ongoing process to exhaust all avenues in the

search for better solutions.

In summary, Crothall Healthcare’s approach to

ensure a safe patient zone:

• Increases focus on patient safety and care

• Prevents HAIs

• Embraces innovative technologies

• Ensures consistently high levels of cleanliness

• Employs environmentally conscious

cleaning practices

• Raises patient and staff satisfaction

• Meets regulatory compliance

• Guarantees service outcomes

• Keeps staff up to date with ongoing

training programs

Successful C. difficile infection reduction

A 400-bed hospital in Maryland

experienced a sharp increase with

C. difficile infections during 2006.

A CDC root cause analysis concluded that

there were opportunities to improve

environmental hygiene. Crothall was

hired to manage the EVS Department

and decrease infection.

Interventions:

• Immediately implemented bleach cleaning

• Later transitioned cleaning to Oxivir

• Created a cleaning guideline checklist

The hospital concurrently:

• Enhanced antibiotic stewardship

• Increased numerous infection prevention interventions addressing surveillance and isolation precautions

• Installed automatic hand sanitizer dispensers and CHG soap

Resultantly, a dramatic infection decrease was noted.(fig. 7)

Num

ber o

f Cas

es

200

180

160

140

120

100

80

60

40

20

0

2003 2004 2005 2006 2007 2008 2009 2010

6265

132163

9371

46 33

Crothall contract start (July 2006)

Yearly Totals of HA C. diff.

Fig 7: Results with Crothall intervention at a 400-bed hospital in Maryland.


• Reduces supply costs

• Is customer-focused (e.g., provides

independent continuous readiness audits)

• Focuses on standardization in protocols,

quality assurance and management tools

MOUNT SINAI HOSPITAL CASE STUDY: AN OUNCE OF PREVENTIONAs one of the largest hospitals and best teaching institutions in the world, The Mount Sinai Medical Center in New York is

not satisfied merely with controlling infections. They are dedicated to prevention, using the Environmental Services (EVS) Department as the first line of defense.

Compatibility, Responsiveness, Resources

Mount Sinai’s 1,171-bed facility has a huge EVS

department, with more than 650 full- and part-

time employees in EVS and Patient Transportation

(PT), and with an additional 44 Crothall Healthcare

managers.

For years, Mount Sinai had been using another

national services company for EVS and PT, but

by 2008, Mount Sinai’s leadership decided they

needed to make a change. In the eyes of Mount

Sinai Vice President of Support Services Daryl

Wilkerson: “We were looking for quality, more

services, more empathy for our employees, and

more of a team approach. Crothall told us what

they would accomplish. The expectations were put

out there in front of everyone.”

Starts with Training, Ends with Technology

The Mount Sinai story is more than a simple EVS

transition story. In 2008, Mount Sinai had 1.06

C. diff. infections per 1,000 patients—and a hospital

goal of dropping that rate to 0.78.

The first strategy, according to Crothall Regional

Manager Paul Killion, was simply to strengthen

the EVS department, with a special emphasis on

retraining. “We had to do major retraining when we

began the contract,” Killion recalled. “Employees

were mixing their own chemicals; sometimes, they

weren’t even using the right chemicals.”

Crothall went beyond simply updating depart-

ment processes. They overhauled everything from

technology to attitude:

• Hospitality training

• New, state-of-the-art equipment

• Environmentally friendly products

HAI rates began dropping. Significantly. In the

first year, the C. diff. rate dropped to 0.91.

Then, in 2010, Crothall began piloting a new

cleaning program specifically geared toward

infection prevention. Two new technologies—

3MTM Clean-TraceTM and Tru-D SmartUVC™

(a UV-irradiation device)—were introduced at

Mount Sinai.

Clean-Trace detects ATP, a protein present in all

living organisms. The test is a simple swab that

gives results in 30 seconds. This was a huge step

over previous measures used at Mount Sinai.

“There was no technology; they just used their

vision and a form,” explained Wilkerson. “Clean-

Trace gives measurable, empirical data. You either

disinfected the surface or you didn’t,” said Killion.

Crothall’s program focuses on high-touch surfaces

known to spread infection, such as toilet flushers,

doorknobs and bed rails. Clean-Trace allows for

directed coaching of staff to actually show them

what they missed and help them improve. In

the first six months of the program, the EVS staff

did surprisingly well—84% compliance in patient

rooms and 78% in OR suites. In the subsequent

six months, compliance jumped to 86% and 81%,

respectively.

The next step was Tru-D, a device that uses highly

concentrated doses of UV energy to sterilize

not only all room surfaces, but also the air itself,

destroying all living organisms, including MRSA,

influenza and even C. diff. spores. A recent study

showed that admission to a room previously

occupied by a MRSA-positive or a VRE-positive

patient significantly increased the odds of


acquiring these pathogens.(37) Tru-D is used by

Mount Sinai in patient rooms with confirmed

infections, as well as high-risk areas like OR suites

and L&D rooms.

“At the end of the day, it’s all about patient care,”

Wilkerson said. “You’ve got to change your

approach. You have to be forward thinking or

you’ll lose the game. Crothall has a lot more

resources, and they know the trends. That’s why

we rely on Crothall to bring those things to our

attention.”

Running Down the Numbers

After a full year with new infection prevention

goals and two years operating with Crothall’s

management focus, the results at Mount Sinai are

conclusive:

• 57% reduction in C. diff. infection rates, from

1.06 in 2008 to 0.60 in February 2011

• HCAHPS cleaning scores have increased from

60% in 2008 to 67% in 2011

• 50% reduction in OSHA incidents,

from 49 to 25

• 48% reduction in lost work days, from 1004 to

527, saving at least $441,000 a year

“I attribute the first-year improvements in both

safety and effectiveness to proper use of chemicals

and training of our staff. Our continued progress is

thanks to the amazing tools we have introduced,

like Clean-Trace and Tru-D,” Killion said. “It wasn’t

just the technology. It was about modifying

our behavior. It was making sure that we were

cleaning and disinfecting effectively.”

For Wilkerson, this level of leadership and

performance is even more than he expected.

“A lot of it is the management on the ground,” he

explained. “Our Crothall managers truly drive the

program.”

SUMMARY

“We must ensure a safe and healthy environment

in which to heal.”

–Crothall Healthcare

Crothall was founded in 1991 to address the need

for a specialized, high-quality, innovative and

responsive support services company, exclusively

serving the unique needs of the healthcare

industry. With more than 1,200 healthcare

clients accompanied with an unblemished Joint

Commission survey record, Crothall provides

excellence with every delivered solution.

As the industry front-runner, Crothall continually

integrates scientifically proven, evidence-based

recommendations, tools and industry best

practices to reduce environmental contamination

and provide a safe environment for patients and

HCP. This synergistic approach, coupled with

ongoing, extensive research and testing, assists

with identifying many innovative, exciting,

cutting-edge technologies that offer significant,

unified advantages to augment our infection

prevention efforts.

Infection prevention is a constant battle that

must be waged daily for the health and safety of

patients and HCP. Crothall’s people and processes

deliver sustainable outcomes that meet high

standards of quality and safety resulting in total

customer satisfaction.

Crothall remains in the forefront and will continue

to pioneer new solutions for our healthcare

customers. No other company has the training,

technology, and, most importantly, thorough

processes, that have made Crothall Healthcare

the industry leader. n

After partnering with Crothall Healthcare, Mt. Sinai Hospital in New York had a 57% reduction in C. difficile infection rates, from 1.06 in 2008 to 0.60 in February 2011.


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May 2012 HEALTHCARE White Paper ENVIRONMENTAL SERVICES