Tuesday, March 3, 2015

Some Thoughts on Healthcare Facilities

Q: Could you touch on some basics regarding controlling the environments in hospital and healthcare settings?

A: “The [Five Second Rule] has many variations, including The Three Second Rule, The Seven Second Rule, and the extremely handy and versatile The However Long It Takes Me to Pick Up This Food Rule.” ~Neil Pasricha,The Book of Awesome
The five second rule on avoiding germs and infections is the subject of much light hearted banter, but the implications of healthcare associated infections (HAIs) are not. Healthcare facilities are fraught with bacteria, germs, infections, contaminated biological waste, bugs, superbugs, viruses, and any number of options to threaten our health. Hospitals, in their frontline role fighting disease, couldn’t have it any other way. 

The results of this simple fact are daunting. The below chart, from the Centers for Disease Control and Infection, outlines the occurrence of HAIs based on a CDC survey of large acute care hospitals. Further, the CDC states that HAIs infect about 1 in 25 hospital patients every day, sometimes with more than one healthcare-associated infection. Estimates vary, but HAIs claim the lives of about 75,000 hospital patients during their hospitalizations, and more than 100,000 overall – exceeding that of fire, drowning, and accidents. More than 50 percent of all HAIs were picked up in areas other than the intensive care unit.

Estimates of Healthcare-Associated Infections Occurring in Acute Care Hospitals in the United States, 20111
Major Site of Infection Estimated No.
Pneumonia 157,500
Gastrointestinal illness 123,100
Urinary tract infections 93,300
Primary bloodstream infections 71,900
Surgical site infections from any inpatient surgery 157,500
Other types of infections 118,500
Estimated total number of infections in hospitals 721,800

The new healthcare regulatory environment has focused on readmissions, many caused by infections, and putting some bite into the government’s bark by reducing reimbursements to healthcare organizations reporting high levels of readmission. HAIs, by the way, account for almost one-third of hospital readmissions, not to mention racking up a healthcare cost of more than $47 billion.

While the vast majority of HAIs are attributed to the lack or inadequacy of simple hand washing - prompting many architects to strategically locate wash stations where healthcare providers need to almost trip over them – other points of control (or contamination) abound. Air circulation systems, surgical suites, isolation units and rooms, procedure areas, even the magazines in waiting areas can be rife with potential infection. What’s a hospital or healthcare facility to do? What role does the facilities engineer play in this challenge of epidemic proportions?

Following are some key areas every healthcare facilities professional should consider in their war on germs:

1. Housekeeping: Any analysis should start with the low hanging fruit offering great potential payback. Housekeeping is one of those areas. A colleague who spent some time with a relative on the organ transplant unit at Massachusetts General Hospital (MGH) related how impressed she was that the housekeeping staff was considered an integral part of the patient care team.  MGH (affectionately nicknamed “Man’s Greatest Hospital” by staff and patients) undertakes some of the most complicated and ground breaking transplants in the world. But all that cutting edge medical knowledge will fail if patients with impacted immune systems are lost due to sloppy housekeeping.

St. Mary’s Regional Medical Center. In hospital ORs, the selection of all room finishes should focus on durability and cleanability to reduce the risk of healthcare associated infections (HAIs). Credit: Sandy Agrafiotis, Photographer; SMRT Architects and Engineers.
St. Mary’s Regional Medical Center. In hospital ORs, the selection of all room finishes should focus on durability and cleanability to reduce the risk of healthcare associated infections (HAIs). Credit: Sandy Agrafiotis, Photographer; SMRT Architects and Engineers.
Bacteria and germs can hide in surprising places: one national study found that soap dispensers – more specifically, the nozzle users press to obtain soap – harbored more bacteria and germs than toilet seats.

Bottom line: stay in tune with your housekeeping staff, and develop an ongoing training and monitoring system. Housekeeping plays an important role in patient health, while impacting readmission statistics and reimbursements.

2. Plant maintenance: In times of tight budgets, it’s tempting to defer maintenance. Don’t.

In 2001 the largest historic outbreak of Legionnaire’s disease is estimated to have sickened more than 800 in Murcia, Spain. Subsequent investigation linked the outbreak to a hospital cooling tower.2 And in 2006, the borough council of Barrow-in-Furness in the U.K. and the architect of the community’s Forum 28 Arts center were fined after a trial concluded the 2002 Legionnaire’s outbreak in that community was attributable to their cooling tower. While they were likely relieved to be cleared of more serious corporate manslaughter charges, the cost was much higher on many fronts than careful design and maintenance would have been.

