Infection Control and the Built Environment: No Easy Answers
By Susan Carr
For more than 160 years, healthcare providers have understood that aspects of the built or physical environment of hospitals may deter healing or cause patients to develop new health problems, including infections, even as they seek help for existing illness and injuries.
Driven by conditions she observed while caring for soldiers during the Crimean War, Florence Nightingale exhorted nurses to make providing clean, healthy environments their first priority:
The very first canon of nursing, the first and the last thing upon which a nurse’s attention must be fixed, the first essential to a patient, without which all the rest you can do for him is as nothing, with which I had almost said you may leave all the rest alone, is this: TO KEEP THE AIR HE BREATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHILLING HIM (1860).
Poor sanitation affected the health of all populations—sick and well—at the time. Although Nightingale did not make the direct connection between pathogens and infection that we understand today, the effect of her crusade to improve living conditions inside and outside hospitals was visionary at the time.
Noskin and Peterson (2001) point out that Semmelweis, known best for making the connection in 1847 between new infections in patients and providers with unclean hands, also identified a more generalized danger of being in the hospital compared with being cared for at home. When Semmelweis realized that women giving birth in one hospital unit, where medical students often assisted with deliveries immediately after performing autopsies, had higher rates of infection than other units, he also recognized that women who gave birth at home had even lower rates of infection than mothers in the safest units in the hospital. Semmelweis knew that providers must wash their hands regularly to protect patients from infection, and that it simply is best to avoid being in the hospital, where there is likelihood of acquiring additional health problems.
Private, single-patient rooms are becoming common in U.S. hospitals, but this is not a new idea in facility design. In JAMA in 1920, Asa Bacon, superintendent of Presbyterian Hospital in Chicago, called for private rooms for all hospital patients, not just for the wealthy, to speed their recovery (Noskin & Peterson, 2001). Bacon recognized then, as we do now, that patients housed together in close proximity were more likely to share their infections and diseases.
The Effects of the Built Environment
Despite dramatic advances in medicine, disinfection techniques, environmental systems, construction methods and materials, the built environment of modern hospitals still presents the risk of what we now call hospital-associated infections (HAIs) and other preventable adverse events. Beyond the fact that hospitals harbor organisms that may cause illness, the design of buildings and furnishings pose other hazards and may even impede efforts to control the transmission of disease and infection.
Although pathogens may be transmitted through air and water, most infection control efforts in hospitals focus on transmission through contact with surfaces: furniture; fabrics; walls; fixtures; devices; and, of course, human hands. Infection control focuses on environmental cleaning and disinfection, with new materials, cleaning products, and disinfection techniques being developed to perform more effectively and, in some cases, even to disinfect themselves. Having the most effective cleaning strategy is, however, not enough. Nor does investment in sinks and hand-sanitizer dispensers guarantee that clinicians will comply with hand hygiene policies. As is true with most improvement efforts, effective infection control requires commitment and collaboration throughout the ranks of professional and service workers, a pervasive and supportive safety culture, and a built environment that supports improvement efforts and best practices.
Although the effects of the built environment on health and healing were recognized long ago, the healthcare industry is still developing an understanding of how to use design effectively to promote infection control and patient safety in general. To understand the effects of the built environment specifically on HAIs, the Agency for Healthcare Research and Quality (AHRQ) recently sponsored a study to evaluate the evidence supporting best practices and the experience of experts in a variety of fields.
Published as a supplement to HERD: Health Environments Research & Design Journal, AHRQ’s report, Understanding the Role of Facility Design in the Acquisition and Prevention of Healthcare-Associated Infections (Hamilton & Stichler, 2013), is available for free download from the publisher (www.herdjournal.com).
Carolyn Clancy, MD, director of AHRQ when the report was written, explains in the introduction that two kinds of science are necessary for preventing HAIs: 1) traditional infection control science—eradicating or reducing the incidence of infection and treating those that occur and 2) human factors and behavioral science—helping healthcare workers employ infection control science effectively and making sure that the environment makes that work easier rather than harder to accomplish (Hamilton & Stichler, 2013).
