FacilityCare recently held a roundtable discussion on infection control. Susan Helmer, editor, asked three industry experts to comment on those infection control issues that pose the biggest threat to patient safety, findings from recent research studies and the implementation of risk assessment during construction.

Susan Helmer: What infection control issue in healthcare do you feel needs the most attention, and why do you think it is such a problem in the industry?

Al Draper: To start with, I think it would help if we looked at some of the numbers. There is an estimated one in 10 American patients that get a hospital-acquired infection. That translates to about 2 million individuals annually. And between 90,000 and 100,000 of those patients die each year from hospital acquired infections. This adds up to between $4.5 and $5 billion dollars in annual excess healthcare costs.

Much of this can best be rectified by washing your hands and following sterile procedures. However, experts estimate that about 10 percent of these infections remain as construction-related. Now 10 percent may not sound like a lot unless, of course, the 1 in 200,000 construction-related infections or the 1 in 10,000 deaths affects your family. Then it becomes very important.

So, in regard to construction-related infection control, I would like to focus on a couple of issues. I think everyone realizes that exposure to the infectious agents Aspergillus and Legionella can be directly related to the lack of construction-related infection control procedures. When we add to the equation the fact that there is an increased prevalence of immunosuppressed patients in the world today and an increased prevalence of emerging antimicrobial-resistant infectious agents, that leads us to be concerned — not only about the procedures and the guidelines necessary, but also about the implementation of these procedures and guidelines.

In the past two decades, the rate of nosocomial infections per 1,000 patient days rose 36 percent. It’s obviously something that we just don’t have a handle on. While the guidelines that are being developed are very important to establish a baseline of control, all the guidelines in the world won’t keep us from having infection control-related illnesses unless we implement those guidelines. From my experience in the industry, I have had a lot of difficulty seeing strong implementation of the guidelines.

Helmer: What research has been completed that can give us insight on the built environment and infection control issues.

Jane Rohde: Recently, the Coalition for Health Environments Research (CHER) held a presentation for a request for proposals for different research projects. One of the research projects presented in a request-for-proposal format was about limiting the spread of infection in the healthcare environment and involved evaluating different materials in relationship to the growth of different types of organisms. Northwestern Memorial Hospital and The Feinberg School of Medicine of Northwestern University were the respondents that were chosen by CHER. Researchers included Dr. Gary A. Noskin, who is an expert in some of the research that has previously been done in this area. Mary G. Lankford was the key researcher who was our contact through CHER.

Basically, they looked through the background of environmental surfaces — things like light switches, flush handles, faucets, telephone handles and door knobs, and different types of equipment, such as electronic ear probes, IV pumps, incubators, respiratory equipment and healthcare workers’ hands in terms of contamination. Similar to what Al said, it’s really more about trying to get the staff to wash their hands more frequently.

They confirmed also that the 90,000 deaths annually came from a study that John P. Burke, MD, reported on in Infection Control — A Problem for Patient Safety, which was confirmed in 2003. Two of the organisms reviewed were VRE (vancomycin-resistant enterococci ) and PSAE (pseudomonas aeruginosa). We basically wanted to investigate how the different environmental surfaces would harbor these different organisms. After cleaning the surfaces with a recovery of the organism, they then evaluated the possible healthcare provider transmission of VRE with healthy human volunteers to see if it would contract and remain, and then be transferable.

The surfaces that were reviewed included upholstery, different fabrics, different flooring materials and different wall finishes. After 24 hours, VRE was found present on all surfaces, and PSAE was present on 13 of the surfaces. After cleaning, they found five surfaces with VRE and four surfaces with PSAE.

The significance here in terms of the physical environment is, what about surfaces that are not cleaned? How long are organisms sitting where they are sitting? What kind of manufacturing protocols are being set up that would assist with the cleaning of surfaces, and how is that being done?

The biggest factor we found was that none of the manufacturers of products that are used in healthcare environments are actually utilized by hospitals. The hospitals use The Centers for Disease Control and Prevention (CDC) or other environmental guidelines for their cleaning protocols, and the manufacturers aren’t testing their products utilizing any of the CDC information.

There are two issues that come out of this. First, how well will products actually endure a healthcare environment, and will they really hold up? And the second issue is, how can we align the two better so that how products are being tested is actually how they are being cleaned, which will allow for hospital staff to be cleaning a product and relying on it being able to hold up.

The study did not show that any one material was better than another material. It was more about washing hands and strongly reinforced that step prior to patient contact. It also aligns with another research project that was completed by The Center For Health Design, “The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity,” which was completed by Roger Ulrich, PhD, and Craig Zimring, PhD. Again, they talked about hand washing and locations of sinks to reduce transmission. That project will be published shortly through CHER and will be available through its Web site.

