Welcome to Stories of Care, a podcast from the American Medical Association and CDC's Project Firstline. In this episode, we are joined by Pam Toppel, the Manager of Environmental Services and Linen for OSF HealthCare, as we discuss the key role of environmental services in infection prevention and control, and how COVID brought their important work to the forefront. To earn CME for listening, visit amafirstlinestories.org and click on the title of this episode to complete the quiz.
Megan Srinivas, MD: Hi, Pam. Thank you so much for joining us today.
Pam Toppel: Hi, Megan. Thank you so much for having me. I'm really excited to be here.
Srinivas: We're excited to hear about your experiences on the frontline before, during, and after the pandemic. So as a EVS, an Environmental Services worker, can you tell us a little bit about your background?
Toppel: Sure, absolutely. I have been with OSF HealthCare in Illinois for the last 22 years. All of it in EVS leadership. And so originally I was at one facility and to date, I am a regional manager for environmental services, so I manage two different facilities and some, a great team to go along with that.
Srinivas: And how did you get involved in environmental services?
Toppel: Well, I've always known that I wanted to be in health care. I just knew that I didn't feel that I was a right fit to be a nurse or a caregiver, just because I, at that time in my life, I felt I was too soft and that it would hit me, you know, too hard and I'd be in the corner crying probably every day.
And so, but I wanted to know where I can make an impact. And actually how I started out my career was cleaning doctor's offices that were offsite, just two hours an evening, every evening and it was like, that's when I got the a-ha moment and really felt the passion and the drive and where I can make a difference.
Srinivas: And to me, I'm laughing as you're talking about being too soft to be a nurse or direct health care provider because I feel like environmental services, you see the hardest of the hardest sometimes, and your job is so tough. You can't be soft.
Toppel: It's true. I'll, it's back when I was five years old.
No. And it's, one of those things where I have the utmost respect for our clinical teams. Cuz what they do face daily is very challenging. Not only in patient care, but just dealing with the, all the aspects of health care. It is very challenging. And what we can do in environmental services to help support that is really important to me.
Srinivas: And for so many people, they work with environmental services or collaborate in different ways. But there might be some people listening to our podcast who don't exactly know what that entails. Can you tell us a little bit about all the things that you do in the multifaceted aspect of being part of EVS?
Toppel: Absolutely. Going back to growing up, you think of what professions you want and what do you want to do when you grow up. Environmental services is not something that anybody really, it, I don't know anyone in our profession that has thought, "Ooh, that's what I want to do when I grow up."
But until you get into health care and until you create those relationships, people do not understand, even in the health care environment, they don't always understand our role in helping keep the environment safe for our patients. So what we do, you know, it's more than back in the day of collecting waste or cleaning toilets.
We're really preventing all that cross-contamination that can occur and does occur in the health care environment.
Srinivas: And being infectious disease, when I was going through my fellowship, they had us work with our infection control unit quite a bit so that way we could learn about all the things that you do.
And this was before the pandemic, but there are so many pathogens out there and it is really your team that helps to prevent the spread from one patient to the next. And it's really kind of amazing, when I was sitting there and learning about all the different cleaning techniques and you have to do certain surfaces with certain products for a certain amount of time versus other surfaces, and it changes depending on what the patient had that was in there before you.
There's just so much to learn. What is the training for somebody who's entering EVS to be able to, to be ready to deal with this. And I mean, even before the pandemic.
Toppel: Yeah. It, so even before the pandemic, what we, as our system has done and many of environmental services professionals are going through this, our professional membership group, which is AHE [Association for the Health Care Environment], part of AHA [American Hospital Association], created and came up with a certification training, which is something that our profession has needed forever.
