Reinvesting in Our First Line of Defense: Environmental Service Workers

Author: Keith H. St. John

Categories: General Infection Prevention & Surface Disinfection April 27, 2021
Healthcare Professionals at hospital

Last May, Kevin Tyan and Dr. Pieter Cohen from Harvard Medical School and Cambridge Health Alliance, respectively, published an article in the Annals of Internal Medicine entitled: “Investing in Our First Line of Defense: Environmental Services Workers.”¹ Almost one year has passed since then, and the COVID-19 pandemic continues to march on, possibly entering the fourth wave in the surge of new cases here in the USA.

Reinvesting our Support

It is appropriate to reinvest our support of these hundreds of thousands of essential environmental services (EVS) personnel devoted to cleaning and disinfecting our hospitals and long-term care (LTC) facilities.  These EVS workers are the most essential to combating the spread of the virus within the facilities they serve but are also the group most likely to be exposed to the virus. These unsung heroes have faced multiple challenges performing their arduous tasks of cleaning and disinfecting multiple surfaces and equipment with even greater efficiency and diligence than ever before.  Pre-pandemic, a once per day cleaning of rooms was the norm, and possibly less frequently in long-term care resident rooms.  With the advent of the pandemic, they have been called to increase the frequency of cleaning/disinfection up to three times per day – a 300% increase in workload and often without additional staff/support.

Furthermore, their devotion to patient/staff safety has been hindered by personal protective equipment (PPE) shortages, germicides placed on allocation/back-order, and ongoing work fatigue due to long hours, as well as anxiety about being exposed to SARS-CoV-2 and possibly bringing it home to family members.

Keeping pace with these challenges is a daunting task, especially with changes in germicide occurring almost weekly with different instructions for use and wet contact times while ensuring it is on the EPA’s List N of approved disinfectants for COVID-19.

Vaccine Hesitancy

With the advent of having two mRNA vaccines and a third viral vector vaccine under FDA emergency use authorization (EUA) available, the priority is to have these EVS workers fully vaccinated as soon as possible.  However, there is often hesitancy that prevents them from pursuing vaccination.

As Tyan and Cohen mentioned in their article¹, a culture of urgency and responsibility needs to be instilled in every employee working in these healthcare settings.  It begins with showing respect/admiration for the EVS staff and taking steps to support their efforts on the frontline of infection prevention., as well as by acknowledging their role as valuable members of the patient care team.  Rather than being a target for cost-cutting efforts when lay-offs loom over their heads, these team members should be viewed as a core critical investment in improving patient outcomes.

EVS Worker Support Strategies

The strategies to support EVS workers were distilled to four key goals by Tyan & Cohen¹:

  1. Culture-Building a culture of respect and recognition while avoiding interrupting or rushing them through tasks.
    1. Involve EVS workers in regular interdisciplinary meetings allowing their voice to be heard.
    2. Provide interprofessional training that highlights the role of EVS workers and fosters a spirit of teamwork.
  2. Investment– Avoid understaffing and have a contingency plan for backup coverage when callouts occur.
    1. Retain workers through increased wages aligned with the importance of their work or pursuit of advanced certifications.
    2. Provide or incentivize certification programs to strengthen their skills and promote hospitality practices.
    3. Provide accessible training materials that account for literacy and language barriers.
    4. Develop EVS teams to improve staff integration and accountability (“family-centered care”).
  3. Effectiveness– Reducing human error (human factors assessments) through frequent monitoring and timely feedback to improve practices.
    1. Implement evidence-based practices and incorporate checklists to ensure accountability.
    2. Encourage the deployment of no-touch technology (e.g., UV-C) with published evidence supporting its adoption, which complements but does not replace the need for thorough manual cleaning and disinfection by skilled EVS workers.
    3. Possibly assign motivated staff to specialize in novel technology and serve in a training role and serve as a technology advocate.
  4. Safety– Implement guidelines and provide comprehensive training to reduce EVS exposure risk to chemicals and possible contagions while being aware of literacy and language barriers.
    1. Account for EVS requirements for PPE and managing the supply effectively to prevent shortages (possible reprocessing of PPE during acute shortages).
    2. Provide adequate health insurance and paid sick leave benefits without having to use vacation time.

Looking Ahead to Our Future

Healthcare will be forever changed after the global pandemic, and no doubt, EVS personnel will continue to play an essential role in infection prevention. By providing the proper tools, novel no-touch technology, continuously active disinfection technology, ongoing education/training, greater access to vaccine and PPE, we can create a new generation of dedicated EVS workers that even extends into public settings, including schools, sports stadiums, travel venues (e.g., buses, trains, airplanes), cruise ships, amusement parks, conference centers, and the list goes on.

Now is an appropriate time to shine a new light on these unsung heroes and acknowledge their patient/LTC resident safety role.

¹ K. Tyan and P.A. Cohen. Investing in Our First Line of Defense: Environmental Services Workers. AIM, vol. 173, no. 4. 18 Aug. 2020, pp. 306-308.


Keith H. St. John MS, CIC, FAPIC
Keith St John, VP Clinical Affairs PDI Healthcare Vice President, Clinical Affairs


Keith St. John has been an Infection Preventionist for the past 30+ years, including 17 years of directing IPC programs at major tertiary teaching institutions.   

Keith is certified in Infection Control & Epidemiology, a Fellow of APIC (FAPIC), and a past President of the Certification Board of Infection Control & Epidemiology (CBIC).  He was a member of the United States Pharmacopeia Convention Expert Compounding Committee for 8 years and is co-author of the current chapters of the USP <797> on Pharmaceutical Compounding – Sterile Preparationsthe USP Chapter <800> on Hazardous Drugs – Handling in Healthcare Settings, as well as a co-author of a chapter in the ASHP Compounding Sterile Preparations resource book entitled Microbiological Issues in Compounding Sterile Preparations, published in 2017.   

Keith has served as a Philadelphia-Delaware Valley APIC Chapter President, First State (Delaware) APIC Chapter President, a member of the National APIC Governmental Affairs Committee, APIC Text Revision Task Force, APIC Education Committee, and is a past member of the Editorial Board for the American Journal of Infection Control.   

In addition to his longstanding involvement with APIC, Keith is also a current member of The Society for Healthcare Epidemiology of America (SHEA), The Healthcare Infection Society (HIS-UK), The International Federation of Infection Control (IFIC), AORN, AACN, AVA, IPAC-Canada, and a newly inducted member of the Surgical Infection Society.   


Phone: (302) 598-5662
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Professional musician & chorister
Vintage film photography
Travel and student of American history


B.S. Medical Technology – University of Delaware
M.S. Clinical Microbiology – Thomas Jefferson University
Ph.D studies in Microbiology – Thomas Jefferson University

Why I love what I do

My interest in microbiology and infectious diseases quickly aligned with an opportunity to enter the field of infection control while still a graduate student at TJU.  A unique opportunity to shadow with Infection Preventionists at ten different hospitals and attend the CDC 1200 G course in infection control created a career opportunity to lead infection prevention efforts in multiple hospital settings, and introduce new technologies to advance those efforts.  My passion for preventing infections and saving lives continues to this day. 

Areas of Expertise

Special interest in environmental microbiology, disinfection and sterilization practices, HAI prevention, electronic surveillance technology, as well as skin antisepsis and the control of multi-drug resistant organisms. 

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