No one who enters a hospital to address an acute or chronic health condition deserves to acquire a dangerous or life-threatening infection as a result of their temporary vulnerability. The Institute of Medicine report (2000), To Err Is Human, described the unnecessary deaths or harm attributable to preventable causes, one of which is infection acquired during a hospital stay. The problem of hospital-acquired infection is increasing around the world (Scott, 2004). It is exacerbated by the emergence of resistant strains among many bacterial and viral infection sources (Capriotti, 2003). Design of the hospital environment plays a role in the control or transmission of infection. Proper hand hygiene is the single most effective intervention in the prevention of infection in hospital settings (Albert & Condie, 1981; Boyce & Pittet, 2002; Larson, 1988). Prevention of infection may be facilitated or hampered by specific physical design features of the facilities for decontaminating hands. How can the design and research communities contribute to important improvements in the prevention of infections? 

1. Facility Design to Reduce
Hospital-Acquired Infection
D. Kirk Hamilton, FAIA, FACHA, EDAC
From Health Environments Research
& Design Journal
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2. Facility Design to Reduce
Hospital-Acquired Infection
No one who enters a hospital to address an acute or
chronic health condition deserves to acquire a dangerous
or life-threatening infection as a result of their temporary
vulnerability. The Institute of Medicine report (2000), To
Err Is Human, described the unnecessary deaths or harm
attributable to preventable causes, one of which is
infection acquired during a hospital stay.
The problem of hospital-acquired infection is increasing
around the world (Scott, 2004). It is exacerbated by the
emergence of resistant strains among many bacterial and
viral infection sources (Capriotti, 2003).
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3. Facility Design to Reduce
Hospital-Acquired Infection
Design of the hospital environment plays a role in the
control or transmission of infection. Proper hand hygiene
is the single most effective intervention in the prevention
of infection in hospital settings (Albert & Condie, 1981;
Boyce & Pittet, 2002; Larson, 1988).
Prevention of infection may be facilitated or hampered by
specific physical design features of the facilities for
decontaminating hands. How can the design and research
communities contribute to important improvements in
the prevention of infections?
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4. Facility Design to Reduce
Hospital-Acquired Infection
Background
Infections that originate in the hospital, also called nosocomial
infections or hospital-acquired infections (HAIs), are a serious problem
(Capriotti, 2003; Struelens, 1998). Infections are caused by bacterial,
viral, or fungal organisms, and strains of these organisms have
developed resistance to the antibiotics used to treat them. Strains of
methicillin-resistant Staphylococccus aureus (MRSA) have been
spreading rapidly in hospitals and in the community.
Struelens (1998) reported that strains of vancomycin-resistant
staphylococci and enterococci are emerging, and that Klebsiella
pneumoniae, Enterobacter, Pseudomonas aeruginosa, and
Acinetobacter baumannii are gradually developing resistance to
“useful classes of antibiotics, including the penicillins, cephalosporins,
aminoglycosides, and fluoroquinolones” (p. 652).
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5. Facility Design to Reduce
Hospital-Acquired Infection
Increased death rates associated with outbreaks of
Clostridium difficile have been reported in North American
hospitals (Wilcox, Cunniffe, Trundle, & Redpath, 1996). Other
community-acquired infections, such as resistant strains of
tuberculosis, also have appeared (Frieden et al., 1993). Fungal
infections, such as Aspergillus (Stevens et al., 2000), can be
found at construction sites, for example, in the case of
hospital renovations.
There are reports that physicians overprescribe antibiotics,
and that patients don't always take their antibiotics to the end
of the prescribed course. These factors tend to increase drug
resistance in the organisms that threaten hospital patients
(Capriotti, 2003).
