Controlling healthcare acquired infection requires intelligent hospital design and practices, write Nigel Klein and Vanya Gant.
The tragic deaths of three babies at a Belfast hospital highlight the dangers of healthcare associated infection.
These deaths – and the infection of three other babies - have reportedly been linked to Pseudomonas bacteria found on sink taps in the neonatal unit at the Royal Jubilee Maternity Hospital. How the organisms spread from the taps to patients is unclear but these cases demonstrate the difficulties of preventing spread of infection in such high-risk settings.
Improvements in healthcare have led to more patients surviving with increasingly complex conditions. Our hospitals are full of very sick patients who are not only vulnerable to infection but who may themselves act as potential sources of bacteria harmful to other vulnerable patients.
Preventing the spread of infection – the transmission event - is very difficult but increasingly essential.
Several infection control strategies have paid off for HCAI prevention but we have investigated steps towards zero avoidable HCAIs. So we have looked at the design of the hospital environment and its relationship to healthcare givers’ behaviours at work. Specifically, our research involves rigorous observation and tracking of how microbes spread through hospitals.
We and others have shown that frequently touched items such as bedside equipment, taps, door handles and security buttons may be re-contaminated within minutes of being cleaned. Some surfaces such as rims of sinks can be missed by regular cleaning and our microbiological swabbing has demonstrated that these are sometimes heavily contaminated.
We have observed these contaminated surfaces being touched, or used to support other objects such as papers, notes, files and medical equipment - often because there may be nowhere else to put them. Such contamination may then be carried off around the hospital.
Many more wash hand basins have been installed in recent years. That’s good if they are used, but our work shows that this depends on whether sinks can actually be seen. If visibility is obscured, either because of the design of the ward or because of curtains pulled around a patient’s bed, hand washing declines.
Swabbing door handles has taught us a great deal: ‘pull’ door handles, requiring a handgrip, are more densely contaminated than ‘push’ doors with a flat metal plate – easily addressed by simple design variation. Automatic power doors, for example, avoid all contact and therefore eliminate this risk. Many hospitals are required for security reasons to have entry pass controlled doors which get touched by all staff, cleaners and visitors. Contamination of such buttons can act as a source for microbial spread. The NHS could consider designing alternatives: foot pedals, for example, are used in some countries to open doors.
We observed a store cupboard outside a ward with a door handle capable of contamination, heavily used by very busy staff. We calculated that to completely avoid contamination would mean consistently perfect hand washing practice between the ward and the cupboard. This, in turn, would mean staff washing their hands for 90 minutes each shift – clearly an unreasonable proposition. Simple redesigns and “retrofits” of ward areas could limit such constant traffic and transmission of infection.
We have been gathering such data by designing and leading several innovative, rigorous studies of real ward environments in UCLH and Great Ormond Street and funded by HaCIRIC, the world’s largest research programme into healthcare infrastructure.
The Centre brings together Imperial College London and the universities of Loughborough, Reading and Salford as well as other Universities such as UCL. We are building a robust evidence base to inform a straightforward and pragmatic approach to the “dos and don’ts” as they relate to better infection control by design.
We plan, eventually, to create virtual models for those who design hospitals, work in them and clean them. We want to show to everyone involved the potential effect of their actions on reducing infection. This is everybody’s responsibility.
We have already shown that simple changes, such as reducing use of door handles, making sinks more visible and placing tables beside basins might have significant impact. But there is still much to learn.
Our findings do not require a new phase of hospital building. Rather, remedial action can be taken within existing infrastructure. Many changes we envisage would be relatively inexpensive – and in the long run cost-effective – adaptations of building design and working practices.
It’s all about adapting and running these existing healthcare facilities more intelligently, by investing in further research, gathering the evidence, and applying the knowledge. Without such evidence, we can’t prove that we need to spend in order to save.
Crucially, we should stop thinking that we can rid hospitals of bacteria, completely and always. While excellent cleaning standards are essential and fundamental, we have to acknowledge that hospitals are full of sick people who may relentlessly produce and shed infectious microbes.
Accordingly, hospitals may be hotspots for infection, not necessarily because of issues of “cleaning”, but because of this mix of the infectious, the infected, and the susceptible – often in one and the same patient.
Alternative radical, blanket “deep clean” decontamination approaches work; but they make an environment safe only momentarily as the patients are brought back in.
Our focus must be more sophisticated. We should target the transmission event from patient to patient and apply the best cleaning systems and programmes to the highest risk areas, being clear as to who should be cleaning what, when and how.
Intelligent infection control will require detailed knowledge of how buildings work and how people use them. Many large hospitals have been built in several stages, sometimes over a century. Each part may have specific issues and vulnerabilities to infection transmission (we know, for example, that some materials are more prone to contamination and more difficult to clean than others). One-size-fits-all infection control policies and practice are inadequate.
Many individual factors must be considered and understood. For example, HaCIRIC also funds research relating to how air, and the organisms it may contain, moves around, and how novel and relatively cheap ventilation strategies might both be energy friendly and better for the patients.
Nurses and others on the front line really understand these issues, making them the key to the solutions. They often see how and why systems fail and resulting costs. They know what makes their lives difficult, such as when stores are distant or when a shelf or table on which to place items would make a difference while hand-washing. And yet these small changes are rarely implemented.
The insight and knowledge which might make a difference is often already there. The evidence that it will make a difference is being sought by our and others’ research. We believe this work will result in a better, more intelligent approach to limiting transmission of organisms in our hospitals.
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The authors’ research is part of a programme run by the Health and Care Infrastructure Research and Innovation Centre.