And the very first module in that training talks about basic microbiology. So it really brings some of the most common pathogens to the forefront. So they get to understand, and that's something that through the years that we have really evolved is explaining the why behind what they do. It's just not to make the place look clean and pretty, and appeasing to the eye. It's actually preventing those microorganisms and those pathogens from going from one place to another and eliminating what we can, where we can. And you're right, absolutely right. Now C. auris is at the forefront and some of the chemicals that we use currently are not on the P list. So that is something that we're quickly changing as we go in our environment. Just like anyone else in health care, you've got to keep up with the pathogens that are coming out with the COVID, the C. auris, the MRSA, the C. diff, those are not going away.
So we have to learn and train our folks how to manage this, and making sure that we're doing the right thing at the right time. Just for us alone, and I can only speak for myself here, we go through, we put our frontline staff, when they're onboarding, through a four-to-six-week training. It's no longer those days of where you do two or three just days to see what's going on, and then you're thrown to the wolves.
That's not how it is. It's not safe for anybody. And we really need to treat it like the profession we are and make sure everyone has the correct skillset to get out there.
Srinivas: And speaking of being safe, I feel like after and during the pandemic, people started to think a lot more about trying to protect every layer of the health care system. But before the pandemic, I often feel like there were certain areas of health care staff that weren't as thought of when it came to trying to do protections. Did you ever feel concerned before the pandemic that you or your staff could get sick or catch something in your job?
Toppel: I think I can speak for a lot of environmental services professionals that we felt we were the unseen and unheard as far as the importance of what we did. I do think that was evolving into something more before the pandemic. But with the pandemic, it definitely escalated quickly into how important our role was, and I think opened a lot of eyes of what we really do in health care.
I would honestly be lying if I said I didn't worry about my staff's safety.
It was the unknown. Just like everyone was worried and concerned. We were reluctant. I wasn't reluctant, but some of my staff were reluctant. I have good administrative support teams that pulled me in early on and with the challenges of PPE and everything else, they wanted to know my opinion and if we would work with nursing or should we go into the rooms for COVID or what should we do? And my first response right outta the gate was, no, we need to continue to do what we need to do. Our clinical teams need to focus on our patients. They need to have, be able to 100% give that focus there, not worried about having to clean up a room or disinfect surfaces for the patient.
Srinivas: When this first came up, we knew nothing about it and we were learning new things every day, how in such an evolving environment did you educate your staff and make them feel comfortable?
Toppel: Okay. It was scary. I'm a big one for CDC and WHO, so I was on top of it. Anytime, WHO was streaming I had it on, sitting at my desk, listening, trying to get as much information as I could to make sure that we were protecting not only our staff but our environment and our patients, as well.
Of course, we didn't have visitors at that time. And we needed to do what we needed to do, not only to keep the place safe and keep our staff safe, but really to be able to support our patients and our clinical teams. Our patients were alone at the time. They didn't have the support that they needed to from family or loved ones or different caretakers.
They had the clinical team, which was spread so thin and worn out already, and working long hours. So when environmental services would go in, it would just be more of at ease. We were there to comfort them. We were there to be able to talk to them, to pray with them and do those things that we needed to do.
So they felt like they had some connection with the outside world, while being alone and afraid.
Srinivas: That is such a critical, it's a critical side to the story that many people who aren't in the health care environment don't quite understand. Because in the normal hospitalization, people have support.
They get to have their families. And COVID opened up a whole nother door where even when you knew somebody wasn't going to make it, you still couldn't let somebody in just because of the danger of that family member catching COVID as well. And it's so beautiful to hear how health care workers like your EVS frontline workers really were helping to fill in that gap.
I can imagine that they must have some stories of bonding with patients through all of this.
Toppel: They do. They do. And I would love to share one of the stories that just comes to mind and it's one of my favorite stories to tell. This was from an EVS Tech, who was working on the floor and at the very early stages of COVID ended up COVID-positive herself.
She was afraid, she was scared, she was pregnant. So there were just multi-facets of where her nerves were rattled. She absolutely recovered. She did well, and when she came back to work, she actually asked to be in the COVID unit. She said that she knows she's pregnant, but she knows that she's protected, and with the proper PAPR or N95 that she would wear, it was her choice.