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6. Facility Design to Reduce
Hospital-Acquired Infection
Scope and Consequences of the Problem
There are strong reasons to reduce rates of HAIs. The cost of
HAIs, in dollars and unnecessary suffering or death (Scott,
2009), is enormous. Infections are more serious than they
have been in the recent past. After World War II it was
assumed that penicillin was a “miracle drug” capable of
defeating any infection. Penicillin, sulfa, and numerous other
drugs provided excellent defenses against infection, but seven
decades later, many infectious organisms have developed
resistance to the range of drugs in the physicians'
armamentarium. More virulent strains of infectious organisms
with greater resistance to antibiotics threaten patients in
healthcare settings with lowered immune responses
(Capriotti, 2003).
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7. Facility Design to Reduce
Hospital-Acquired Infection
The number of infections, adverse events, and errors in
critical care environments is especially significant
(Rothschild et al., 2005) in ICUs, where the most
vulnerable patients face increased risk for every day
they stay.
If configuration and features of the hospital and critical
care environments can make a significant difference in
reducing infections, then discovery of better designs
must become a high priority.
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8. Facility Design to Reduce
Hospital-Acquired Infection
Contact Transmission and Hand Hygiene
The transmission of infection from one patient to
another is often through the contact of a caregiver
with a patient, or with objects and surfaces either
may touch.
As a result, the rate of hospital-acquired, or
nosocomial, infections is correlated with adherence
to hand hygiene recommendations on the part of
caregivers and visitors (Centers for Disease Control
& Prevention, 2002).
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9. Facility Design to Reduce
Hospital-Acquired Infection
Purposefully designed stations, providing sinks with
soap and water and/or alcohol rub dispensers at
which hand hygiene can be properly performed, are
required for consistent adherence. If such stations
are absent, poorly located, or lacking key features,
the result can be a reduction in proper hand
hygiene adherence and thus higher levels of
infection (Ulrich et al., 2008).
Is there a combination of design interventions that
might improve the likelihood that hands will be
washed or sanitized?
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10. Facility Design to Reduce
Hospital-Acquired Infection
Contact Transmission and Surfaces
Transmission of infectious organisms can occur when surfaces or
furnishings in the room are capable of supporting a pathogen.
Reducing the potential for moisture to accumulate and harbor a colony
has long been a goal of designers. Surfaces chosen by designers for
their ability to stand up to harsh cleaning solvents have been another
infection control strategy.
Materials with anti-microbial characteristics have been used for some
time in furnishings, carpeting, and drapes or privacy curtains. Today
there seems to be much attention given to the specification of
materials and surfaces featuring impregnated copper or silver (Casey
et al., 2010). How do material selections and specifications impact
infection rates, and how best to study their effects? Can we learn what
role the furnishings in hospital rooms play in the spread of infection?
How can better designs make a difference?
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11. Facility Design to Reduce
Hospital-Acquired Infection
Airborne Transmission and HVAC Systems
Systems for heating, ventilation, and mechanical air conditioning
(HVAC) are pervasive in North American hospitals. Fifty or more years
ago this was not universal, and these systems still are not widely
employed in many less-developed countries. In the United States
atmosphere in a hospital is measured in air changes, cubic feet per
minute (CFM), temperature, humidity, and degree of filtration. It is
described as consisting of some percentage of “outside air” and a
corresponding percentage of re-circulated air.
The mechanical systems serve zones within the hospital, comprising
thousands of square feet and many rooms at once. Organisms that
escape filtration can be spread anywhere within a zone, where they
can and do spread airborne infections (Nicas, Nazaroff, & Hubbard,
2005).
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12. Facility Design to Reduce
Hospital-Acquired Infection
Isolation rooms used to reduce the chance that an infected
patient may contaminate others, which guidelines in the
United States specify as 10% of patient rooms, are separated
from the air systems of larger zones.
Advocates of better protection from airborne infection
recommend 100% fresh air from outside the hospital, and
100% exhaust from each patient room. Others advocate
higher percentages of isolation rooms, above and beyond a
commitment to private patient rooms. Filtration is vital if air
must be re-circulated, although there are severe energy
consumption penalties to be paid for the force required to
move air through the likes of a hepa-filter. What is the best
future system to increase safety without excessive energy
cost?