It’s important that healthcare facilities design to both required maintenance and the capabilities of the institution’s maintenance staff. Your systems (including piping, ductwork, and exhaust of air handling, water supply systems, decorative elements such as fountains, and your mechanical areas) should be easy to access, inspect, and maintain. 

It’s important that healthcare facilities develop and execute a comprehensive maintenance staff training program, and it’s important to identify all facility components capable of transmitting or contributing to HAIs, then develop a corresponding maintenance program.

3. Codes or a higher standard of care?: In designing new or renovated healthcare spaces, serious consideration should be given to the level of desired design, based upon the function of the space, its clinical program, and the risk of HAIs. Design identified as “best practice” earned that label through study and clinical results. Sometimes designing to code is adequate; sometimes it’s nothing more than meeting the minimum requirements.

4. Humidity control: Humidity levels play a major role in maintaining health and avoiding impacts from bacteria, viruses, fungi, mites, molds, and chemical interactions. While optimal humidity levels vary both between types of healthcare facilities and within specialized areas of healthcare facilities, many advocate for a relative humidity level between 40% and 60%, with operating rooms around 50%, ICUs around 40%, and patient rooms around 45%.

MaineGeneral Alfond Center for Health. Laminar flow diffusers and a perimeter air curtain maintain a sterile field over the patient in this surgical suite. Credit: © Anton Grassl/Esto; SMRT Architects and Engineers.
MaineGeneral Alfond Center for Health. Laminar flow diffusers and a perimeter air curtain maintain a sterile field over the patient in this surgical suite. Credit: © Anton Grassl/Esto; SMRT Architects and Engineers.
In critical care and procedure rooms, special attention should be paid to the locations of humidistats. There can be a large difference in the humidity levels of a patient occupied area such as in a surgical suite, and a humidistat is located on a far wall. While a generally accepted best practice is to locate humidistats in the return air duct as close to expected patient locations as practical, it’s important to remember to provide access for cleaning, servicing, calibrating, and replacement.

Tying your humidistats, as well as other building conditions monitoring tools, into a Building Management System (BMS) will allow continuous monitoring of critical conditions, provide real time alerts when systems fall out of calibration, and reduce the risk of human oversight.

5. It’s in the air we breathe: Books can (and have been) written on this subject, far outstripping the editorial space for this column. Suffice it to say, the pinnacle of superior air quality depends upon the volume of new air circulating in a space, dilution, carefully calibrated filtration and, where appropriate, either positive or negative pressurization. Each of these factors will require varying parameters, depending upon the location and use of the area. Lobby or surgical suite? NICU or cafeteria? The end use will prescribe the air handling specifications.

While the facilities engineer is always balancing cost, efficacy, maintenance requirements, and a myriad of other factors in determining appropriate systems, the brave new worlds of reimbursement formulas and liability have added additional considerations.

6. Future thinking: The futurists of the world are enamored with healthcare. New materials and processes are constantly being introduced, the healthcare R&D world is buzzing. Expect continuing developments in HVAC systems and controls, materials including the accepted UVGI systems, copper and silver infused products, non-toxic and anti-fungal bio-based textiles, and a host of other new technologies and modifications to known options. While some of these materials and systems carry a high price tag, continuing R&D efforts are expected to bring down costs.

7. In closing: Every healthcare facilities professional, architect, and engineer should have a copy of Guidelines for Design and Construction of Hospitals and Outpatient Facilities, 2014 edition, published by The Facilities Guidelines Institute. This handy reference, all 400+ pages, includes the ANSI/ASHRAE/ASHE Standard 170-2013: Ventilation of Healthcare Facilities. You can order a copy through www.fgiguidelines.org or by calling 1-800-242-2626.

This handy tome will provide much more information, and might possibly be the antidote you need on those sleepless nights when your mind is pondering the challenge of keeping your facilities healthy for the sake of your patients, staff, and the public. But remember, it starts and ends with the patients.


1. Magill SS, Edwards JR, Bamberg W, et al. Multistate Point-Prevalence Survey of Health Care–Associated Infections. N Engl J Med 2014;370:1198-208.
2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3020623/

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