Helmer: Has there been any discussion on looking into what would be the best products to use before construction or remodeling begins so that the design team is aware of what works best with what surfaces in regard to specific infection control protocols?

Rohde: No, that’s actually one of the big gaps. When we talk about cleaning in general, it basically comes down to the cleaning of surfaces. Manufacturers have not worked together to look at the process as a system. Take the floor and walls for example. Manufacturers can tell you how to clean the floor, but they can’t tell you what happens when you get their cleaner on the wall.

So there are two issues here. One is looking at the whole system and having manufacturers help you clean better with the whole system being complete. And then the other part of it is really looking at the materials themselves to see how they are being cleaned so that manufacturers are giving appropriate recommendations. For example, one fabric manufacturer only recommended the use of soapy water on its product. We asked if they could give us something more technical in writing. I got this little hand-written fax that said, “Use soapy water.” So that’s what designers and architects are utilizing for their cleaning recommendations for this fabric. And that’s what’s being passed on to the hospital. But the hospitals are not using that information anyway. They are looking at the CDC and other environmental guidelines to establish how to clean things.

The other issue that hospital staff has with manufacturers is that they each may have a certain product type they want the hospital to use to clean. However, it would be impossible and OSHA regulations would probably be an issue in terms of having way too many types of cleaners and too many people trying to understand how to clean with all of these different cleaners. It would be cost-prohibitive, staff would have a difficult time keeping up with it and there are no instructions that help a multilingual staff clean better. So I think addressing all of these issues with the assistance of the manufacturers could help for a better environment in terms of cleaning.

Draper: The American Society for Microbiology just finished a study and found out that bacteria can survive for up to three weeks on many hospital surfaces. To me that is just flabbergasting. I never thought bacterial could survive on a hospital surface for that length of. I think that tells us something. We talk about washing hands but you know another surface that touches the patient is hospital surfaces. And I think they need to be cleaned as rigorously as one’s hands.

Rohde: And what we found in the CHER study that is similar to those results is that the organisms would last for seven days or longer if you didn’t clean at all. And so to me the bigger question was, what about the surfaces that aren’t cleaned appropriately or at all?

My understanding from studying the CDC guidelines is that if you don’t know what a substance is, then you use a higher level of disinfection and a higher level of cleaning. So there are different levels based on the different fluids, or suspect fluids if you will, that need to be cleaned. The gap between that and manufacturers not even understanding that there is a gap is alarming.

Jennie Evans: If you find bacteria on a surface in a waiting room, has there been any correlation that that is where patients are getting their infections?

Rohde: It’s more from the palm or contact between a staff person and a patient, unless it is an airborne issue.

Evans: So when you are talking about materials, I’m thinking of all the chairs that are disbursed throughout a hospital.

Rohde: Suppose you have an open woven fabric, and bacteria gets into that material. Then someone comes along and touches that material and then touches the doorknob. A staff person comes through and touches that same doorknob and then touches an immunocompromised patient. That is how it could be transmitted.

Evans: And they didn’t wash their hands.

Rohde: Exactly. I did have one question when we did a presentation recently where someone asked if soap and water didn’t clean an environmental surface very well, why would it clean hands any better? That was a very good question, and the real answer is that they have to clean their hands vigorously with soap under warm water. The staff person cleaning an environmental surface is probably not going to be using warm water with soap and scrubbing vigorously.

The other thing that we haven’t talked about is the onset of green cleaners. Those cleaners also have not been tested on products and we have no idea of what the impact to infection control would be utilizing some of the green cleaners that are out there.

Helmer: In what areas has infection control during construction improved the most since the implementation of risk assessment during construction?

Evans: When the American Institute of Architects (AIA) implemented the infection control risk assessment (ICRA), the goal was to identify risks for susceptible disruption to the patient as well as patient care services. And it basically stated that each renovation or new construction project in a hospital must include the leadership of an infection control epidemiology leader. As a project manager, I have actually had firsthand experience working with infection control with the construction group. The presence of the infection control personnel at the construction planning table absolutely encouraged and led the team to put patient safety first and provide a quality control for the project.

The projects I participated in had the infection control leader, construction project manager, superintendent and facility representative all review the plans together with the patient unit director and work collaboratively to devise the safest plan for the renovation work. What we found was having the team in the same room simultaneously enabled each one of us to hear the challenges that each party faced. There was a synergy that occurred, and quite often we would come up with a plan that was more creative than what anyone had thought and it would perhaps expedite construction because as we all know construction is timely and costly. So working together we were able to provide a plan that was timely, ensured everybody was communicated to at the same time and created the best practice for a facility. So the AIA guidelines were really instrumental in making this happen.