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13. Facility Design to Reduce
Hospital-Acquired Infection
International Variation
There are wide variations in infection rates observed in different
countries (Coello, Gastmeier, & de Boer, 2001; Grundmann et al., 2010;
Köck et al., 2010). Rates in the U.S., Canada, the United Kingdom, and
Mediterranean countries are comparatively high, while rates in
Sweden, Scandinavian countries, and the Netherlands are very low.
Countries with the lowest rates are involved in aggressive “search and
destroy” efforts to eliminate infections wherever found (Vos et al.,
2009).
One of the factors in resistance to antibiotics is their widespread use in
livestock and poultry (Feingold et al., 2012). Europeans, especially in
the Netherlands, Sweden, and Denmark, are addressing the issue with
public policy. The population of the United States is exposed to
antibiotics through their presence in the food supply.
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14. Facility Design to Reduce
Hospital-Acquired Infection
A newly completed infectious disease hospital in
Malmo, Sweden, offers some interesting design
concepts. It features access to each patient room
from outside, via an external open-air balcony, air
lock anterooms on both the internal (staff) side and
the external entrance, with all air exhausted
through the patient's toilet room. What can we
learn from this example in a country that maintains
an exceptionally low rate of infection? Do we need
completely new ideas in addition to incremental
improvements.
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15. Facility Design to Reduce
Hospital-Acquired Infection
Knowledge Gaps
While there is some information available on best practices for design of hand
hygiene facilities (Provincial Infectious Diseases Advisory Committee, 2008),
there is an unfortunate lack of studies that describe design interventions and
report associated infection rates. Hand hygiene adherence is usually treated
as a surrogate for the clinical outcome, and the majority of the findings do
not directly answer the crucial question of design's relationship to nosocomial
infection.
The object of design interventions is reduction or elimination of contactborne and airborne infection, so the absence of relevant data reduces the
value of the studies. One significant possibility is that a European-style
intervention aimed at eliminating antibiotic use in livestock and poultry
(Feingold et al., 2012), along with aggressive “search and destroy” policies
(Vos et al., 2009) would make far greater difference than improved facility
design by eliminating much of the sources prior to transmission, and
decreasing the development of resistant strains.
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16. Facility Design to Reduce
Hospital-Acquired Infection
Conclusion
Hospital-acquired infection is a serious and
growing problem in U.S. health facilities, as it is
in several other countries, and infection control
efforts are ongoing. At the same time, valuable
lessons can be learned from countries like
Sweden and the Netherlands where hospital
infection rates are dramatically lower.
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17. Facility Design to Reduce
Hospital-Acquired Infection
There is a need for research to describe and explain the role
of the purposefully designed physical environment as it
relates to hospital-acquired infection. Research relating design
features for hand hygiene facilities to associated infection
outcomes is an important first step. Further research into the
antimicrobial potential for different materials is warranted.
It would be helpful to have better understanding of the
mechanical air handling systems and filters providing intended
air exchanges in patient rooms. Such a research program
dealing with contact-borne, water-borne, and airborne
pathogens will lead to predictions of specific evidence-based
design features that will play a significant role in preventing
future hospital-acquired infections.
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18. Facility Design to Reduce
Hospital-Acquired Infection
The design of hospital and healthcare environments plays
an important role in reducing the problem of infection. It
is likely that the best and most effective future design
interventions will benefit from creative and imaginative
reference to the best available evidence from research.
It is also likely that the best results will come from
synergistic combinations of interventions applied
together because no single intervention promises to be
the magic bullet. Success will mean many lives will be
saved and unnecessary harm and pain will be avoided.
That is a noble goal.
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19. Health Environments Research
& Design Journal
(HERD)
Health Environments Research & Design Journal (HERD) is an
interdisciplinary, peer-reviewed journal whose mission is to
enhance the knowledge and practice of evidence-based healthcare
design by disseminating research findings, discussing issues and
trends, and translating research into practice.
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