Facility Design to Reduce Hospital-Acquired Infection

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No one who enters a hospital to address an acute or chronic health condition deserves to acquire a dangerous or life-threatening infection as a result of their temporary vulnerability. The Institute of Medicine report (2000), To Err Is Human, described the unnecessary deaths or harm attributable to preventable causes, one of which is infection acquired during a hospital stay.

The problem of hospital-acquired infection is increasing around the world (Scott, 2004). It is exacerbated by the emergence of resistant strains among many bacterial and viral infection sources (Capriotti, 2003).

Design of the hospital environment plays a role in the control or transmission of infection. Proper hand hygiene is the single most effective intervention in the prevention of infection in hospital settings (Albert & Condie, 1981; Boyce & Pittet, 2002; Larson, 1988).

Prevention of infection may be facilitated or hampered by specific physical design features of the facilities for decontaminating hands. How can the design and research communities contribute to important improvements in the prevention of infections? 

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Facility Design to Reduce Hospital-Acquired Infection

  1. 1. Facility Design to Reduce Hospital-Acquired Infection D. Kirk Hamilton, FAIA, FACHA, EDAC From Health Environments Research & Design Journal Vendome Healthcare Media | www.herdjournal.com
  2. 2. Facility Design to Reduce Hospital-Acquired Infection No one who enters a hospital to address an acute or chronic health condition deserves to acquire a dangerous or life-threatening infection as a result of their temporary vulnerability. The Institute of Medicine report (2000), To Err Is Human, described the unnecessary deaths or harm attributable to preventable causes, one of which is infection acquired during a hospital stay. The problem of hospital-acquired infection is increasing around the world (Scott, 2004). It is exacerbated by the emergence of resistant strains among many bacterial and viral infection sources (Capriotti, 2003). Vendome Healthcare Media | www.herdjournal.com
  3. 3. Facility Design to Reduce Hospital-Acquired Infection Design of the hospital environment plays a role in the control or transmission of infection. Proper hand hygiene is the single most effective intervention in the prevention of infection in hospital settings (Albert & Condie, 1981; Boyce & Pittet, 2002; Larson, 1988). Prevention of infection may be facilitated or hampered by specific physical design features of the facilities for decontaminating hands. How can the design and research communities contribute to important improvements in the prevention of infections? Vendome Healthcare Media | www.herdjournal.com
  4. 4. Facility Design to Reduce Hospital-Acquired Infection Background Infections that originate in the hospital, also called nosocomial infections or hospital-acquired infections (HAIs), are a serious problem (Capriotti, 2003; Struelens, 1998). Infections are caused by bacterial, viral, or fungal organisms, and strains of these organisms have developed resistance to the antibiotics used to treat them. Strains of methicillin-resistant Staphylococccus aureus (MRSA) have been spreading rapidly in hospitals and in the community. Struelens (1998) reported that strains of vancomycin-resistant staphylococci and enterococci are emerging, and that Klebsiella pneumoniae, Enterobacter, Pseudomonas aeruginosa, and Acinetobacter baumannii are gradually developing resistance to “useful classes of antibiotics, including the penicillins, cephalosporins, aminoglycosides, and fluoroquinolones” (p. 652). Vendome Healthcare Media | www.herdjournal.com
  5. 5. Facility Design to Reduce Hospital-Acquired Infection Increased death rates associated with outbreaks of Clostridium difficile have been reported in North American hospitals (Wilcox, Cunniffe, Trundle, & Redpath, 1996). Other community-acquired infections, such as resistant strains of tuberculosis, also have appeared (Frieden et al., 1993). Fungal infections, such as Aspergillus (Stevens et al., 2000), can be found at construction sites, for example, in the case of hospital renovations. There are reports that physicians overprescribe antibiotics, and that patients don't always take their antibiotics to the end of the prescribed course. These factors tend to increase drug resistance in the organisms that threaten hospital patients (Capriotti, 2003). Vendome Healthcare Media | www.herdjournal.com
  6. 6. Facility Design to Reduce Hospital-Acquired Infection Scope and Consequences of the Problem There are strong reasons to reduce rates of HAIs. The cost of HAIs, in dollars and unnecessary suffering or death (Scott, 2009), is enormous. Infections are more serious than they have been in the recent past. After World War II it was assumed that penicillin was a “miracle drug” capable of defeating any infection. Penicillin, sulfa, and numerous other drugs provided excellent defenses against infection, but seven decades later, many infectious organisms have developed resistance to the range of drugs in the physicians' armamentarium. More virulent strains of infectious organisms with greater resistance to antibiotics threaten patients in healthcare settings with lowered immune responses (Capriotti, 2003). Vendome Healthcare Media | www.herdjournal.com