For the report, a multidisciplinary team of researchers from AHRQ, RTI International, Emory University, and the Georgia Institute of Technology reviewed current literature to learn how the design of hospital environments affects the transmission of infectious organisms by air, water, and contact. Working with experts in library science, researchers chose more than 1,000 articles in various disciplines, which were narrowed down to more than 780 for further review, and more than 200 for final review. The materials came from the “gray” literature—such as technical reports, conference proceedings, and government publications—as well as peer-reviewed journals. Overall, researchers found that clear evidence for best practices in using design to combat HAIs is lacking:
There are, however, few rigorous studies demonstrating the link between design and a subsequent reduction in HAIs. As a result, the field largely remains an idiosyncratic patchwork of best practices and inferential steps from lab or epidemiological research (Hamilton & Stichler, 2013, p. 14).
Evidence, Guidelines, and Experience
Lack of definitive evidence related to patient outcomes, however, does not mean that improvement efforts are performed without guidance. There are aspects of facility design that clearly improve infection control. To reduce the incidence of HAIs, for example, the use of single occupancy inpatient rooms and convenient placement of hand hygiene equipment—sinks and dispensers—are recommended, intuitively compelling, supported with research, and guided by regulation.
In recommended guidelines for the “hospital of the future,” The Joint Commission pointed out that single rooms offer better privacy and comfort for patients, space for their visitors, and further stated that “single-patient rooms may have the single most important impact on patient safety” among other improvements to the built environment (2008, p. 34–35). Single-patient rooms were also number one on the Institute for Healthcare Improvement’s 2009 list of design priorities for hospitals engaged in new construction or major renovation (p. 7). In addition to decreased opportunity for patient-to-patient germ transfer, IHI claims that providers caring for patients in single rooms are more likely to wash their hands between patients, perhaps prompted by the obvious passage in and out of separate rooms. Detsky and Etchells (2008) cited similar advantages in “Single-Patient Rooms for Safe Patient-Centered Hospitals,” published in JAMA in August 2008. The Facility Guidelines Institute, a non-profit organization that publishes Guidelines for Design and Construction of Health Care Facilities, designated single-patient rooms as a “minimum standard” for hospitals in the 2010 edition of the guidelines.
The use of single-occupancy rooms is, however, not a simple solution for HAIs and illustrates how advances in patient care and the built environment may pose new challenges. In addition to infection prevention efforts, recent attention to patient preferences and comfort—patient-centeredness and satisfaction—have influenced the move toward single-occupancy hospital rooms. For all their advantages, these newly designed patient rooms are harder to clean. Hospitals are providing better accommodations for friends and family members, with more space, open visiting hours, and sometimes upholstered furniture or recliners that allow overnight visits, all of which complicate cleaning strategies. Computer terminals with touchscreens for patient and provider use, likewise, improve patient care and require additional cleaning. While mounting hand-sanitizer dispensers in each room improves usage, they present more surfaces—especially the dispenser’s operable bar or button—in need of regular cleaning. All of these items complicate and prolong the process of cleaning and disinfecting the room after discharge as well as on a daily basis.
In addition to a literature review, researchers working on the AHRQ-sponsored report (2013) performed small-group interviews with interdisciplinary teams of experts, including professionals in infection control, facility design, and hospital and medical administration. An infection preventionist interviewed for the AHRQ report commented,
Thinking back to 1975 when all we had was an overhead table, bedside table, and an IV pole, it was easy to turn over a room. Now, we have a hugely complex environment with frequent patient-to-surface contact—adequate cleaning on a daily basis is becoming insurmountable (Hamilton & Stichler, 2013, p. 35).
There should be no turning back on these efforts to improve the patient experience. It is important, however, to recognize that infection prevention in this environment requires increased collaboration, resources, time, and support.
Advances in Materials and Processes
Copper, now being used in new ways in healthcare for its continuous antimicrobial characteristics, and disinfection techniques such as ultraviolet germicidal irradiation (UVGI) and hydrogen peroxide vapor (HPV), may help make these newly complex environments easier to manage. As with any new process or technology, however, these solutions come with caveats.
AHRQ researchers found that copper has proven anti-microbial qualities, but there is no research that shows its use reduces infections in patients (Hamilton & Stichler, 2013). It is also not yet known how the anti-microbial activity will hold up to intensive, repeated cleaning over time.
