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Myths and Realities: The Role of the Built Environment in

Infection PreventionPaula Wright, RN, BSN, CICProject Manager, Infection Control UnitMassachusetts General Hospital

Healthcare-Associated Infections: 5 Categories

Pathogens* may be spread from patient to patient via:• hands of healthcare workers• contaminated equipment or environmental

surfaces• equipment or surfaces act as “fomites”

• inanimate objects that can spread infection

*e.g. MRSA, VRE, MDRO gram-negativebacteria (e.g. CRE) or C. diff.

Contact Spread(Direct and Indirect)

Health Design Insights

1Categories of HAIs

A. Lerner et al. J. Clin. Microbiol. 2013;51:177-181

Locations of testing for environmental CRE (eCRE). 1, personal bedside table; 2 to 4, bed linen around the

pillow (2), crotch (3), and legs (4); 5, pulse oximeter; 6, personal bedside chair; 7, electrical outlet line; 8, manual

respirator bag; 9, infusion pump; 10, dedicated stethoscope; 11, ventilator; 12, suction machine; 13,

cardiovascular monitor screen; 14, enteral feeding pump.

Associated with invasive devices such as:

• indwelling urinary catheters

• central venous catheters-contaminated either at the time ofinsertion or during use

• ventilators- that bypass normalprotections for the lungs

Device-related infections

Health Design Insights

2Categories of HAIs

• surgical site infections

• bloodstreaminfections – postendoscopy

Procedure-related infections include:

Health Design Insights

3Categories of HAIs

Spread from patient to patient or from staff to patients via:

• aerosolized large droplets such as influenza or pertussis

• inhalation of small droplet nuclei such as chickenpox or TB

• close personal contact with an infected person

• consumption of contaminated food or water

• contact with contaminated surfaces, e.g. norovirus gastroenteritis

Communicable diseases

Health Design Insights

Categories of HAIs

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• fungal spores (e.g. aspergillus in construction dust, or fungi from wet building materials)

• Legionella (e.g. from contaminated ice machine, cooling towers, shower heads)

• gram-negative bacteria (e.g. from biofilm in a sink drain)

• atypical mycobacterium (e.g. contaminated equipment, heater/coolers)

Infections that result from exposure to an environmental source such as:

Health Design Insights

Categories of HAIs

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“Contaminated heart surgery devices may pose infection risk to thousands”

Interventions r/t the Built Environment:3 Categories

1. Prevent transmission by direct or indirect contact

2. Prevent transmission via the airborne route or via

airborne contaminants

3. Prevent transmission via water sources

Interventions to Prevent Transmission by Direct or Indirect Contact

1

Single patient rooms

Health Design Insights

Preventing Transmission by Contact

Overall, 87% of studies reported advantages associated with SPRs (some a combination of advantages and disadvantages or a

combination of advantages and neutral results). Outcomes with the best evidence of benefit include communication, infection

control, noise reduction/perceived sleep quality, and preference/perception.

E. Taylor et al. HERD.2018;11:85-100

Easily cleaned surfaces:

• smooth and non-porous

• tolerate cleaning

products and methods

• durable

• integral sinks - avoid

undermount

Health Design Insights

Preventing Transmission by Contact

Mechanisms for containment and disposal of waste

Health Design Insights

Preventing Transmission by Contact

Provisions for PPE storage and donning and doffing at the room

entrance

Health Design Insights

Preventing Transmission by Contact

Handwashing station at the room entrance

Health Design Insights

Interventions to Prevent HAIs

Accessible ABHR at the entrance and in the room

Health Design Insights

Preventing Transmission by Contact

Separation of clean and dirty - cont.

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Preventing Transmission by Contact

Interventions to Prevent Transmission Via Airborne Route or R/T

Airborne Contaminants

2

Health Design Insights

Use of Airborne Infection Isolation Rooms (AII)

or local source controlmethods for airborne

diseases

Preventing Transmission by Air

Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC ) 2003

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Health Design Insights

Use of negative airflow to contain contaminants in

dirty spaces

Toilet Room

Soiled Utility EVS

Closet

BSC in lab

Preventing Transmission by Air

Preventing Transmission by Air & Contact

Health Design Insights

Use of Protected Environment Rooms for highly

immunocompromised

patients

Health Design Insights

Preventing Transmission by Air

Use of pressurization, ACH, air supply design and face velocity to minimize contamination of

the surgical wound

Health Design Insights

Preventing Transmission by Air

Health Design Insights

Use of

Protected Environment Rooms (PE)

for highly immunocompromised

patients

Preventing Transmission by Air

Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC ) 2003

Interventions Aimed at Eliminating Water Sources for Infection

3

ASHRAE 188

Water Management Plan

Health Design Insights

Preventing Transmission by Water

Water systems designed to avoid dead leg

Health Design Insights Preventing Transmission by Water

Elimination of aerators

Treatment and location of cooling towers

ASHRAE 170-2017

25 feet from air intakes

Health Design InsightsPreventing Transmission by Water

Regular PM of ice machines

Keeping a clear splash zone around water sources (sinks) to protect sterile supplies- 4 feet