She wanted to make sure that those patients knew that they were loved, that they were gonna be okay, that somebody cared. So she would go in, she would pray with them, she would sit and hold their hands. She actually gave some a hug. She received several focused recognitions from patients themselves saying that they, that she was actually the angel in their stay.
Srinivas: Oh, that is really beautiful. And it highlights the important work that you all do, that so many people don't realize. That you're such a critical part of the frontline staff and the patient experience. Thank your staffer for us. That's an amazing story.
Toppel: One thing I guess I want everyone to know is our frontline EVS techs really care about our patients. We, they really care about the outcome of our patients. I think that is sometimes, a lot of times not realized. That, we consider ourselves part of the care team. We may not be the clinical part, but we have that same passion and drive, and we want successful outcomes for our patients.
Srinivas: Oh gosh. Now, when I was in residency, the EVS workers in my hospital were a part of the care team always. When I was on crazy long hour calls, they would sometimes show up with a soda cuz they'd know that I hadn't gotten a chance to drink anything in hours. And they were just such a big part of the support team.
And so another part of the pandemic that you kind touched on before was a PPE shortage. It was national, it had nothing to do with where you were working or anything of that nature.
How did your staff, how did they embrace that? How did you handle that?
Toppel: Because we were going into the rooms, we were monitoring it very closely. Cuz at any point in time it could have been critical to where we needed to save the PPE for our clinical teams. And that, completely understand that. Care of the patient is the first and foremost.
But that's where we were able, and by the grace of God, we were able to obtain PAPRs, to be able to use those versus having to rely on the shortage of N95s. So our team exclusively wore PAPRs, which helped. And it helped save the N95s for the clinical teams that needed them. They also had PAPRs as well, but not as many.
We shared batteries just in case somebody's would go out, it was like, here, use this one. Just to make sure everyone was safe and comfortable to be able to do the things they needed to do. So that's, our system monitored it very closely. And we handled it very well.
Srinivas: That's impressive. And you touched on something with your staffer who was pregnant.
There were a lot of things that we just didn't know about COVID with or without PAPRs or whatever PPE was available. When it came to concerns about people who might be immunocompromised or pregnant or have higher risk, how did you handle that with your staff and their concerns?
Toppel: Once that started coming out with the CDC was advising that pregnant females were, should not go into COVID rooms, and immunocompromised, we pulled those to the non-COVID areas to make sure we kept our staff safe.
Srinivas: How did that balance with, I'm sure you were all facing staff shortages as well during this very strenuous time. How did you balance everything as far as keeping that in mind and trying to make sure that people weren't getting burned out, but there were still enough staff to do the work?
Toppel: Again, I can only speak for my facilities, was we asked our staff, we were very transparent upfront with them.
We kept them in the loop on everything. Every day at daily huddles we were giving them the latest news, the latest statistics on our facilities and what was going on. I think the trust was there because the transparency was there. So they would actually say, "okay, no, I'm comfortable. I'll go in the, into the COVID unit today. I don't have a problem with that." So they, just as our clinical teams stepped up, they stepped up when they needed to step up and we didn't have the issue. And they watched out, we all watched out for each other to make sure people were not going to get burned out. I was side by side with them.
I would go into the rooms with them, cleaning our ED, you know, the supervisors would as well. So I think they realized that, it wasn't a "just do as I say," it was we're all a part of this team and we're in it together, and we got this.
Srinivas: I always think back to the eighties back with HIV. And one of the stories that I always am so impressed by was Dr. Fauci, this very famous person who didn't need to be on the frontline, said, if I'm not willing to go in there when we don't know what this is, and treat HIV patients early on, then why should I expect you to. And it's exactly that motto of leadership, acting and modeling to make the rest of the staff feel safe. I love that. That's really great.
Srinivas: And along with all of that, and modeling behavior, hesitancy, everything of that nature, trying to work with your staff, that brings us into the world of vaccines when those were suddenly available. How did your staff handle that? There was so much on social media, like you alluded to, that made people concerned, have questions. It was something new. How did that fear, or those concerns manifest themselves in your hospital system?
