By Elias Tannous, Infection Control Specialist, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE; and Michael Rollins, Consultant Environmental Infection Prevention Specialist, UK Associate: Hahdat Al Tamyuz, Abu Dhabi, UAE

Healthcare settings, unique environments

The WHO defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Given this definition, a healthcare environment should not solely be a place where people come to be cured from a disease or a condition but a place providing health and which heals people in a safe and caring environment.

These environments are complex. They house vulnerable individuals (patients), possess interconnected, interdependent and intricate systems, processes and technologies; they are divided into several specialised services, and are always required to have higher safety features.

In general, the worldwide population is always growing and ageing. This will ultimately result in more people seeking healthcare services. Thus, more healthcare settings would be needed; new ones would be built, old ones would be renovated and maintenance would always be required. These activities anticipate more hazards and will have a great impact on patient safety as well as healthcare workers’ safety.

Design of Care Environment

Similar to quality science, the Donabedian model of “structure, process and outcome" could always be used as a conceptual model when designing/renovating healthcare settings.

When designing a healthcare setting, there must be a written functional programme describing the delivery of care model (concepts), the services to be provided, and the populations to be served. These will dictate the layout and the operational planning of the structure of care. In addition to ensuring that the physical environment will be compliant with some specific codes in terms of air quality, fire safety, etc,the design should promote some specific features such as patient confidentiality and dignity, reduce staff stress level and medical errors, reduce noise level, promote way findings, and other requirements that are deemed for the satisfaction and safety of whoever comes within the scope of practice of the facility. In summary it should be of a healing environment design.    

Effect of the Design and the Environment of Care on Patient Safety
In terms of safety, the physical environment plays an integral part of ensuring good patient outcome.  Studies show that the rate of hospital-acquired infections decreased after allocating single-bedded rooms and worked on changing the location of hand hygiene facilities. Other studies pointed out that patient falls decreased after placing patients in closer proximity to the nurse stations. In terms of environmental factors, there is an abundance of studies which correlates air and water to infectious events and outbreaks.

Infection Control Considerations During Construction/Renovation
In order to ensure the desired outcome for a construction/renovation project, a multidisciplinary team should be formed. And the planning and design should include administrators, clinicians, infection control, safety officers, support staff, construction specialists, and other members (as needed).

In terms of structure and design, there are many standards and recommendations. Nowadays, the Facility Guidelines Institute–FGI is being used the most. The FGI is a non-profit organisation dedicated to developing guidance for the planning, design, and construction of healthcare settings by the American Institute of Architects Standards (AIA).  Of course, these requirements can differ from country to country and to the standards used by each facility. For instance, according to some  guidelines, in new construction, single patient rooms should be at least 12 feet (3.66 metres) wide by 13 feet (3.96 metres) deep (or approximately 160 square feet, or 14.86 square metres) exclusive of toilets, closets, lockers, wardrobes, alcoves, or vestibules.

Heating, Ventilating, and Air-Conditioning (HVAC) Systems, and water quality also has some specifications. For e.g.; for the operating and delivery room air supply, the recommended air change rate in an operating room is 20 to 25 air changes per hour (ACH) for ceiling heights between 9 feet (2.74 metres) and 12 feet (3.66 metres).

In essence, a thorough Infection Control Risk Assessment should be performed by the multidisciplinary team.

Infection Control Risk Assessment (ICRA)
Most facilities nowadays have adopted ICRA developed by Virginia Kennedy. This represents risk assessment and preventive measures based on the level of construction activity that may occur within a healthcare facility and patients risk groups.

For a new stand-alone facility, the work is relatively easy due to the fact that no occupants are present. However, working on an operational facility poses different challenges; plans for risks mitigations should therefore be in place to eliminate the risk of airborne and waterborne infections to everyone present in the facility.

ICRA processes assess (1) the design before the start of the construction project; (2) the required mitigation strategies and planning for conducting the work; and (3) continuous monitoring.

• During the design phase: The assessment should include the general requirements (according to the guidelines and/or standards used) and other design features such as the specification of airborne infectious isolation rooms, protective environment rooms, HVAC systems requirement, water systems, hand hygiene facilities, furniture, equipment management, storage requirements, waste management, staff, patients, and visitors flow should also be considered.
• The required mitigation strategies and planning for conducting the work using ICRA.

First, describe and assign the type of construction activity. For example, A representing non-invasive activities such as removal of ceiling tiles for visual inspection only, painting (but not sanding), wall covering, electrical trim work. B is assigned for small scale, short duration activities which create minimal dust i.e.; installation of telephone and computer cabling, while C is assigned for work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies such as sanding of walls for painting or wall covering, removal of floor coverings, ceiling tiles and casework, etc. And D could represent major demolition and construction projects, including, but is not limited to activities which require consecutive work shifts and/or heavy demolition or removal of a complete cabling system, new construction, etc.

Second, identify  the patient risk groups that will be affected, this is done according to the patient susceptibility to infection. For instance,  low risk groups include office areas and highest risk groups include those areas or patients at greatest risk for contamination or infection such as immunocompromised patients, patients with burns, and the central sterile department.

Third, match the type of construction with the patient categories to identify the required precautions. These precautions would be applied during and after completion of the project.

Other infection control considerations also include: the impact of the project on the adjacent units, issues related to the disruption of ventilation, plumbing, electrical, impact on air quality, working hours, traffic for the workers, waste management, and debris removal.

• Monitoring: ICRA requires continuous monitoring of construction/renovation sites to ensure preventative measures are always in place.

Commissioning:  Once the work is complete, checking the systems and finishes is crucial to ensure that the work was conducted based on previously agreed specifications and that safety features of a healthy environment are in fact present, before occupancy.  
The following are some preventative points to consider based on ICRA:

• Patient placement and relocation
• Construction/renovation site isolation
• Measures required to protecting adjacent areas
• IC permits at doors
• Whether there would be disruptions of essential services due to the construction/renovation and what are the alternatives
• Debris removal (who will remove, how and how often)
• Traffic flow
• Cleanup, testing and certification
• Training of construction staff
• Noise and vibration
• Whether air balancing will be required
• Water and/or air sampling

In addition, when deciding and evaluating environmental surfaces/products, the following are some characteristics to consider:

• Durability
• Flammability (fire rating class)
• Ease of maintenance and repair
• Ease of cleaning
• Low or no volatile organic compound
• Slip resistant (for flooring)  
• Cost

References available on request                
Elias Tannous is a Speaker at the Infection Control Conference held as part of Patient Safety Exhibition in Dubai, on 26th October, 2017.