An Issue Brief onF I N D I N G S Cleanliness · Recent outbreaks of HAIs, such as Ebola, severe acute respiratory syndrome (SARS), and methicillin-resistant Staphylococcus aureus

An Issue Brief on Cleanliness

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Copyright 2015 The Center for Health Design. All Rights Reserved.

F I N D I N G S

Copyright 2017 © The Center for Health Design. All Rights Reserved.

Healthcare-associated infections (HAIs) are defined as infections that patients

acquire during the process of receiving care in healthcare facilities (Office of

Disease Prevention and Health Promotion, n.d.). HAIs are among the most common

complications found in healthcare systems, directly contributing to morbidity and

mortality as well as billions of dollars of preventable healthcare costs each year.

Recent outbreaks of HAIs, such as Ebola, severe acute respiratory syndrome

(SARS), and methicillin-resistant Staphylococcus aureus (MRSA), further highlight

the importance of prevention efforts. Prevention practices may lead to a 70%

reduction in HAIs and annual financial benefits of $25–31.5 billion (Scott, 2009).

In the U.S., financial measures have been in place to incentivize healthcare

organizations to reduce HAIs. Since 2008, legislation has been enacted to connect a

hospital’s performance in infection prevention to the payment it receives from the

government. Poor performance leads to significant payment reduction (Centers for

Medicare & Medicaid Services, n.d.; West & Eng, 2014).

Many factors impact the likelihood of pathogen transmissions in healthcare

settings, including the sources of infectious pathogens, susceptible patients (e.g.,

patient characteristics), and transmission routes (i.e., modes). Infection prevention

efforts aim to cut off the major routes of transmission (Siegel, Rhinehart, Jackson,

Chiarello, & Health Care Infection Control Practices Advisory Committee, 2007):

Contact transmission (the most common transmission mode), including:

o Direct contact: Pathogens transmitted directly from person to person

o Indirect contact: Pathogens transmitted through an intermediate object

(e.g., hands of nursing staff, inanimate environmental surfaces);

Droplet transmission by respiratory droplets (>5 μm) carrying infectious

pathogens over a short distance; and

Airborne transmission by droplet nuclei or small particles which remain

airborne and are dispersed for a long distance by air flow.

Most countries lack tracking

systems for HAIs, and even

those that do have them

often lack standardized

diagnosis criteria.

In the U.S., the National

Healthcare Safety Network

(NHSN) is the most widely

used national tracking

database for HAIs.

Currently, more than 14,500

healthcare facilities ranging

from acute care hospitals to

nursing homes are tracking

HAIs and reporting data to

NHSN.

Standard metrics and

analytics tools enable

individual facilities and

government agencies to

identify problems and engage

in improvement efforts.

See the associated Issue Brief

for additional detail.

2 Copyright 2017 © The Center for Health Design. All Rights Reserved.

DISCOVERIES Backgrounder: HAIs

Different pathogens (including bacteria, viruses, fungi, parasites, and prions) may be

transmitted through one or more routes (Siegel et al., 2007).

Centers for Medicare & Medicaid Services. (n.d.). Linking quality to payment.

Retrieved from https://www.medicare.gov/hospitalcompare/linking-quality-to-

payment.html

Office of Disease Prevention and Health Promotion. (n.d.). National action plan to

prevent health care-associated infections: Road map to elimination. Retrieved

from http://health.gov/hcq/prevent-hai.asp

Scott, R. D. (2009). The direct medical costs of healthcare-associated infections in

U.S. hospitals and the benefits of prevention. Atlanta, GA: Centers for Disease

Control and Prevention.

Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Health Care Infection Control

Practices Advisory Committee. (2007). 2007 guideline for isolation

precautions: Preventing transmission of infectious agents in health care

settings. American Journal of Infection Control, 35(10 Suppl 2), S65–164.

http://doi.org/10.1016/j.ajic.2007.10.007

West, N., & Eng, T. (2014). Monitoring and reporting hospital-acquired conditions: A

federalist approach. Medicare & Medicaid Research Review, 4(4).

http://doi.org/10.5600/mmrr.004.04.a04

The Center for Health Design

advances best practices and

empowers healthcare leaders with

quality research that demonstrates

the value of design to improve health

outcomes, patient experience

of care, and provider/staff

satisfaction and performance.

Learn more at

www.healthdesign.org


The following design solutions are a brief summary of the content found in the SRA

Issue Brief “Infections: Mitigating Risk in Healthcare Facility Design.” They are

organized by building design category.

There may be sources of contamination in or near healthcare facilities. These

potential sources should be identified and addressed through disinfection

methods (e.g., isolation, filtration).

Physical separation and isolation represent a key method of infection control

through unit layout design. Considerations include:

o Separation of supplies/equipment; and

o Separation of patients through the provision of negative-/positive-

pressured isolation rooms.

A sufficient number of hand hygiene devices should be provided throughout the

unit to increase hand hygiene compliance.

Considerations should include the occupancy of both the patient room and

bathroom, as well as the placement of sinks and other hand hygiene devices.

Single occupancy rooms are ideal in terms of infection prevention. Room layout

should allow easy visual and physical access to hand hygiene devices but prevent

water splashes from sinks from reaching patient care areas.

Plumbing system design considerations include:

o Ease of cleaning and maintenance;

OVERVIEW

To mitigate the risk of HAIs,

efforts should be made to

cut off the main routes of

pathogen transmission:

airborne, droplet, contact,

and water transmission.


PATHWAYS SRA: Design Strategies for HAIs

o Design elements to prevent contamination of fixture-related water

splashing; and

o Proper water disinfection methods if needed.

Implement technology to monitor and enhance hand hygiene performance (e.g.,

audible or visual reminders).

To minimize surface contamination, it is important to select surface materials that

are easy to clean, disinfect, and maintain; contain antibacterial/antimicrobial

characteristics; and/or minimize dust collection (e.g., sloped instead of horizontal

surfaces).

Avoid environmental furnishings and fixtures that are likely to serve as reservoirs

of pathogens, and include environmental measures (e.g., disinfection methods) to

control infection risks. In addition, design should consider features (e.g., movable

furniture) to make it easy to clean environmental surfaces and equipment.

Considerations include:

o Location and accessibility of filters (e.g., point-of-use for critical areas);

o Adequate monitoring for pressurization, filter life, temperature, and

humidity;

o Appropriate quantity and configuration of HVAC zones to allow

environmental control flexibility;

o Appropriate number of AII or PE rooms needed for intended use of space;

o Use of specialty HVAC features/systems to support unique environmental

conditions (e.g., entryways, ICU, or neonatal areas);

o Antibacterial characteristics that reduce the risk of contamination; and

o Easy access to properly maintain or replace contaminated HVAC and other

building components.


PATHWAYS SRA: Design Strategies for HAIs

CDC 2003 Guidelines for Environmental Infection Control in Health-Care Facilities

http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf

Infection Control Risk Assessment Matrix of Precautions for Construction &

Renovation www.ashe.org/advocacy/organizations/CDC/pdfs/assessment_icra.pdf

Understanding the Role of Facility Design in the Acquisition and Prevention of

Healthcare-Associated Infections: A Special Supplement to the Health

Environments Research & Design Journal

http://digimags.vendomegrp.com/html/HERD-Supplement/HERD_Special.pdf

This summary was created as a supplement to the Safety Risk Assessment (SRA)

toolkit and other SRA-related Issue Briefs, Backgrounders, and Top Design

Strategies. This toolkit is not intended to be a guarantee of a safe environment; the

environment is one part of a safety solution that includes operational policies,

procedures and behavior of people. It is intended for use with collaborative input of

project- and facility-based expertise.






outcomes, patient experience of

care, and provider/staff

satisfaction and performance.