Toppel: And that, that goes back to our CMO because, I was nervous. I was afraid. And as a leader, I knew it was my responsibility to be one of the first to get it. If I expected that from my team, or we as a system were expecting that from all of our team. So I had to be comfortable with it. And the way it, I have to give all of it to our CMO to be able to really explain in layman's terms how we got here. How the vaccine was approved so quickly, what it was created with what. He just went into such great detail that it was, then it was like, okay.
And that's where it's “follow the science.” I have faith in our physicians. I have faith in our clinical teams. I, and if they're saying that this is what's best for us, this is what's best for us. Yeah, you need the explanation. You need to understand the “why.” I get it.
There was still hesitance. There absolutely was. But people, when they have the information, the real information and not listening to all the social media or all the fear, then they're more apt to go and be supportive and get the vaccine.
Srinivas: And you were amongst the first of EVS staff to get it to model to your staff, right?
Toppel: Yes. Yep. Myself and my supervisors. Yeah. And we were amongst the first, yes.
Srinivas: And how did you see that play out with the rest of your team, when they saw, hey, she also had some concerns and she's getting it?
Toppel: Yeah, they were right behind us. There was, very few were hesitant about it. Little nervous, of course. We all were, you know, we'd be lying if we said we weren't. So it. But, no, I had volunteers jumping immediately saying, I'll get it. I'll, I, yeah, absolutely. I'll go next in line. And EVS was included in the first round because, vaccine was shortage as well because it was just coming out.
So they had to do it categorically of who was going to have, was patient-facing to be able to get that first. So EVS was included in that as well.
Srinivas: And, that's so important. The hospital system that I was working with, they actually, I was, I'm consulting services, so I wasn't on service for two weeks after they released the first wave.
And so we prioritized our EVS staff who was there every single day before those of us who still had a few weeks before we were going to see patients again got it. And I thought that was so important.
Toppel: Yes. Yeah. It is. It is very much important. And I think that's one thing that, you know, that's why I said early on that I believe EVS was evolving more in health care, because we were being noticed as part of the clinical team.
And I think that's a really important piece to demonstrate that. EVS was put in the forefront there, versus being put behind or at the end or saying no, they don't need it quite yet, or anything like that. So, I do believe that our world was evolving more to realize that EVS was part of the clinical, the care team.
Srinivas: And with the evolution of information happening so quickly throughout the pandemic. Did it change your education, your training methods for staff? Were you having to update things more? Did you have to create a new way of providing training?
Toppel: I think for myself, I've always tried to stay up with training and education because I'm very passionate about that and very passionate about keeping our staff safe as well as our patients and our caretakers.
So I've always been trying to keep up and wanting to learn more. With COVID, it really did open your eyes that you need to always look a little bit further out than what you did previously. C. auris has been out there, it's been out there.
So it's just one of those things that it really makes you look, look at the, what's next.
Srinivas: And you've always been very training-minded. I saw that you've been leading trainings, even before pandemic, at the national level.
Srinivas: But for the overall, EVS world, do you feel like the pandemic has pushed us in a direction where there is now more focus on infection prevention and control, both for the EVS world, but also the greater health care world? Recognizing EVS is in an important position in that world, in that part of it.
Toppel: Yeah, I do. I am very involved with Association for the Health Care Environment and have a lot of peers across the states. And we have those discussions quite often and we do feel like that is something that EVS as a whole, the education, the training is there.
There's more available to us to be able to help with our frontline staff. And get them on board and trained and feel comfortable to understand really what is in the environment and what they're dealing with, yeah.
Srinivas: That's really great. Have you ever felt through any of this that EVS was deprioritized compared to other health care positions?
Toppel: No, I honestly don't feel that we were. And I don't think any of my peers feel that way either, at least those that I have spoken with, which has been many.