  7. 7. Facility Design to Reduce Hospital-Acquired Infection The number of infections, adverse events, and errors in critical care environments is especially significant (Rothschild et al., 2005) in ICUs, where the most vulnerable patients face increased risk for every day they stay. If configuration and features of the hospital and critical care environments can make a significant difference in reducing infections, then discovery of better designs must become a high priority. Vendome Healthcare Media | www.herdjournal.com
  8. 8. Facility Design to Reduce Hospital-Acquired Infection Contact Transmission and Hand Hygiene The transmission of infection from one patient to another is often through the contact of a caregiver with a patient, or with objects and surfaces either may touch. As a result, the rate of hospital-acquired, or nosocomial, infections is correlated with adherence to hand hygiene recommendations on the part of caregivers and visitors (Centers for Disease Control & Prevention, 2002). Vendome Healthcare Media | www.herdjournal.com
  9. 9. Facility Design to Reduce Hospital-Acquired Infection Purposefully designed stations, providing sinks with soap and water and/or alcohol rub dispensers at which hand hygiene can be properly performed, are required for consistent adherence. If such stations are absent, poorly located, or lacking key features, the result can be a reduction in proper hand hygiene adherence and thus higher levels of infection (Ulrich et al., 2008). Is there a combination of design interventions that might improve the likelihood that hands will be washed or sanitized? Vendome Healthcare Media | www.herdjournal.com
  10. 10. Facility Design to Reduce Hospital-Acquired Infection Contact Transmission and Surfaces Transmission of infectious organisms can occur when surfaces or furnishings in the room are capable of supporting a pathogen. Reducing the potential for moisture to accumulate and harbor a colony has long been a goal of designers. Surfaces chosen by designers for their ability to stand up to harsh cleaning solvents have been another infection control strategy. Materials with anti-microbial characteristics have been used for some time in furnishings, carpeting, and drapes or privacy curtains. Today there seems to be much attention given to the specification of materials and surfaces featuring impregnated copper or silver (Casey et al., 2010). How do material selections and specifications impact infection rates, and how best to study their effects? Can we learn what role the furnishings in hospital rooms play in the spread of infection? How can better designs make a difference? Vendome Healthcare Media | www.herdjournal.com
  11. 11. Facility Design to Reduce Hospital-Acquired Infection Airborne Transmission and HVAC Systems Systems for heating, ventilation, and mechanical air conditioning (HVAC) are pervasive in North American hospitals. Fifty or more years ago this was not universal, and these systems still are not widely employed in many less-developed countries. In the United States atmosphere in a hospital is measured in air changes, cubic feet per minute (CFM), temperature, humidity, and degree of filtration. It is described as consisting of some percentage of “outside air” and a corresponding percentage of re-circulated air. The mechanical systems serve zones within the hospital, comprising thousands of square feet and many rooms at once. Organisms that escape filtration can be spread anywhere within a zone, where they can and do spread airborne infections (Nicas, Nazaroff, & Hubbard, 2005). Vendome Healthcare Media | www.herdjournal.com
  12. 12. Facility Design to Reduce Hospital-Acquired Infection Isolation rooms used to reduce the chance that an infected patient may contaminate others, which guidelines in the United States specify as 10% of patient rooms, are separated from the air systems of larger zones. Advocates of better protection from airborne infection recommend 100% fresh air from outside the hospital, and 100% exhaust from each patient room. Others advocate higher percentages of isolation rooms, above and beyond a commitment to private patient rooms. Filtration is vital if air must be re-circulated, although there are severe energy consumption penalties to be paid for the force required to move air through the likes of a hepa-filter. What is the best future system to increase safety without excessive energy cost? Vendome Healthcare Media | www.herdjournal.com