Learn more at


http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf

http://www.ashe.org/advocacy/organizations/CDC/pdfs/assessment_icra.pdf

http://digimags.vendomegrp.com/html/HERD-Supplement/HERD_Special.pdf

An Issue Brief on Cleanliness

1

Copyright 2015 The Center for Health Design. All Rights Reserved.

F I N D I N G S

2

An Issue Brief on HAIs F I N D I N G S


Healthcare-associated infections (HAIs) are defined as infections that patients

acquire during the process of receiving care in healthcare facilities. Among the

most common complications in U.S. healthcare, HAIs directly contribute to the

deaths of ten of thousands of patients and cost billions of dollars every year,

despite being largely preventable. Mounting research evidence indicates that

the physical environment of healthcare facilities plays a significant role in

infection prevention. Key recommendations include:

Single-bed patient rooms, as compared with multi-bed rooms, may

provide physical separation between patients and thereby reduce the

risk of cross-contamination through air and contact transmission;

Isolation rooms with proper air flow design may help reduce airborne

transmission of pathogens;

Hand hygiene device design (including quantity, location, and features

that reduce the possibility of re-contamination) and reminders may

impact hand hygiene performance, which is considered the single most

important measure of infection prevention;

Heating, ventilation, and air conditioning (HVAC) design can provide air

dilution, filtration, and disinfection for the purpose of reducing air

contamination;

Easy-to-clean/maintain finishes and furnishings can contribute to

environmental cleanliness; and

Potential sources of contamination, such as construction sites, should

be monitored and controlled.

There is no silver bullet for solving the problem of HAIs. When healthcare

organizations endeavor to prevent HAIs, they often find a systems approach to

be most effective. In this approach, physical environment measures are

Xiaobo Quan, PhD, EDAC

Senior Researcher

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coordinated with many other factors, including organizational and clinical

policies and procedures, as well as the workflow and behavior of caregivers,

staff, and patients who use the facility, to achieve the best possible outcomes.

Construction sites, as well as other building activities or components, may

become a source of contaminants and cause infection outbreaks. Research has

found that certain disinfection methods, including HEPA filtration, are effective

in controlling major sources of contaminants, such as construction sites (Barnes

& Rogers, 1989).

Contaminated air flow from rooms where airborne infectious patients stayed

was reported to increase the risk of infections among patients and staff in

nearby spaces (Gustafson et al., 1982; Hutton, Stead, Cauthen, Bloch, & Ewing,

1990). Research strongly suggests that airborne infectious patients should be

isolated in negative-pressured rooms to minimize the risk of cross-

contamination by preventing contaminated air from flowing from isolation

rooms to nearby spaces (Sehulster & Chinn, 2003). Immunocompromised

patients are particularly vulnerable to infections. Research strongly suggests

that immunocompromised patients should be isolated in positive-pressured

rooms to minimize the risk of contracting airborne pathogens by preventing

potentially contaminated air from flowing from nearby spaces into the isolation

rooms (Sehulster & Chinn, 2003).

Hand hygiene is considered the single most important method of infection

prevention, as pathogens are often transferred via the unwashed hands of staff,

patients, and families. The number of hand hygiene devices is an important

factor, significantly impacting hand hygiene performance. More sinks, gel

dispensers, and other hand hygiene devices likely make it easier for staff,

patients, and families to gain access to the devices and clean their hands when

needed (Kaplan & McGuckin, 1986).

The contamination of linen and other supplies increases the risk of infections.

Physical separation (e.g., a separate soiled utility room) is an important method

of preventing the transfer of pathogens from soiled to clean linen, equipment,

and other supplies.

With respect to specific space types, research has found that frequent door

openings during surgical procedures may generate disturbances to air flow and

Construction sites could

potentially become sources of

contamination and should

therefore be monitored and

controlled using methods such

as high-efficiency particulate air

(HEPA) filtration.