I do believe in some of the teachings that I teach outside of my system, the general consensus is no, we were not. Gosh, if COVID did anything, it was elevate our profession even more. So, yeah. Yeah. If something good had to come out of it, that's one thing as far as the EVS world goes.
Srinivas: That's really great. How do you see the role and the relationships of EVS technicians alongside other people who work in the hospital? How do you see that evolving and how do you think that we can foster those relationships more?
Toppel: One thing that has come about, and this even started before the pandemic, so I don't really wanna say it was COVID.
I do believe the collaboration across the continuum has been great and has increased. And some of it is due to the certification in our techs and frontline, understanding the why behind what they do. And just that basic microbiology really does help them, and be able to have those conversations with nurses, with PCTs or CNAs.
And even with the doctors. I don't think I have any staff that are timid, they're not afraid to ask a doctor, "Hey, Dr. So-and-so, I don't think you realize this is an isolation room. Do you need some PPE?" Or whatever it may be.
I know they've had conversations with the clinical team, with nurses and CNAs about, "Wait, that's not the right way to disinfect something. Let me show you or let me help you." In all aspects, some of the things we get back is we weren't taught that in school. You're taught the clinical aspect in school.
And that's why we want to partner with you. We want to help you, we want to support you, and we want you to be safe.
Srinivas: I will say, there are times, because I'm in consulting service, I'm not the main service provider, so I'll be called in to see a patient. We don't know what's going on, or maybe something's been discovered in tests that I haven't gotten a chance to see yet because I'm on my way to come see the patient.
And EVS staff has warned me at times, been like, "Hey, you might want to wear this, you might want to do that." So it is very much that collaborative environment and I, you know, I love it. I love it.
Toppel: Even as far as service recovery goes, a lot of times patients are very open with us because we're not in there to do anything invasive with them.
We're in there to clean their environment, to have a conversation, and to make them feel as comfortable as they can. So they're very open with us, and if we can be that first source of, hey, there's an issue, or there might be a concern here, or you know what, your patient is like really cold.
There's just signs that we teach our frontline that, if somebody's all of a sudden displaying that they're really cold in the room, you're kind comfortable in there, bring it to somebody's attention. Cuz that could mean that they're getting a fever. That could mean something's going south, you just don't know.
So any way we can help support the team is what we're willing to do.
Srinivas: That's great. What barriers do you see that currently exist in the role that EVS staff play as a part of the health care team? Are there challenges that you're hoping we can overcome?
Toppel: I think the biggest barrier is our role in patient throughput.
It's sometimes challenging because we need to get the patients in the right place at the right time, for that right level of care. But sometimes not everyone understands what we have to do in a room. We can't get a room clean and turned over in 15 minutes. It's just virtually impossible.
It is possible, but then it's not safe. And we need to make sure that environment is safe. So I think that is our biggest roadblock in being able to help with the patient throughput.
Srinivas: That makes sense. And they're just, you're right. There are certain things I learned when I was going through our IPC unit in fellowship about it doesn't matter how fast your staff can work because some of the chemicals just need to be on the surface for 15 minutes at least.
Toppel: Yeah. Yep. And generally, some of our quats [quaternary ammonium compounds], I think generally is 10 minutes. And it does, it needs to be there for that long. And all the surfaces we hit, it doesn't matter how fast we are. We still have to hit everything. We have to make sure that we're applying friction. We have to make sure that it's just not a quick swipe and run. There's just a lot of things that we have to do to make sure we remove or eliminate as much of the pathogen load that is in the environment.
Srinivas: And one thing I found that was really cool when I was learning more about the work that you do for infection prevention and control was, at least in my facility, the supervisors would go through after, on random room checks and you would have little daubers where you could double check and see, "Hey, we put a daub here. Did they actually get every surface?" So you're doing a lot of quality internal checks all the time, and I didn't realize this until I was working hand in hand with you all. Can you tell us more about that process?
Toppel: Sure, absolutely. There's two systems that we generally use and it's either black light with a dauber or some kind of luminescence.
