In the US “One in 25 patients have a hospital-acquired infection...Each day, over 205 deaths occur from HAIs...” — Centers for Disease Control, 2011 An overview of this month’s article follows with bullet-points of the advantages and disadvantages of various environmental interventions in the prevention of Healthcare-Associated Infections (HAIs), often referred to as hospital-acquired infections. Paragraph summaries of Cleaning Strategies, Materials, Room Design and Hand-Hygiene are listed below. These provide broad themes and findings from the article. Reading the full article is always of benefit for a fuller understanding and is recommended. Click here to access the full article on the HERD Journal website.

1. ARTICLE
Steinberg, J. P., Denham, M. E., Zimring, C.,
Kasali, A., Hall, K. K., & Jacob, J. T. (2013). The
role of the hospital environment in the prevention
of Healthcare associated infections by contact
transmission. Health Environments Research &
Design Journal, 7(Suppl), 4673.
KEYWORDS
Patient Safety, Infection Control, Materials,
Medical Planning, Interior Design, Hospital,
Healthcare
BACKGROUND ON HEALTHCARE-
ASSOCIATED INFECTION
The Safety Problem
In the seminal 2000 report, To Err is Human, the
Institute for Medicine (IOM) exposed the drastic
deficits in patient safety lacking in our healthcare
system.1
The IOM hoped this article would turn the tide. Unfortunately, 15 years later we still have over 205
patient deaths each day from HAIs.2
Financial Cost
“While there is considerable variability in the costs of HAI, the low cost estimates of $5.7 to $6.8 billion
annually are still substantial when compared to the cost of inpatient stays for other medical conditions.”3
For
care of a HAI, cost estimates range from $20,549 - $25,903 per patient. This is independent of the cost of
care for a patient’s initial condition for which they were hospitalized (direct medical hospital patient costs based
on 2007 CPI for Inpatient hospital services).
Role of Environment
Approximately 20% of HAIs are estimated to be attributed to environmental surfaces (Weinstein, 1991).4
There are many factors that go into the prevalence of HAIs, including patient population, cleaning procedures,
clinical culture, hand washing behaviors. Many of these items are often expressed in terms of clinical and
staff protocols, however that is only part of the story. The environment in which care is provided is quietly
and consistently modifying the behaviors of those that inhabit it. In this way, the environment is a behavioral
catalyst and can be used to foster positive preventative measures, and to deter negative actions. For example,
proper location of alcohol-based hand rub stations has been shown to increase hand hygiene behaviors.
The question is: what can architects, interior designers and medical planners do to contribute to healing this
broken system? Dr. Steinberg and his colleagues at Emory University and Georgia Technical Institute attempt
to answer this question in their 2014 article, summarized below.
THE HOSPITAL ENVIRONMENT:
PREVENTING HAIS BY CONTACT TRANSMISSION
This article is a literature review, summarizing the existing body of literature on the relationship between the
built environment, and contact (i.e. touch) transmission of HAIs.5
The authors reviewed 59 peer-reviewed
articles and summarized their findings into the following:
I. Cleaning Strategies and Technologies
Ineffective cleaning by EVS appears to be major cause of residual contamination. High turn-over, low-wages,
and time constraints add to this problem. Novel technologies are emerging to complement existing cleaning
practices, primarily the following:
ULTRAVIOLET GERMICIDAL IRRADIATION (UVGI)
Advantages:
• Can kill C. diff., in addition to MRSA, VRE and other pathogens.
• Cleans the air and the surfaces
Disadvantages:
• Primarily only used for terminal cleaning
• Takes up to 1 hour. (Although time may be reduced with UV-reflective wall coatings.)
• All must vacate room for duration of UV cleaning
• Does not clean surface not exposed to direct UV
HYDROGEN PEROXIDE VAPOR (HPV)
Like UVGI, HP is used primarily in terminal room cleaning. Use of vapor (HPV) shown to be more effective
than HP aerosol mist.
Advantages:
• Can kill C. diff., in addition to MRSA, VRE and other pathogens.
• Cleans the air and the surfaces
• Has been shown effective in numerous studies
Disadvantages:
• More difficult to use than UVGI
• Entire room must be sealed including ducts.
• Recommended for epidemics, not standard cleaning practices
II. Surfaces
COPPER-BASED MATERIALS
Advantages:
• Copper ions are fatal to many pathogens
• Has been shown effective in lab and clinical settings
• Microbial killing happens in hours
Disadvantages:
• May be more reactive to harsh cleaning methods
• Can build debris and reduce efficacy over the life-time of the material
• Cannot use anti-corrosive coating, it will make copper copper ions ineffective
FLOOR COVERING: CARPET
Note: Most studies of floor coverings published in this article occurred prior to 1995, and thus suggests
that there is limited timely knowledge on modern carpet technologies.
Advantages:
• Commonly discussed benefits of carpet include reduced noise, skid resistance, reduced impact from
falls, and musculoskeletal fatigue for healthcare workers.
