Although recent Ebola cases have garnered the national spotlight, healthcare-associated infections (HAIs) claim the lives of 99,000 Americans every year. Not only is the human toll of HAIs staggering, the cost of treating them in the U.S. is estimated by the Centers for Disease Control and Prevention (CDC) to be upwards of $20 billion—one of the reasons why hospitals are facing reductions in Medicare payments if they don’t reduce HAIs by 2015.

Much of the effort to reduce infections centers on protocols and process. However, there’s general consensus and increasing evidence that the design of the built environment plays an important role in preventing HAIs in healthcare facilities.

Making the connection
The U.S. Department of Health and Human Services has made reducing HAIs a priority, introducing several nationwide initiatives since 2008. The latest is the Partnership for Patients campaign that strives to save 60,000 lives a year by reducing complications and readmissions, and improving the transition from one care setting to another. At the core of this initiative are 26 Hospital Engagement Networks, which are working with healthcare providers and institutions in 3,700 U.S. hospitals to identify best practices and solutions.

Central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSI) are three of the nine conditions targeted for 40 percent reduction by CMS as part of the campaign. They are also among the top five HAIs, along with C. diff (Clostridium difficile) and MRSA (methicillin-resistant Staphylococcus aureus).

Because they are more procedure based, CLABSI, CAUTI, and SSI are less affected by the design of the built environment. However, air quality and traffic flow in and out of operating rooms can impact SSIs, while room layout and size may be factors in CLABSIs and CAUTIs. “If the room is too small and people are climbing all over each other trying to put in a central line, the risk of contamination is higher,” says Loie Ruhl Couch, infection prevention specialist at Barnes-Jewish Hospital in St. Louis, which is participating in a Hospital Engagement Network.

There’s growing evidence that the environment plays a role in the transmission of pathogens that are spread by air, water, and contact, too. However, according to research done by Georgia Institute of Technology’s Craig Zimring and colleagues, published in the Health Environments Research & Design Journal in 2013, the exact cause is often hard to establish.

“The way that hospitals approach infection problems is by thinking about the chain of transmission,” Zimring says. “And the built environment is an intervention that can help stop the chain of transmission.”

Balanced design
One of the primary interventions that the built environment can help facilitate is handwashing, which is generally thought to be the biggest factor in preventing the spread of contact pathogens in a hospital. Organisms can live on surfaces for days or months, and while the placement of sinks and gel dispensers is a factor in encouraging handwashing, it’s extremely difficult to control human behavior. Some hospitals have tried monitoring systems, but staff may find workarounds. “People have to do it not because you’re forcing them to do it, but because it’s the right thing to do,” Couch says.

Easy-to-clean surfaces and materials with no cracks or crevices are also critical to preventing the spread of contact pathogens. “If it were up to me, all of the furniture would be concrete,” Couch states, conceding that a happy medium must be struck to facilitate a less institutional approach to hospital interiors.

“The balance between making it look noninstitutional and easy to clean is a challenge,” says Mitch Goplen, vice president of facility services at Billings Clinic (Billings, Mont.). Goplen relies on a committee made up of individuals from nursing, facilities, infection control, and a community member. “They help establish standards,” he says, explaining that products have to perform from a cleaning standpoint but also meet the functional and design standards set by the committee.

Sheila Cahnman, founding principal of JumpGarden Consulting (Wilmette, Ill.), says, “We’re starting to see a new vocabulary in healthcare interior design that incorporates a more contemporary look that may reflect the public’s desire to have a hospital environment that’s less about being home-like and more about looking and being technologically advanced and free of infection.”

In some projects, this may translate to pristine, white, or clutter-free walls with less casework and fewer details that are harder to clean. “This was the paradigm up until the early 1980s,” Cahnman says. “Our challenge as designers is to create an experience that is reassuring and uplifting, and not too sterile.”


More to come
New technology and products are available that may also help reduce infection rates and risk. Hydrogen peroxide vapor systems, for example, have proven effective in patient rooms. “You still have to wipe the room down, but it’s an extra precaution,” Goplen says. Meanwhile, the jury is still out on UV light systems that are wheeled into rooms to kill pathogens. “If there’s anything on the surface masking [the pathogen], it will just stay on the surface,” says Andrew Striefel, a hospital environmental specialist in University of Minnesota’s department of environmental health and safety (Minneapolis). “You have to clean the surfaces first for it to work at all.”

Copper has also been touted for its antimicrobial properties. “It has some benefit, but it’s expensive” Couch says.  And the material may take some time to be effective—for example, it may take hours to kill a patch of MRSA on a doorknob. “So even though it’s copper, it still has to be cleaned,” she explains.

Cahnman calls for more research into where infections are most-often harbored so that money may be spent on the most efficient solutions. “If handwashing compliance is an ongoing issue, is there any other way to reduce the spread of infection by hand contact?” she says. Doors that open on voice command, for example, is one idea she offers.

Such research could inform the Facility Guidelines Institute’s (FGI) Guidelines for Design and Construction of Hospitals and Outpatient Facilities, whose recent revisions have already been crafted with an eye on infection control, according to FGI CEO Thomas Jung. He says reducing HAIs influenced many of the body’s requirements for all areas of the hospital, including those for handwashing sinks in patient rooms, distances and clearances, and flow of materials in and out of
ORs, for example

Striefel, who serves on the FGI’s guidelines revision committee, says that building commissioning and maintenance training will be more of a focus in the next edition. “Buildings are designed and built that people don’t know how to maintain,” he says. “For example, if you don’t clean out cooling coils, they fill up with dirt, which impacts air quality.” And, he adds, “We’re looking at expanding the section on commissioning so hospitals aren’t stuck with contaminated systems before they even open.”


United front
Preventing infections requires engagement of many individuals within an entire hospital system, each of whom has different priorities and goals, a conclusion Zimring and his colleagues came to after reviewing more than 3,800 references related to HAIs in the design and medical fields. To address this problem at the system level, they recommend engaging designers, clinicians, and representatives from departments including quality improvement, facilities, infection control, environmental control, and purchasing.

This type of collaboration may not always be easy to achieve, though. While the healing environment committee at Billings Clinic is working today, it took Couch 10 years to get the facilities staff at Barnes-Jewish Hospital on board. But she was persistent, earning their respect by educating them on environmental factors that impact infections, such as surfaces and materials, room sizes, location of ventilation systems, etc.

“I didn’t talk about just what they needed to do, but why they needed to do it,” Couch says.

Sara O. Marberry is a contributing editor for Healthcare Design. She can be reached at