And then there's also the ATP, which so many are familiar with. So depending on what your facility uses, they're both great tools. And yes, we do, we go in. Just as an example, for my facilities, we hit so many surfaces in a room. Each supervisor is required to do 15 rooms a month. That's a lot of surfaces cuz you're generally doing more than 10 surfaces in the room.
It really helps our team understand what they're hitting and what they're not. And you can tell, with black light, you can tell if there was enough friction or if there wasn't. Cuz you can still maybe see a smear or see something to that effect. And with ATP, of course, your number is high or is low.
And it's really measuring the bio load, what's on the surface. Is there dust? We don't have anything that'll tell you if there's pathogens, but within dust we know what's in there. So as much as we can remove, it is really good. The staff really like it because they can actually see and they want to know where they can improve, and then the next go around they're absolutely thrilled when they see they have improved. And it's, it, just because you're doing great doesn't mean you stop glow testing or stop doing your ATP.
So those are the things that we do. All the time. I like to have our staff go in when we know there's going to be a discharge, and also explain to those patients that, first of all, of course, ask their permission if we can do it while they're still in the room, and explain to 'em why we're doing what we're doing.
And it really helps. Sometimes they're, really, really fond of their EVS tech and will get ahold of them and let 'em know.
Srinivas: [laughter] Gettin' the cheat sheet.
Toppel: [laughter] Yeah. Which is okay. They're always upfront and they're like, "Oh yeah, let me know," or whatever it is. But others, I think it's really given our patients a sense of comfort knowing that we are making sure the rooms are clean and disinfected appropriately, and that our staff are being monitored, you know. And they're wanting to know what they're missing. So I think all the way around, it's a great program. And it is also part of the CDC, there's a toolbox out there that explains a lot of that, as well.
Srinivas: I need to borrow this toolbox and bring a dauber home and try this out on my partner sometime.
Toppel: You might be scared afterwards.
Srinivas: Seriously. Oh gosh.
So with everything that you have done and all the things that your staff does as a part of the frontline of all of our hospital systems and clinics, what is it that you would want health care workers that don't work with EVS every day, or maybe some that do, what is it that you'd want them to know? What do you think is a message that you want every physician to know about EVS?
Toppel: I think the biggest thing for everyone to know, our physicians, our clinical teams: we care about your patients.
We care about your patients as much as we do. We want positive outcomes. We want the absolute best for them. We want to comfort those that are end of life. We are there as part of your team, and always utilize us as that. We're very passionate about what we do or we wouldn't be here.
Srinivas: So I would only edit that to say our patients because
Srinivas: We're all a team.
Srinivas: We're all, your patient too.
Srinivas: But that's a beautiful message and I love to see that people are embracing that more, but there's always work to be done. So thank you so much for sharing that. Is there anything else that you would want our listeners to know or to leave here today hearing?
Toppel: I would just say in EVS, we help save lives. We absolutely do.
Srinivas: I can't say anything more to that. Thank you so much for joining us. This has truly been such a wonderful conversation.
Toppel: Thank you so much, Megan. I really appreciate being here.
Srinivas: And thank you for your work. Thank you. And all of your staff for the hard work you do.
Stories of Care is a publication of the AMA and CDC's Project Firstline. Project Firstline is a national infection control training collaborative, working to provide all health care professionals with the foundational infection control knowledge they need and deserve to protect themselves, their patients, their coworkers, and their communities. For more information, trainings and other infection control resources, visit CDC.gov/projectfirstline and AMAfirstline.org.
CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
If applicable, all relevant financial relationships have been mitigated.
Stories of Care is a publication of the AMA and CDC's Project Firstline. Project Firstline is a national infection control training collaborative, working to provide all health care professionals with the foundational infection control knowledge they need and deserve to protect themselves, their patients, their coworkers, and their communities. For more information, trainings and other infection control resources, visit CDC.gov/projectfirstline and AMAfirstline.org.