The implementation of the infection control risk assessment has really risen the level of accountability for projects occurring in occupied facilities, and I think besides working together during the planning and programming phases of construction, it also would be beneficial for facilities to consider this sort of team approach to creating the policies within their own facility for construction, which may lead to what Al was alluding to about the fact that there is so many infections occurring as a result of construction and what are we doing about it.

I think that sometimes these policies and the follow-through with them are carried out in silos and that construction is multifaceted and requires a multidisciplinary approach. Bringing the construction personnel into that is an important piece.

Draper: I couldn’t agree more. I think you hit the nail on the head in that the greatest planning can sometimes be in a silo where everybody in the room agrees but somehow in the field things break down. And I think we have a responsibility to see that things in the field are the same as discussed — that the same guidelines are implemented and followed, there’s checks and balances to make sure that the controls are in place, and that we have a plan should a control fail. I think that’s the key because in the real world, that’s where a patient is most affected.

Evans: Right, and the 2006 AIA Guidelines make that pretty clear. It says that the owner shall ensure that construction-related infection control risks mitigation recommendations as well as ICRA-generated design recommendations are incorporated into the project requirements.

Where I worked previously we had an involved infection control department where they checked partitions on a daily basis. Well, first they would check the plan, the dust partitions, the location of the dust partitions, the type of partition that was going to be put up, did it require a negative air machine, did it require two negative air machines, were the partitions taped over seams? And so they took an active role and a lot of responsibility for the construction project and I think that really what we all need is some sort of level of accountability that ties into the cleaning as well as that oversight. I think sometimes we underestimate the importance of a manger on a project to provide that oversight and accountability that we as humans require.

Draper: And who is tasked with performing those inspections?

Evans: I think it is up to the hospital facility to put that in their policy. According to these guidelines the facilities are responsible for it. I know that the infection control principals in hospital construction also recommend that the infection control personnel do that — someone designated from that department as well as the facility manager. But the construction company is responsible for putting them up, and they should put them up according to the requirements of the hospital. But they need to be inspected.

Rohde: The idea is having a quality control person who took on all those different aspects of making sure that they get installed correctly, and follow-through prior to installation of other pieces too, right down to the last piece of FF&E that goes into the building.

Evans: The ICRA guidelines say that the infection control personnel need to be involved but there also needs to be someone watching to make sure the construction personnel have had the education and training about infections and what they can do to help decrease nosocomial infections. Are they decreasing the spread of particles throughout the facility? Are they wearing their protective equipment? Are they keeping trash covered up when they are moving debris through the hospital? Are there adhesive mats at the entrances and exits where they are performing construction to help keep dust from being spread throughout the facility? So, there really should be a team of people set up to help oversee construction projects.

Rohde: The point about training I think is really key on all levels as well. If you think about an $8-an-hour worker being responsible for maintaining environmental surfaces and they are not trained accordingly yet the hospital is facing millions or billions of dollars in losses due to nosocomial infection. There seems to be a gap between training and equitable payment and things like that to the source of personnel that if you train them correctly it could help reduce that rate. There seems to be a gap there in terms of understanding.

Evans: Right, because if we put a dollar figure like what Al was talking about in terms of those 200,000 people who are hospitalized or have an extended hospital stay as a result of nosocomial infection it would be a large number.

Draper: In my experience, there is a huge difference in the quality of training from company to company. A lot of companies go to the extra effort to get the additional training and to get special healthcare and construction-related trainings so that they have crews that are specifically dedicated to nothing but healthcare institutions. However, other competitors don’t necessarily tow that line. There is a tremendous difference in the quality that the hospital receives at the end of a project reflecting the type of training that’s involved. A lot of times it’s a shame that the hospital doesn’t spend more time emphasizing and wanting documentation that the contractor really understands the business that he is professing that he can do.

Evans: It’s all about teamwork. It takes all of us to get a job done sometimes so we can’t sit back and just let things happen. I think we have to take an active stance and that’s what this ICRA guideline is about. It’s about having someone take an active stance in taking responsibility. That is what family participation and bedside care is about. Families want to take an active stance in helping their family member get better. I think that that’s what we have to do in the world that we live in — that this is where we must go.

FC

Alfred C. Draper III is director of restoration at LVI Services, Oklahoma City; (405) 273-4800; E-mail: adraper@lviservices.com; Internet: lviservices.com.

Jennie Evans, RN, is director of clinical operations at HKS Inc., Dallas; (214) 969-5599; E-mail: jevans@hksinc.com; Internet: hksinc.com.