Health Design Insights

Correct sink design to prevent splash-FGI 2.1-8.4.3.2

Preventing Transmission by Water

Intensive Care Unit Wastewater Interventions to Prevent Transmission of Multispecies Klebsiella pneumoniae Carbapenemase–Producing Organisms Amy J. Mathers,1,2 Kasi Vegesana,3 Ian German Mesner,3 Katie E. Barry,1 Aaron Pannone,4 Josh Baumann,3 Derrick W. Crook,5,6Nicole Stoesser,5,6 Shireen Kotay,1 Joanne Carroll,2 and Costi D. Sifri1,7 Clin Infect Dis. 2018 Feb 2

Preventing Transmission by Water

(a) Layout of the zones of the sink counter, bowl, and extension surface designated to

monitor droplet dispersion and (b) layout of the TSA plates used for GFP-expressing E. coli

droplet dispersion on the surfaces surrounding the sink.

Shireen Kotay et al. Appl. Environ. Microbiol.

2017;83:e03327-16

Spread from the Sink to the Patient: In Situ Study Using Green Fluorescent Protein (GFP)-Expressing Escherichia coli To Model Bacterial Dispersion from Hand-Washing Sink-Trap Reservoirs

Locate sink away from patient bed

Health Design Insights

Hota Study-

“Once you have the biofilms in there, short of ripping the sinks and the piping out, it’s impossible to get rid of. And in fact, even if you do that, it frequently comes back,” ….Dr. Alex Kallen, CDC’s division of health care quality promotion.

Preventing Transmission by Water

Will technology save us from HAIs

or drive increases?

• Copper

• Silver

Antimicrobial Surfaces –The Truth about Metals

Health Design InsightsInfection Prevention Technologies

• Copper

• Silver

Antimicrobial Surfaces-Marketing

Health Design Insights Infection Prevention Technologies

“Temple VA to use copper-infused surfaces to help prevent infections”

“Antibacterial coatings will also reduce the risk of infected surfaces acting as a reservoir for transmission to food and

humans.”

Copper Development Assoc.

• Antimicrobials, e.g. Triclosan - resistance and length of efficacy concerns

“FDA issues final rule on safety and effectiveness of antibacterial soaps Rule removes triclosan andtriclocarban from over-the-counter antibacterial hand and body washes”

Kaiser Permanente Rejects Antimicrobials for Infection Control With no proof that antimicrobial-treated furniture and fabrics improve infection prevention, health care system bans 15 chemicals from use in interior products

• Surface modification – Sharklet – “Forget chemicals or pills in the fight against nasty bacterial infections. Entrepreneur Mark Spiecker is betting that the secret lies with sharks”. Surface fails over time.

• Antimicrobial paint - Paint Shield® first EPA-registered microbicidal paint that kills greater than 99.9% of Staph (Staphylococcus aureus),

MRSA (Methicillin-resistant Staphylococcus aureus), E. coli (Escherichia coli), VRE (Vancomycin-resistant Enterococcus faecalis) and Enterobacter aerogenes within two hours of exposure on painted surfaces.

It continues to kill 90% of these bacteria even after repeated contamination on painted surfaces. The effectiveness lasts for up to four years as long as the integrity of the surface is maintained.

Antimicrobial Surfaces – Just the Facts

Health Design Insights

Infection Prevention Technologies

Marketing HAI Prevention-Read the Fine Print

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Health Design Insights

“When the Integrity of the Surface

is maintained”

“Reduces human

cleaning

errors”

Infection Prevention Technologies

• UV light • H2O2 vapor

Robots to the Rescue – Touchless Disinfection

Health Design Insights

Infection Prevention Technologies

• Work stations on wheels (COWs or WOWs)

• Voalte phones

• Tablets

• Touch screens

• Lanyard communication devices

Electronics and Handheld Devices – More Surfaces to Clean and “Fomites” to Worry About

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Health Design Insights

Infection Prevention Technologies

Bottom Line – What’ important when planning Healthcare Spaces?

Pre-construction Safety Risk-Assessment

Health Design Insights

Planning HC Spaces

Hand hygiene – optimizing sink locations and design

Health Design Insights

Back to Basics – What Works

Smooth, cleanable, durable, moisture resistant surfaces

Health Design Insights

Back to Basics – What Works

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Design to facilitate cleaning

Back to Basics – What WorksHealth Design Insights

What keeps Infection Preventionists up at night?

Health Design Insights

Non-compliance by HCW’s with HH, PPE, Equipment cleaning/disinfection

So much equipment in the room - time pressure for room turnover - difficult to clean

More and more touch surface technology- HCW constant interaction with technology - they can’t separate clean and dirty activities

Device complexity – difficulty cleaning and disinfecting (e.g. scopes )

Antibiotic Resistance and Highly Pathogenic Avian flu (pandemic risk)

Contact Paula Wright at:

• Email - pjwright@partners.org

• Phone - 508-341-1724

Questions?

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Health Design Insights