Investing in Our First Line of Defense: Environmental Services Workers
Authors: Kevin Tyan, Pieter A. Cohen
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions18 August 2020Investing in Our First Line of Defense: Environmental Services WorkersFREEKevin Tyan, BA and Pieter A. Cohen, MDKevin Tyan, BAHarvard Medical School, Boston, and Cambridge Health Alliance, Cambridge, Massachusetts (K.T., P.A.C.) and Pieter A. Cohen, MDHarvard Medical School, Boston, and Cambridge Health Alliance, Cambridge, Massachusetts (K.T., P.A.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-2237 Annals Author Insight Video - Kevin Tyan, BA and Isabella Teixeria In this video, Kevin Tyan, BA and Isabella Teixeria, offer additional insight into the article, "Investing in Our First Line of Defense: Environmental Services Workers." (Duration 3:49) SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail During 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 well-deserved 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 (1–3). 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 (1–3). 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 doorknobs (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).Table. Strategies to Support EVS WorkersWe 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.Health care will inevitably be reimagined after the global pandemic, and it is time to invest in EVS employees and their essential role in patient safety. As the COVID-19 pandemic illuminates the importance of infection prevention, we are offered a chance to shine new light on these unsung heroes.References1. Zuberi D. Cleaning Up: How Hospital Outsourcing is Hurting Workers and Endangering Patients. Cornell Univ Pr; 2013. Google Scholar2. Dancer SJ. Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination. Clin Microbiol Rev. 2014;27:665-90. [PMID: 25278571] doi:10.1128/CMR.00020-14 CrossrefMedlineGoogle Scholar3. Litwin AS, Avgar AC, Becker ER. Superbugs versus outsourced cleaners: employment arrangements and the spread of health care–associated infections. ILR Review. 2017;70:610-41. doi:10.1177/0019793916654482 CrossrefGoogle Scholar4. Cohen B, Liu J, Cohen AR, et al. Association between healthcare-associated infection and exposure to hospital roommates and previous bed occupants with the same organism. Infect Control Hosp Epidemiol. 2018;39:541-546. [PMID: 29486805] doi:10.1017/ice.2018.22 CrossrefMedlineGoogle Scholar5. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 [Letter]. N Engl J Med. 2020;382:1564-1567. [PMID: 32182409] doi:10.1056/NEJMc2004973 CrossrefMedlineGoogle Scholar6. Ong SWX, Tan YK, Chia PY, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient. JAMA. 2020. [PMID: 32129805] doi:10.1001/jama.2020.3227 CrossrefMedlineGoogle Scholar7. Liu Y, Ning Z, Chen Y, et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature. 2020. [PMID: 32340022] doi:10.1038/s41586-020-2271-3 CrossrefMedlineGoogle Scholar8. Himmelstein DU, Woolhandler S. Health insurance status and risk factors for poor outcomes with COVID-19 among U.S. health care workers: A cross-sectional study. Ann Intern Med. 2020. [PMID: 32343764]. doi:10.7326/M20-1874 LinkGoogle Scholar9. Brown N, Cooke K. In fight for masks, hospital janitors sometimes come last. Reuters. 6 April 2020. Accessed at www.reuters.com/article/us-health-coronavirus-housekeepers/in-fight-for-masks-hospital-janitors-sometimes-come-last-idUSKBN21O2JF on 28 April 2020. Google Scholar10. Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:1-7. [PMID: 18171180] doi:10.1086/524329 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment RichardEVS Worker27 June 2020 On Point The thoughts expressed in this article is so on point. It seems with outsourcing there is extreme pressure to do more with less. You can't have it both ways. It's simply impossible to cover huge amounts of areas and at the same time quality. It's actually created a culture of "Trash and Dash." Attrition is high. In any other "business", that would send red flags all over the place. In the end, while many healthcare facilities, including the hospital I work at, may preach that "the patient comes first," in reality this outsourced culture has created just the opposite. We are putting the health of the patient and notwithstanding, the EVS workers health, both physical and emotional at risk. Author, Article, and Disclosure InformationAffiliations: Harvard Medical School, Boston, and Cambridge Health Alliance, Cambridge, Massachusetts (K.T., P.A.C.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-2237.Corresponding Author: Kevin Tyan, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115; e-mail, [email protected]harvard.edu.Current Author Addresses: Mr. Tyan: Harvard Medical School, 25 Shattuck Street, Boston, MA 02115.Dr. Cohen: 236 Highland Avenue, Somerville, MA 02143.Author Contributions: Conception and design: P.A. Cohen, K. Tyan.Analysis and interpretation of the data: P.A. Cohen.Drafting of the article: K. Tyan.Critical revision for important intellectual content: P.A. Cohen, K. Tyan.Final approval of the article: P.A. Cohen, K. Tyan.This article was published at Annals.org on 1 May 2020. 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(Duration 3:49) FiguresReferencesRelatedDetails Metrics Cited byDevelopment and validation of the regarding infection prevention and control among environmental service workers on knowledge, attitudes, practise, and experience questionnaireImpact of COVID-19 on environmental services workers in healthcare settings: a scoping reviewA multiphase intervention of novel color additive for bleach disinfectant wipes improves thoroughness of cleaning in an academic medical centerForgotten frontline workers: Environmental health service employees' perspectives on working during the COVID‐19 pandemicUnveiling the unseen: Distinguishing and dignifying the essential role of environmental services staffThe High Stakes of Outsourcing in Health CareFactors associated with environmental service worker cleaning practices in health care settings: A systematic review of the literaturePractical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative reviewHealth Care Organizations Should Be as Generous as Their WorkersLeonard L. Berry, PhD, MBA and Rana Lee Adawi Awdish, MDConsiderations for the Selection and Use of Disinfectants Against SARS-CoV-2 in a Health Care Setting 18 August 2020Volume 173, Issue 4Page: 306-307KeywordsCOVID-19DisclosureEnvironmental healthEthanolHealth careIntensive care unitsNosocomial infectionsPathogensPersonal protective equipmentSafety ePublished: 1 May 2020 Issue Published: 18 August 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...