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increase the air contamination level in operating rooms (ORs) (Andersson,

Bergh, Karlsson, Eriksson, & Nilsson, 2012). The need for OR door openings

during surgical procedures may be reduced through building design (e.g.,

locating certain supplies within the OR; wireless consultation). This, in turn, may

help reduce the risk of infections for OR patients.

Direct and indirect contact constitute major routes of pathogen transmission

between patients (Chang & Nelson, 2000). Reducing the chances of

direct/indirect contact between patients by physically separating and isolating

them, especially with single-bed patient rooms, has been associated with

significantly lower risks of HAIs and better health outcomes (MacKenzie et al.,

2007; McManus, Mason, McManus, & Pruitt, 1992).

Water splashes from sinks have been found to increase the risk of

contamination and infection transmission of water-borne pathogens. Research

has found that the location and orientation of hand hygiene devices are

important factors that impact the possibility of water splashes from sinks

reaching nearby patient care areas (Hota et al., 2009). Carefully located hand

hygiene devices may make it easy for staff and other individuals to see and use

the devices to clean their hands.

Shared bathrooms may serve as reservoirs of infectious pathogens that can

spread from patient to patient in a short period. Single-patient bathrooms may

help reduce cross-contamination and improve environmental cleanliness. Even

in bathrooms less frequently used by patients, pathogens could be brought in on

staff members’ hands or used equipment and supplies.

There are reports about infections associated with fixtures and equipment (e.g.,

certain types of water faucets) (Sydnor et al., 2012). Fixtures and equipment

that are easy to clean and maintain may be associated with a lower chance of

becoming pathogen reservoirs and a lower risk of contributing to infection

transmission.

Hand hygiene devices themselves may become contaminated and play a role in

pathogen transmission by contaminating the hands of staff, patients, and

families (Harrison, Griffith, Ayers, & Michaels, 2003). Certain features of hand

hygiene devices, such as foot-operated sinks and hands-free faucets, may help

reduce the likelihood of re-contamination of hands after cleaning. In addition to

the location of sinks, the design of sinks should be considered in order to

prevent splashing into nearby patient care areas. Several sink design features

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were recommended by research studies: faucet spouts that do not flow directly

into the drain, decreased water

pressure, and physical barriers

between sinks and adjacent

preparatory spaces (Hota et al., 2009).

Research has found different levels of

effectiveness of various water

disinfection methods in preventing or

controlling various types of water

contamination and outbreaks of water-

borne infections (Modol et al., 2007).

Proper water disinfection methods

should be considered when designing

plumbing systems.

Design solutions that provide reminders (electronic or visual) and/or offer

automated compliance reporting have been found in multiple studies to

improve hand hygiene compliance (Armellino et al., 2012; Fakhry, Hanna,

Anderson, Holmes, & Nathwani, 2012).

Research shows that the contamination of environmental surfaces may serve as

a link in the chain of infection transmission. Certain surface materials have been

reported to be easier to clean, disinfect, and maintain and are associated with a

lower risk of contamination (Anderson, Mackel, Stoler, & Mallison, 1982; Harris,

Pacheco, & Lindner, 2010; Lankford et al., 2006; Noskin, Bednarz, Suriano,

Reiner, & Peterson, 2000). Recent research reports indicated that antibacterial

and antimicrobial characteristics of certain surface materials may be associated

with a lower risk of surface contamination and may therefore help to prevent

infection transmission (Karpanen et al., 2012; Takai et al., 2002).

Dust particles may also carry pathogens. Without proper cleaning,

environmental surfaces (especially high-touch objects) may catch dust and

become reservoirs of pathogens. Design that reduces the amount of dust caught

on environmental surfaces may help reduce the risk of environmental surfaces

becoming pathogen reservoirs, thereby reducing the risk of infection

transmission (Williams, Singh, & Romberg, 2003).

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Environmental design may facilitate the cleaning of high-touch objects (e.g.,

door handles, toilet handles, hand rails), thus reducing environmental

contamination and reducing the risk of infection transmission (Williams et al.,

2003). According to multiple recent epidemiological reports, without proper

maintenance and cleaning, certain environmental features (e.g., open water

fountains, curtains) could become reservoirs of pathogens and cause outbreaks

of infections (e.g., Palmore et al., 2009). Precautions should be taken to reduce

the risks involved with environmental features known to be potential reservoirs

of pathogens.

Research indicates that HVAC system design elements (including the location of

ventilation grilles, air pressure difference between nearby spaces to prevent

leakage of contaminated air, type and location of air filters, air disinfection, and

ventilation rates) significantly impact an HVAC system’s effectiveness in

reducing air contamination and improving air hygiene in healthcare settings

(Beggs, Kerr, Noakes, Hathway, & Sleigh, 2008; Menzies, Fanning, Yuan, &

FitzGerald, 2000).

Data shows that the filtered air is often re-contaminated after being filtered

with central filters (located inside the main air ducts) and before flowing into

healthcare spaces. Peripheral filters (located at the openings of ducts) were

found to make the air flowing into healthcare spaces cleaner (Crimi et al., 2006).

HVAC equipment can be contaminated and subsequently contaminate the air

entering into other healthcare spaces (Lutz, Jin, Rinaldi, Wickes, & Huycke,

2003). Studies found that certain HVAC components with antibacterial

characteristics were associated with a lower risk of HVAC system

contamination and air contamination (Schmidt et al., 2012). Research has

identified cases in which the ventilation systems may not work as designed (e.g.,

air flowing from negative pressure rooms to other spaces) and the deficiency in

ventilation may cause infection outbreaks (Fraser et al., 1993). Proper

monitoring, commissioning, and maintenance should be done in order to

optimize the performance of ventilation systems.

Research indicates that environmental hazards such as dampness in the HVAC

system may result in contamination during the lifecycle of a building (Lutz et al.,

2003). It’s essential to proactively monitor potential environmental hazards and

identify methods of controlling contamination. After the identification of

potential problems, easy access to system components is very important to

facilitate necessary maintenance or replacement to mitigate the environmental

hazards.

HVAC system design elements

significantly impact the

effectiveness of reducing air

contamination and improving air

hygiene in healthcare settings.

Factors include:

• Location of ventilation grilles

• Air pressure difference

between nearby spaces to

prevent leakage of

contaminated air

• Type and location of air filters

• Air disinfection (e.g., ultraviolet

germicidal irradiation)

• Ventilation rates

• Air flow design (e.g., laminar

flow)

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With respect to specific space types, the effectiveness of different OR

ventilation methods (e.g., conventional, laminar, non-aspirating, displacement)

varies significantly depending on different surgical procedures and OR layout

(Memarzadeh & Manning, 2002). To minimize the risk of infections contracted

in the OR, the most effective OR ventilation method should be selected.

The physical environment of healthcare facilities constitutes an essential

component in infection prevention. A multifactorial systems approach should

be taken to coordinate environmental design efforts around layout (building,

unit, and room), finishes, furnishings, HVAC systems, and plumbing fixtures,

with efforts coordinated around organizational policies and procedures, as well

as the individual users of healthcare spaces (e.g., caregivers, maintenance staff,

and patients).

The literature review content for the SRA was supported by The Center’s

research team (Anjali Joseph, PhD, EDAC; Ellen Taylor, AIA, MBA, EDAC;

Xiaobo Quan, PhD, EDAC; and Upali Nanda, PhD, EDAC) and the expert

workgroups for each topic area.

Anderson, R. L., Mackel, D. C., Stoler, B. S., & Mallison, G. F. (1982). Carpeting in hospitals: An epidemiological evaluation. J

Clin Microbiol, 15(3), 408–15.

Andersson, A. E., Bergh, I., Karlsson, J., Eriksson, B. I., & Nilsson, K. (2012). Traffic flow in the operating room: An

explorative and descriptive study on air quality during orthopedic trauma implant surgery. American Journal of

Infection Control, 40(8), 750–5.

