key: cord-0927426-xu1sgguh
authors: Tyan, Kevin; Cohen, Pieter A.
title: Investing in Our First Line of Defense: Environmental Services Workers
date: 2020-05-01
journal: Ann Intern Med
DOI: 10.7326/m20-2237
sha: c8ffa6f03b5b7e6fa23ae48cd3b6df1f9df3fc55
doc_id: 927426
cord_uid: xu1sgguh

Environmental services personnel are a critical first line of defense against the spread of COVID-19. This commentary discusses the importance of environmental cleaning during the pandemic and the essential role of environmental services personnel in patient safety.

D uring the height of the pandemic in New York City, thousands of residents leaned out their windows every evening to cheer and celebrate the physicians, nurses, and other professionals on the frontline of combating COVID-19. Employees at groceries, pharmacies, and other essential businesses have also received welldeserved recognition. Largely absent from national attention, however, are the hundreds of thousands of workers devoted to disinfecting our hospitals. These environmental services (EVS) personnel are among those most likely to be exposed to the virus and most essential to combating its spread.

These staff perform the arduous tasks of wiping down beds, cleaning bathrooms, and decontaminating hospital equipment. They are the unnoticed sinews of a well-functioning hospital. These essential personnel are still often called "housekeepers"-a relic from a time when their role was regarded as purely janitorial rather than fundamental to patient safety. In the face of this pandemic, they are among the unsung heroes, the critical first line of defense against infection.

Yet their task of hospital cleaning and their stature in the health care hierarchy have long been underappreciated (1) (2) (3) . This is despite extensive evidence that environmental contamination places patients and health care personnel at risk for life-threatening disease. When a hospitalized patient suffers an infection, the next patient to occupy their room has a 6-fold greater risk of acquiring the same pathogen (4). In intensive care units, dirty objects and failure to remove surface bioburden correlate with increased acquisition of infections (2) . Across hospital systems, cost-cutting to reduce EVS staff and cleaning hours has been associated with increased nosocomial infections (1) (2) (3) . In light of evidence that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can survive on surfaces for up to 3 days (5), along with studies demonstrating that viral shedding contaminates over 80% of the interior of hospital rooms (6) and aerosolization of SARS-CoV-2 causes extensive surface contamination (7), it is now more urgent than ever to emphasize the importance of environmental cleaning.

Unfortunately, EVS personnel have been a target for cost-cutting since the mid 1990s. Cleaning staff have been whittled down by 25% during this time, and more than one third of hospitals have disbanded their own EVS teams to outsource this work to contractors, shedding valuable institutional experience while exacerbating high turnover and inadequate training (1). Some new hires receive only 3 days of training, forcing 83% of EVS staff to train new recruits on the job, furthering the notion that their work is menial and unskilled rather than vital to patient outcomes. Meanwhile, stagnant low wages condemn over three quarters of workers below the poverty line (1) . A recent analysis found that 30.5% of health workers at risk for poor COVID-19 outcomes lack paid sick leave, and support workers remain uninsured at rates above the national average (8) . It is no accident that many EVS workers feel invisible to the rest of the hospital team-they are systemically devalued, ignored, and relegated to the bottom of the socioeconomic hierarchy. Now, as the surge of COVID-19 cases threatens to overwhelm our hospitals, EVS workers are being asked to do more with less. Even before the COVID-19 pandemic, two thirds of EVS staff reported working under chronically understaffed conditions, and over 80% worry that this impedes high-quality work (1). To thoroughly disinfect a hospital room, EVS workers need sufficient time, proper technique, and effective tools. Each worker must methodically work their way through each room, removing soiled linens, discarding trash, and mopping floors. To eliminate potential reservoirs for disease, they must meticulously wipe down all of the high-touch surfaces of a room, including bed rails, tables, intravenous poles, and door knobs (2) . In deploying their arsenal of disinfectants ranging from bleach to ethanol, they must be trained on the different contact times necessary to kill different pathogens (2) . The presence of high-risk pathogens complicates their work. They must garb themselves in personal protective equipment (PPE) to render these spaces safe for their colleagues and patients, and many EVS staff now find themselves deprioritized in the distribution of scarce protective gear against COVID-19 (9). This is a daunting set of tasks for anybody to accomplish, yet hospitals are asking their EVS workers to perform it all in less than 15 minutes for up to 36 rooms a day (1) . Many are pressured to cut corners and rushed to turn over rooms for waiting patients. The inevitable result: A study of more than 1000 patient rooms across 23 hospitals revealed that less than 50% of surfaces are properly cleaned (10) .

There are alternatives. A culture of agency and responsibility could be instilled in every hospital employee. Airplane mechanics and parachute packers are recognized for their critical work, as each tightened bolt and each untangled line represents crises averted, lives saved. We should afford the same respect to our EVS workers and take steps to support their efforts on the frontline of infection prevention (Table) .

We can start by properly acknowledging their role as valuable members of the patient care team. Hospitals need to embrace EVS employees as a core investment in improving patient outcomes. Further research and innovation should be directed toward enhancing their efforts. Crucially, EVS employees need sufficient PPE to protect themselves as they endeavor to protect others.

Cleaning Up: How Hospital Outsourcing is Hurting Workers and Endangering Patients

Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination

Superbugs versus outsourced cleaners: employment arrangements and the spread of health careassociated infections

Association between healthcareassociated infection and exposure to hospital roommates and previous bed occupants with the same organism

Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1

Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient

Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals

Health insurance status and risk factors for poor outcomes with COVID-19 among U.S. health care workers: A cross-sectional study

Accessed at www.reuters.com /article/us-health-coronavirus-housekeepers/in-fight-for-masks -hospital-janitors-sometimes-come-last-idUSKBN21O2JF on 28

Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals