Current views of health care design and construction: Practical implications for safer, cleaner environments

Infection preventionists (IP) play an increasingly important role in preventing health care-associated infection in the physical environment associated with new construction or renovation of health care facilities. The Guidelines for Design and Construction of Hospital and Healthcare Facilities, 2010, formerly known as ''AIA Guidelines'' was the origin of the ''infection control risk assessment'' now required by multiple agencies. These Guidelines represent minimum US health care standards and provide guidance on best practices. They recognize that the built environment has a profound affect on health and the natural environment and require that health care facilities be designed to ''first, do no harm.'' This review uses the Guidelines as a blueprint for IPs' role in design and construction, updating familiar concepts to the 2010 edition with special emphasis on IP input into design given its longer range impact on health care-associated infection prevention while linking to safety and sustainability. Section I provides an overview of disease transmission risks from the built environment and related costs, section II presents a broad view of design and master planning, and section III addresses the detailed design strategies for infection prevention specifically addressed in the 2010 Facility Guidelines Institute edition. Key Words: Health care design; construction; ventilation; water quality; operating room design; sustainability. INTRODUCTION Infection preventionists (IP) are integral members of the team of professionals who design, construct, operate, and work in health care facilities. IP's subject matter expertise on prevention of cross transmission and design/operations of facilities aimed at safety of all occupants in the built environment initially led to the foundation of the infection control risk assessment (ICRA) process. The ICRA grew out of concern related to increasing reports of health care-associated infections (HAIs) caused by construction/renovation in facilities. Details of this have been reviewed elsewhere. 2 This forecast plus increasing focus on prevention of HAIs are key developments that will call on continued expansion of the IP's scope of practice. 3 This scope will include oversight of containment of microorganisms and contaminants under the ICRA but increasingly emphasize more proactive involvement in design of the environment of care (EoC) from concept to occupancy. 4 This review will focus on the IP's expanding role in the development and operations of the built environment in the 21st century. OVERVIEW OF DISEASE TRANSMISSION RISKS FROM THE BUILT ENVIRONMENT Disease transmission risks Air. Although the actual percentage of HAIs directly related to construction is unknown, the morbidity, mortality, and costs of mitigation are considerable. Vonberg and Gastmeier reviewed outbreaks of infection caused by Aspergillus spp and found that almost half were associated with construction or renovation in hospitals. 5 In addition, a dose of only 1 colony forming unit/m 3 was needed to cause infection in immunocompromised patients and highlights the critical need for isolation and containment of construction activities from other occupied spaces. Other pathogens transmitted during Water. The reservoir of microbes of pathogens present in potable water and its delivery network are vast. These include gram-negative bacteria, eg, Legionellae and Pseudomonas spp, nontuberculous Mycobacteria, protozoa, and fungi. 8 Disruption of water utility systems during construction or renovation can disrupt the biofilm present in water delivery pipes, posing a threat to patients, including those far away from an active construction zone. Environmental surfaces and patient care equipment. The relative importance of the inanimate environment as a reservoir of organisms has undergone renewed emphasis, given the emergence of a wide range of microorganisms including multidrug-resistant organisms (MDROs) present in health care settings. Presence of MDROs on surfaces that appear relatively clean and transfer of these on hands of personnel has been described. The bioburden of an inpatient room has been studied given the concern over environmental reservoirs of MDROs. Huang et al found admission to a room previously occupied by a patient with MDROs increases the likelihood of acquisition of these organisms by subsequent patients. 14 More recently, Hamel et al describe increased risk of acquisition and cross infection of 2 key MDROs and Clostridium difficile to roommates in multibed patient rooms. 15 Equipment and devices used to support electronic health records can also become contaminated with microbes; however, Lu et al demonstrated that the concentration of this contamination is low and often unrelated to strains recovered from patients. Construction trends and changes in health care delivery in US hospitals Annual construction and design cost. United States trends indicate a continued major expenditure in health care construction and renovation even with economic downturn in [2008][2009]. Changes in patient acuity, aging, and reduced capitol funds have affected construction expenditures in a number of ways. Recent trends show that dollars are spent primarily on inpatient specialty beds (eg, cardiac and cancer) along with increasing demands for assisted-living and skilled nursing centers. Construction for hospitals and clinics in the fourth quarter of 2008 totaled $40.7 billion with three quarters of projects involving either expansion or renovation. 17 Interestingly, among the top 5 design features incorporated into patient room design was an in-room handwashing sink (almost 50% of new construction), separate from that in the bathroom attached to the room. Looking ahead, there will likely be a stabilization in construction activities with modest growth as noted earlier, but the economic constrains may lead to a drop in the total square footage of built environment for the next several years. Planning for future needs. The increasing age of US health care facilities generates a constant need for repair, remediation work (cabling, room additions), or replacement. These processes increase risks of environmental contamination, affecting air and water quality and sustainability. Planning for surge capacity. Planning for surge capacity needed for potential airborne infectious agent releases or a major influx of patients with communicable disease such as an influenza pandemic is also challenging with increased numbers of single or variable acuity patient rooms. Some institutions include extra utilities, so some rooms, including ICUs, have essentially 2 head walls with duplicate utilities needed for such critical circumstances that could require 2 patients in each room. DESIGN AND MASTER PLANNING SAFETY AND INFECTION PREVENTION Design layout trends New elements being incorporated into design and master planning of health care facility construction S2 Bartley, Olmsted, and Haas Designs aimed at environmental sustainability are also being used in over 80% of active projects based on a survey from 2008, and this is likely to continue. 2 These green design features include enhanced efficiency of heating, ventilation, and air conditioning (HVAC) systems; building utilities (power and water); surface and finish treatments that lessen use of volatile organic compounds; and use of natural lighting, lowemission glass, and waste reclamation. Contractors frequently reclaim/recycle materials produced during demolition. Addressing economic challenges while maintaining quality and safety of patient care has led to increasing use of Six Sigma Lean methods and principles. The goal of Lean is to create maximum value for patients by reducing waste through improved quality, efficiency, and safety. It employs a range of performance assessment and improvement tools and depends heavily on datadriven decision making. Lean principles have been adopted widely by health care planners and are increasingly making an impact on design of the built environment, supporting the goal of increased efficiency and waste elimination

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates

The James Webb Space Telescope Mission

Twenty-six years ago a small committee report, building on earlier studies, expounded a compelling and poetic vision for the future of astronomy, calling for an infrared-optimized space telescope with an aperture of at least $4m$. With the support of their governments in the US, Europe, and Canada, 20,000 people realized that vision as the $6.5m$ James Webb Space Telescope. A generation of astronomers will celebrate their accomplishments for the life of the mission, potentially as long as 20 years, and beyond. This report and the scientific discoveries that follow are extended thank-you notes to the 20,000 team members. The telescope is working perfectly, with much better image quality than expected. In this and accompanying papers, we give a brief history, describe the observatory, outline its objectives and current observing program, and discuss the inventions and people who made it possible. We cite detailed reports on the design and the measured performance on orbit.Comment: Accepted by PASP for the special issue on The James Webb Space Telescope Overview, 29 pages, 4 figure

To Bathe or Not to Bathe With Chlorhexidine Gluconate:Is It Time to Take a Stand for Preadmission Bathing and Cleansing?

No abstract availabl

Current views of health care design and construction: Practical implications for safer, cleaner environments

Infection preventionists (IP) play an increasingly important role in preventing health care-associated infection in the physical environment associated with new construction or renovation of health care facilities. The Guidelines for Design and Construction of Hospital and Healthcare Facilities, 2010, formerly known as ''AIA Guidelines'' was the origin of the ''infection control risk assessment'' now required by multiple agencies. These Guidelines represent minimum US health care standards and provide guidance on best practices. They recognize that the built environment has a profound affect on health and the natural environment and require that health care facilities be designed to ''first, do no harm.'' This review uses the Guidelines as a blueprint for IPs' role in design and construction, updating familiar concepts to the 2010 edition with special emphasis on IP input into design given its longer range impact on health care-associated infection prevention while linking to safety and sustainability. Section I provides an overview of disease transmission risks from the built environment and related costs, section II presents a broad view of design and master planning, and section III addresses the detailed design strategies for infection prevention specifically addressed in the 2010 Facility Guidelines Institute edition. Key Words: Health care design; construction; ventilation; water quality; operating room design; sustainability. INTRODUCTION Infection preventionists (IP) are integral members of the team of professionals who design, construct, operate, and work in health care facilities. IP's subject matter expertise on prevention of cross transmission and design/operations of facilities aimed at safety of all occupants in the built environment initially led to the foundation of the infection control risk assessment (ICRA) process. The ICRA grew out of concern related to increasing reports of health care-associated infections (HAIs) caused by construction/renovation in facilities. Details of this have been reviewed elsewhere. 2 This forecast plus increasing focus on prevention of HAIs are key developments that will call on continued expansion of the IP's scope of practice. 3 This scope will include oversight of containment of microorganisms and contaminants under the ICRA but increasingly emphasize more proactive involvement in design of the environment of care (EoC) from concept to occupancy. 4 This review will focus on the IP's expanding role in the development and operations of the built environment in the 21st century. OVERVIEW OF DISEASE TRANSMISSION RISKS FROM THE BUILT ENVIRONMENT Disease transmission risks Air. Although the actual percentage of HAIs directly related to construction is unknown, the morbidity, mortality, and costs of mitigation are considerable. Vonberg and Gastmeier reviewed outbreaks of infection caused by Aspergillus spp and found that almost half were associated with construction or renovation in hospitals. 5 In addition, a dose of only 1 colony forming unit/m 3 was needed to cause infection in immunocompromised patients and highlights the critical need for isolation and containment of construction activities from other occupied spaces. Other pathogens transmitted during Water. The reservoir of microbes of pathogens present in potable water and its delivery network are vast. These include gram-negative bacteria, eg, Legionellae and Pseudomonas spp, nontuberculous Mycobacteria, protozoa, and fungi. 8 Disruption of water utility systems during construction or renovation can disrupt the biofilm present in water delivery pipes, posing a threat to patients, including those far away from an active construction zone. Environmental surfaces and patient care equipment. The relative importance of the inanimate environment as a reservoir of organisms has undergone renewed emphasis, given the emergence of a wide range of microorganisms including multidrug-resistant organisms (MDROs) present in health care settings. Presence of MDROs on surfaces that appear relatively clean and transfer of these on hands of personnel has been described. The bioburden of an inpatient room has been studied given the concern over environmental reservoirs of MDROs. Huang et al found admission to a room previously occupied by a patient with MDROs increases the likelihood of acquisition of these organisms by subsequent patients. 14 More recently, Hamel et al describe increased risk of acquisition and cross infection of 2 key MDROs and Clostridium difficile to roommates in multibed patient rooms. 15 Equipment and devices used to support electronic health records can also become contaminated with microbes; however, Lu et al demonstrated that the concentration of this contamination is low and often unrelated to strains recovered from patients. Construction trends and changes in health care delivery in US hospitals Annual construction and design cost. United States trends indicate a continued major expenditure in health care construction and renovation even with economic downturn in [2008][2009]. Changes in patient acuity, aging, and reduced capitol funds have affected construction expenditures in a number of ways. Recent trends show that dollars are spent primarily on inpatient specialty beds (eg, cardiac and cancer) along with increasing demands for assisted-living and skilled nursing centers. Construction for hospitals and clinics in the fourth quarter of 2008 totaled $40.7 billion with three quarters of projects involving either expansion or renovation. 17 Interestingly, among the top 5 design features incorporated into patient room design was an in-room handwashing sink (almost 50% of new construction), separate from that in the bathroom attached to the room. Looking ahead, there will likely be a stabilization in construction activities with modest growth as noted earlier, but the economic constrains may lead to a drop in the total square footage of built environment for the next several years. Planning for future needs. The increasing age of US health care facilities generates a constant need for repair, remediation work (cabling, room additions), or replacement. These processes increase risks of environmental contamination, affecting air and water quality and sustainability. Planning for surge capacity. Planning for surge capacity needed for potential airborne infectious agent releases or a major influx of patients with communicable disease such as an influenza pandemic is also challenging with increased numbers of single or variable acuity patient rooms. Some institutions include extra utilities, so some rooms, including ICUs, have essentially 2 head walls with duplicate utilities needed for such critical circumstances that could require 2 patients in each room. DESIGN AND MASTER PLANNING SAFETY AND INFECTION PREVENTION Design layout trends New elements being incorporated into design and master planning of health care facility construction S2 Bartley, Olmsted, and Haas Designs aimed at environmental sustainability are also being used in over 80% of active projects based on a survey from 2008, and this is likely to continue. 2 These green design features include enhanced efficiency of heating, ventilation, and air conditioning (HVAC) systems; building utilities (power and water); surface and finish treatments that lessen use of volatile organic compounds; and use of natural lighting, lowemission glass, and waste reclamation. Contractors frequently reclaim/recycle materials produced during demolition. Addressing economic challenges while maintaining quality and safety of patient care has led to increasing use of Six Sigma Lean methods and principles. The goal of Lean is to create maximum value for patients by reducing waste through improved quality, efficiency, and safety. It employs a range of performance assessment and improvement tools and depends heavily on datadriven decision making. Lean principles have been adopted widely by health care planners and are increasingly making an impact on design of the built environment, supporting the goal of increased efficiency and waste elimination