  13. 13. Facility Design to Reduce Hospital-Acquired Infection International Variation There are wide variations in infection rates observed in different countries (Coello, Gastmeier, & de Boer, 2001; Grundmann et al., 2010; Köck et al., 2010). Rates in the U.S., Canada, the United Kingdom, and Mediterranean countries are comparatively high, while rates in Sweden, Scandinavian countries, and the Netherlands are very low. Countries with the lowest rates are involved in aggressive “search and destroy” efforts to eliminate infections wherever found (Vos et al., 2009). One of the factors in resistance to antibiotics is their widespread use in livestock and poultry (Feingold et al., 2012). Europeans, especially in the Netherlands, Sweden, and Denmark, are addressing the issue with public policy. The population of the United States is exposed to antibiotics through their presence in the food supply. Vendome Healthcare Media | www.herdjournal.com
  14. 14. Facility Design to Reduce Hospital-Acquired Infection A newly completed infectious disease hospital in Malmo, Sweden, offers some interesting design concepts. It features access to each patient room from outside, via an external open-air balcony, air lock anterooms on both the internal (staff) side and the external entrance, with all air exhausted through the patient's toilet room. What can we learn from this example in a country that maintains an exceptionally low rate of infection? Do we need completely new ideas in addition to incremental improvements. Vendome Healthcare Media | www.herdjournal.com
  15. 15. Facility Design to Reduce Hospital-Acquired Infection Knowledge Gaps While there is some information available on best practices for design of hand hygiene facilities (Provincial Infectious Diseases Advisory Committee, 2008), there is an unfortunate lack of studies that describe design interventions and report associated infection rates. Hand hygiene adherence is usually treated as a surrogate for the clinical outcome, and the majority of the findings do not directly answer the crucial question of design's relationship to nosocomial infection. The object of design interventions is reduction or elimination of contactborne and airborne infection, so the absence of relevant data reduces the value of the studies. One significant possibility is that a European-style intervention aimed at eliminating antibiotic use in livestock and poultry (Feingold et al., 2012), along with aggressive “search and destroy” policies (Vos et al., 2009) would make far greater difference than improved facility design by eliminating much of the sources prior to transmission, and decreasing the development of resistant strains. Vendome Healthcare Media | www.herdjournal.com
  16. 16. Facility Design to Reduce Hospital-Acquired Infection Conclusion Hospital-acquired infection is a serious and growing problem in U.S. health facilities, as it is in several other countries, and infection control efforts are ongoing. At the same time, valuable lessons can be learned from countries like Sweden and the Netherlands where hospital infection rates are dramatically lower. Vendome Healthcare Media | www.herdjournal.com
  17. 17. Facility Design to Reduce Hospital-Acquired Infection There is a need for research to describe and explain the role of the purposefully designed physical environment as it relates to hospital-acquired infection. Research relating design features for hand hygiene facilities to associated infection outcomes is an important first step. Further research into the antimicrobial potential for different materials is warranted. It would be helpful to have better understanding of the mechanical air handling systems and filters providing intended air exchanges in patient rooms. Such a research program dealing with contact-borne, water-borne, and airborne pathogens will lead to predictions of specific evidence-based design features that will play a significant role in preventing future hospital-acquired infections. Vendome Healthcare Media | www.herdjournal.com
  18. 18. Facility Design to Reduce Hospital-Acquired Infection The design of hospital and healthcare environments plays an important role in reducing the problem of infection. It is likely that the best and most effective future design interventions will benefit from creative and imaginative reference to the best available evidence from research. It is also likely that the best results will come from synergistic combinations of interventions applied together because no single intervention promises to be the magic bullet. Success will mean many lives will be saved and unnecessary harm and pain will be avoided. That is a noble goal. Vendome Healthcare Media | www.herdjournal.com
  19. 19. Health Environments Research & Design Journal (HERD) Health Environments Research & Design Journal (HERD) is an interdisciplinary, peer-reviewed journal whose mission is to enhance the knowledge and practice of evidence-based healthcare design by disseminating research findings, discussing issues and trends, and translating research into practice. Get a FREE Issue Today! Vendome Healthcare Media | www.herdjournal.com

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