Armellino, D., Hussain, E., Schilling, M. E., Senicola, W., Eichorn, A., Dlugacz, Y., & Farber, B. F. (2012). Using high-

technology to enforce low-technology safety measures: The use of third-party remote video auditing and real-time

feedback in healthcare. Clin Infect Dis, 54(1), 1–7.

Barnes, R. A., & Rogers, T. R. (1989). Control of an outbreak of nosocomial aspergillosis by laminar air-flow isolation. J

Hosp Infect, 14(2), 89–94.






outcomes, patient experience of

care, and provider/staff s

atisfaction and performance.

Learn more at


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Beggs, C. B., Kerr, K. G., Noakes, C. J., Hathway, E. A., & Sleigh, P. A. (2008). The ventilation of multiple-bed hospital wards:

Review and analysis. American Journal of Infection Control, 36(4), 250–9.

Chang, V. T., & Nelson, K. (2000). The role of physical proximity in nosocomial diarrhea. Clinical Infectious Diseases, 31(3),

717–22.

Crimi, P., Argellati, F., Macrina, G., Tinteri, C., Copello, L., Rebora, D., . . . Rizzetto, R. (2006). Microbiological surveillance of

hospital ventilation systems in departments at high risk of nosocomial infections. Journal of Preventive Medicine and

Hygiene, 47(3), 105–109.

Fakhry, M., Hanna, G. B., Anderson, O., Holmes, A., & Nathwani, D. (2012). Effectiveness of an audible reminder on hand

hygiene adherence. American Journal of Infection Control, 40(4), 320–3.

Fraser, V. J., Johnson, K., Primack, J., Jones, M., Medoff, G., & Dunagan, W. C. (1993). Evaluation of rooms with negative

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Gustafson, T. L., Lavely, G. B., Brawner, E. R., Jr., Hutcheson, R. H., Jr., Wright, P. F., & Schaffner, W. (1982). An outbreak of

airborne nosocomial varicella. Pediatrics, 70(4), 550–6.

Harrison, W., Griffith, C., Ayers, T., & Michaels, B. (2003). Bacterial transfer and cross-contamination potential associated

with paper-towel dispensing. American Journal of Infection Control, 31(7), 387-91.

Harris, D., Pacheco, A., & Lindner, A. S. (2010). Detecting potential pathogens on hospital surfaces: An assessment of

carpet tile flooring in the hospital patient environment. Indoor and Built Environment, 19(2), 239–249.

Hota, S., Hirji, Z., Stockton, K., Lemieux, C., Dedier, H., Wolfaardt, G., & Gardam, M. A. (2009). Outbreak of multidrug-

resistant Pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room

design. Infect Control Hosp Epidemiol, 30(1), 25–33.

Hutton, M. D., Stead, W. W., Cauthen, G. M., Bloch, A. B., & Ewing, W. M. (1990). Nosocomial transmission of tuberculosis

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408–10.

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antimicrobial efficacy of copper alloy furnishing in the clinical environment: A crossover study. Infect Control Hosp

Epidemiol, 33(1), 3–9.

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commonly utilized in health care: Implications for bacterial survival and transmission. American Journal of Infection

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surgical patients, associated with a contaminated air-handling system. Clin Infect Dis, 37(6), 786–93.

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MacKenzie, F. M., Bruce, J., Struelens, M. J., Goossens, H., Mollison, J., & Gould, I. M. (2007). Antimicrobial drug use and

infection control practices associated with the prevalence of methicillin-resistant Staphylococcus aureus in European

hospitals. Clinical Microbiology and Infection, 13(3), 269–76.

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Documents

An Issue Brief onF I N D I N G S Cleanliness · Recent outbreaks of HAIs, such as Ebola, severe acute respiratory syndrome (SARS), and methicillin-resistant Staphylococcus aureus