There is much interest in the use of UVGI for disinfecting rooms at turnover. Its limitations are that it is “not 100% effective against all pathogens (Hamilton & Stichler, 2013, p. 39),” is effective only when the light beam makes direct contact with surfaces, and it requires everyone to leave the space being disinfected for an extended period. While UVGI, like copper, offers advantages for infection control programs over some older processes, it has not been shown to reduce rates of infection in patients, and its long-term effect on devices and room furnishings is unknown. Hospitals are also exploring the use of HPV for disinfecting patient rooms at turnover. Similar to UVGI, it requires a vacated room for a certain period of time, but it reaches areas that UVGI cannot reach and leaves only water as a residue, which is an improvement over other products used for disinfection.
More research is needed before the full effects and best practices for use of these new tools will be fully understood. In addition to new research, observation, training, and follow-up are needed for effective implementation of these and other new materials and processes.
The idea of “evidence-based design” is appealing, but AHRQ and others have found limited evidence to link features of the built environment directly to patient outcomes, including hospital-associated infections. Referring to interviews performed for the study, AHRQ reports:
The experts were supportive of the concept of evidence-based design but expressed concerns regarding its definitions and inconsistent standards of evidence. The terminology that these experts preferred was “evidence-influenced design.” The need for additional evidence addressing cost, return on investment, and, most importantly, efficacy in reducing infections was a recurring topic discussed in the interviews (Hamilton & Stichler, 2013, p. 132-133).
Recognizing the complexity of infection prevention and the built environment, the report also calls for increased cooperation among design experts, health professionals including infection preventionists, executives, and facility mangers. In addition to using evidence and guidelines, experience across many disciplines will provide the best guidance possible for reducing HAIs.
In the end, the built environment is but one element of the healthcare system that must be accounted for in safety and quality improvement. As with other patient safety efforts, reduction of HAIs can only be accomplished with collaboration and a commitment to support front-line caregivers with effective training, technology, leadership, and resources.
Susan Carr is editor of Patient Safety & Quality Healthcare. She may be contacted at firstname.lastname@example.org.
Carr, S. (2014). Infection control and the built environment: No easy answers. Patient Safety & Quality Healthcare, 11(2), 38–44.
Attewell, A. (2012). Illuminating Florence: Finding Nightingale’s legacy in your practice. Indianapolis, IN: Sigma Theta Tau International.
Bacon, A. S. (1920). Efficient hospitals. JAMA, 74, 123–126.
Bartley, J. M., Olmstead, R. N., & Haas, J. (2010, June). Current view of health care design and construction: Practical implications for safer, cleaner environments. American Journal of Infection Control, 38(5), S1–12.
Detsky, M. E., & Etchells, E. (2008, August 27). Single-patient rooms for safp Patient-centered hospitals. JAMA, 300(8), 954.
Facility Guidelines Institute. Guidelines for design and construction of health care facilities. 2010 edition. Chicago: American Society of Healthcare Engineering of the American Hospital Association. Available from: http://www.fgiguidelines.org
Hamilton, D. K., & Stichler, J. (Eds.). (2013). HERD: Health Environments Research & Design Journal, Understanding the Role of Facility Design in the Acquisition and Prevention of Healthcare-Associated Infections. Retrieved from https://www.herdjournal.com/article/special-supplement-understanding-role-facility-design-acquisition-and-prevention-healthcare-
The Joint Commission. (2008). Health care at the crossroads: Guiding principles for the development of the hospital of the future. Oakbrook Terrace, IL: Author. Retrieved from http://www.jointcommission.org/assets/1/18/Hosptal_Future.pdf
Nightingale, F. (1860). Notes on nursing. New York: D. Appleton and Company.
Noskin, G. A., & Peterson, L. R. (2001). Engineering infection control through facility design. Emerging Infectious Diseases, 7(2), 354–357.
Premier. Single room occupancy as a minimum. Retrieved March 23, 2014, from https://www.premierinc.com/safety/topics/construction/single-room.jsp
Sadler, B. L., Joseph, A., Keller, A., & Rostenberg, B. (2009). Using evidence-based environmental design to enhance safety and quality. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/resources/Pages/IHIWhitePapers/UsingEvidenceBasedEnvironmentalDesignWhitePaper.aspx