Disadvantages:
• May be more reactive to harsh cleaning methods, build debris, reduce efficacy over the life of the material
III. Recommended Physical Features
SINGLE-PATIENT ROOMS
• More frequent terminal/overall room cleaning
• Reduced spread of infection between roommates
• Eliminates need to move infectious patients
• Improved hand-hygiene moving between patients
CURTAINS
• Remove curtains when possible (based on CDC Guidelines)
• Curtains are “high-touch” surface which often harbor pathogens
• Increase frequency of cleaning and replacing curtains
• Antimicrobial curtains showed to delay contamination for 2 wks.
HAND HYGIENE
• Most effective when located in visual proximity to the patient.
• Recommends clearly visible, convenient, standardized, and comfortable heights
• Increased number of alcohol rubs has been shown more effective than increased sinks
• Real-time feedback to staff shown effective for improving compliance
IV. Supplement:
WHAT IS THE DIFFERENCE BETWEEN HAIS VS HACS:
• A hospital-acquired condition (HAC) “ is a medical condition or complication that a patient develops
during a hospital stay, which was not present at admission.”
6
• A healthcare-associated infection (HAI), is a type of HAC that is specific to the patient developing an
infection during a hospital stay which was not present at admission.
MOST COMMON TYPES OF HAIS
7
:
• CLABSI: central line-associated bloodstream infections
• CAUTI: catheter-associated urinary tract infections
• MRSA: methicillin resistant Staphylococcus aureus (bloodstream infections)
• C. diff: Clostridium Difficile (digestive tract)
• VAP: Ventilator-associate Pneumonia
• SSIs: Surgical site infections (location-related)
1. Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, D.C: National
Academy Press.
2. Scott, R. D. (2009). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of preven-
tion. Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf
3. Scott, R. D. (2009). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of preven-
tion. Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf
4. Weinstein Robert A. (1991). Epidemiology and control of nosocomial infections in adult intensive care units. The American
Journal of Medicine, 91 (3, Supplement 2), S179S184.
5. Steinberg, J. P., Denham, M. E., Zimring, C., Kasali, A., Hall, K. K., & Jacob, J. T. (2013). The role of the hospital environment
in the prevention of Healthcare associated infections by contact transmission. Health Environments Research & Design Journal, 7(Suppl),
4673.
6. American Hospital Directory. (2012). Quality Definitions and Methodology: Hospital Acquired Conditions. Retrieved from:
http://www.ahd.com/definitions/hqi_acq_cond_measures.html
7. Magill, S.S., Edwards, J.R., Bamberg, W., Beldavs, Z., Dumyati, G., W., Kainer, M... Fridkin, S. (2014). Multistate Point-Preva-
lence Survey of Health Care–Associated Infections: CDC HAI Prevalence Survey. N Engl J Med 2014;370:1198-208.
In the US “One in 25 patients have a hospital-acquired
infection...Each day, over 205 deaths occur from HAIs...”
— Centers for Disease Control, 2011
PURPOSE
This newsletter is intended to provide a quick and easy-to-use Summary Brief of a selected article and references, which
allow designers and planners to review ideas and design implications on important industry topics.
HOW TO USE
An overview of this month’s article follows with bullet-points of the advantages and disadvantages of various environmental
interventions in the prevention of Healthcare-Associated Infections (HAIs), often refered to as hospital-aquired infections.
Paragraph summaries of Cleaning Strategies, Materials, Room Design and Hand-Hygiene are listed below. These provide
broad themes and findings from the article. Reading the full article is always of benefit for a fuller understanding and
is recommended. Click here to access the full article on the HERD Journal website. For more
information, contact Erin Peavey, Senior Researcher + Medical Planner.
RESEARCH NEWSLETTER:
Exploring Healthcare Environments
January 2015
HOK | HEALTHCARE
1065 Avenue of the Americas, 6th Floor | New York, NY 10018 | t +1 212 9817303 f +1 212 633 1163 | hok.com
Healthcare-Associated Infections
Figure 1. Ultra-Violet Radiation room treatment 2. Hydrogen
Peroxide room treatment 3. High-touch, high-contamination
surfaces 4. UMPC Patient Room Design with strategically
placed hygiene stations (designed by HOK).
Key Takeaways
• Environments that foster hand-washing or use of alcohol rubs has been shown to reduce infection rates.
• Hygiene stations are best when clearly visible, coinvent, standardized and located in visual proximity to
the patient. (i.e. when one looks at the patient they see the hygiene station in the periphery.
• Ultraviolet germicidal irradiation (UV) and hydrogen peroxide vapor (HPV) are not stand alone cleaning
methods - use for terminal cleaning (i.e. room turn-over) and should be in conjunction with standard
cleaning practices.
• UV is better for terminal cleaning whereas HPV is best for ending epidemics.
• Existing cleaning is sub-optimal due to standard operational limitations (see above) thus should be
supplemented by materialization, advanced cleaning technologies, and strong hand-hygiene.
• Hand-hygiene is recognized as the leading prevention strategy for reducing HAI transmission.