Emerging results from a large study focused on the relationships between design and healthcare-associated infections (HAI) point to risks in common design materials and how design can reduce risks, researchers told attendees at the Healthcare Design conference in Phoenix.

When evaluating the impact of healthcare facility design on HAI, researchers have concluded that some widely used materials and design features can become contaminated even when recommended cleaning and maintenance are performed.

Water walls and decorative fountains have been linked to Legionnaires disease. One cluster was in a radiation oncology suite where a water wall was found to be the source of the infection despite having been properly maintained. Findings have led the researchers to issue a recommendation that "Water walls and decorative water fountains present unacceptable risk in hospitals serving immunocompromised patients (even with standard maintenance and sanitizing methods).”

Initial conclusions from the study, which focused on hospitals, point to a growing evidence of the impact of design on links in the chain of infection. There is little direct causal evidence linking design to infection but research, evidence, and simulation helps researchers move from a focus on outbreak to an understanding of mechanism.

Also, much infection control depends on behavior and context. Although different pathogens respond to different cleaning measures, one of the team’s greatest learning lessons was that it is possible to get surfaces and materials quite clean using normal cleaning products and procedures. However, the problem is that a combination of low-wage workers and ineffective managers consistently fail to meet such standards of cleanliness.

Handwashing continues to be a common source of contamination and the spread of infectious disease. Researchers found that line of sight visibility for dispensers and surveillance increased hand hygiene compliance. Just moving dispensers for greater visibility increased compliance in one case from 33.6 percent to 60 percent. Other simple design interventions such as alert lights, notices, and even unobtrusive but interactive video monitors increased compliance.

Curtains are another potential source of infection. Cleaning recommendations don’t specify frequency. Curtains made from newer technologies, such as those impregnated with antimicrobial agents, can reduce contamination, but there is no data on the prevention of transmission. This suggests that design strategies that eliminate the need for curtains may be optimal.

Strategies such as UV light, antimicrobial coatings on materials, and improved ventilation offer designers options to reduce pathogens and reservoirs of infection. New and promising technologies that coming on to the market include copper impregnated surfaces and cleaning using ultraviolet germicidal irradiation (UVGI) in plenums or UVGI or hydrogen peroxide for terminals. The cleaning measures are  practical if you have an outbreak, presenters said, but impractical for routine cleaning.

Researchers highlighted the need for more research. Specifically, they are looking for research on decorative fountains, plants, carpeting, operable windows, displacement ventilation, air change rates outside the operating room, HEP filtering for general care spaces, and aerosolization from toilets.

Funded by the U.S. Department of Health and Human Services, the study was conducted by a multidisciplinary team of physicians, hospital epidemiologists, health system engineers, informationists, architects and evidence-based design specialists from Agency for Healthcare Research and Quality (AHRQ), RTI International, Emory University, and Georgia Institute of Technology, focused on hospitals. Researchers conducted a review and assessment of the scientific and general literature as well as interviews with industry experts. Final results of the study are expected to be published within the next few months.