Dr Shanom Ali is the lead for the Environmental Research Laboratory (ERL) — a multi-disciplinary microbiology diagnostics and research facility based in London, an associate professor at University College London and the London School of Hygiene and Tropical Medicine and a trustee for the Healthcare Infection Society.* He is also Director of a UKAS accredited microbiology testing laboratory at the ERL, that performs over 50,000 tests annually from various hospitals in and around London to keep patients safe from acquiring infection.
Dr Ali discusses how well-informed thinking on infection prevention and control (IPC) should impact on design to reduce risks behind the very serious IPC issues that can occur in new facilities — and also reflects on how design that improves the overall patient experience can be achieved without compromising patients’ safety. Dr Ali is quoted in this article in a personal capacity.
How has your work at the ERL informed your thoughts on the infection prevention and control (IPC) considerations needed when new hospitals are designed?
The ERL, which comprises a team of healthcare scientists and academics, provides academic research and consultancy to address anti-microbial resistance (AMR) and infection control management, as well as exploring novel antimicrobial therapeutics (medicines and treatments) and diagnostics.
For the last 15 years the ERL has also been providing an environmental screening and surveillance service, developing considerable experience in investigating infection control outbreaks and “looking for the unusual.”
How you design, build and test new hospitals is currently being widely discussed. However, there is not much of a focus on the patient environment, hospital building and environmental monitoring until there’s anIPC issue. "We have some guidelines such as ‘Health Building Notes(HBN)’to guide the design of hospitals and wards and the Health Technical Memorandums(HTMs) to support how we test (air, surfaces and water) to monitor the patient environment. However, I don’t think we’ve got it right for existing buildings.There is little consultation with IPC in the early design stages for new hospitals."
In clinical settings, when it comes to training and development, most of the clinical interest isin patient to patient transmission and the clinical side of microbiology as opposed to the environmental microbiology aspect, i.e. the influence of air,water and surfaces.
"There is an assumption that you can swab a surface or extract some air and a result comes out and it’s as easy as that...”
There needs to be an understanding that the matrix being tested (air, surface, water) will determine what kind of test is used: for example, swabs shouldn’t be used for testing water samples. When sampling surfaces, the swab needs to be the correct one for the type of surface being tested and the target organism. A swab that works for E.coli may not work for MRSA or Clostridioides difficile.
Looking at other considerations, for example, in water sampling: 100 mL samples are usually taken for routine water monitoring for Pseudomonasaeruginosa, however, monitoring of Legionella is more difficult.
These require 1 litre samples, with a mass of 1 kg perbottle to be collected. Logistically these add up to a huge weight across the thousands of samples that might be generated from numerous outlets across manywards.
While swabs are small, the size of Legionella samples makes for complex logistics around storage and transport— and this needs consideration in planning design.
In the meantime, as NHS England’s New Hospitals Programme1is rolled out, a new standardised hospital design has been proposed,designated ’Hospital 2.0’: “we have to consider what can be built now that will [both] cover enough of the infrastructure [and allow us to] add new tech and new innovations and new ways of working with it.”
How do the latest design trends to improve patients’experiences impact on IPC?
Roof top gardens
Mental health and mental wellbeing are increasingly, quite rightly, under discussion, particularly for long term patients who may feel trapped between their four walls. The idea ‘to bring the outdoors in’ in the form of rooftop gardens and other greenery is therefore very welcome,especially in cancer hospitals where patients can walk on grass, breathe the air, see the trees and sit amongst ‘nature’.
However, this vegetation brings infection control risks withit: soil, compost and the plants themselves may harbour pathogenic microorganisms that can be particularly dangerous for immuno-compromisedpatients. This can pose a number of challenges.
Alongside the plants, garden taps in rooftop gardens can also be problematic as they could become colonised with Pseudomonas. These outlets may be used by cleaners and porters to fill their buckets, potentially spreading contaminated water around the hospital.
"I work with the hospital IPC, estates and microbiology teams to survey and test these areas to assure no risk or harm top atients ever occurs."
With regards to 'Hospital 2.0', these changes to how hospital buildings are used will need to be reflected in the way we test and monitor patient spaces.
“As well as routine testing of outlets for bacterial contamination across our client hospitals, we also design new and innovative ways of testing, particularly if a hospital has an outbreak of something outside of the usual routine screening.My team is the only NHS-based team in the country that monitors these types of events and applies innovation and research and development to further our knowledge and expertise.
“Because we have academic interests in learning how pathogens transmit and the behaviour of both staff and patients, you build an idea of what is good and what is not.....Just because something looks clean, or has been looked after, doesn’t [necessarily] mean it is sterile.”
Wood
Wood surfaces are now being considered to enhance the patient environment, inspired by Scandinavian design in particular. Wood can have anti-microbial properties, although this is very low and the properties of different types of wood vary. Most woodis treated and coated with a varnish or resin to make it more durable, which creates a barrier between bacteria on one side and the anti-microbialproperties of the wood on the other. There are some synthetic products and coatings on the market that have some anti-microbial activity, as a means to“self clean”, but these are often trialled in a best case scenario.
If the new Hospital 2.0 standards integrate antimicrobial surfaces and coatings, these products will need to be tested and trialled robustly to ensure they provide safety to patients and healthcare providers, as there is always the scope for transmission of bacteria between surfaces via the hands of healthcare staff, patients and visitors.
Water v. waterless
There are increasing discussions about whether to reduce the number of outlets in various healthcare settings. For example, in single patient rooms, is it necessary to have a hand wash basin (HWB) in both the roomand the bathroom? Or a HWB beside each bed in a four-bed ward, as well as a clinical HWB and another HWB in the ward bathroom?
The obvious advantage of taking away water is that this removes the inherent risk that water brings in terms of waterborne pathogens.However, we do know that for patients to be able to bathe and clean themselves in a shower or bath helps their general wellbeing. The question is — how do we still allow that for them and maintain IPC? Using alcohol gels in hand-rubs isone way to disinfect some pathogens from hands, but over time these can damage the skin and the gel component of some rubs becomes a sticky coating on the hands.
We also have to think about how to maintain good infection control if we remove water, as well as how we audit and educate staff to maintain high standards. The main pathogens that need to be tackled in hospitals in the context of hand washing are P. aeruginosa and Clostridioidesdifficile. C. difficile produces robust spores that can persist for years and are resistant to alcohol, UV radiation and many disinfectants — handwashing is the primary option to remove it.
Solutions
Innovation: monitoring
In order for patients to be able to use rooftop gardens where there is an inherent risk to themselves or others, extensive monitoring with regular testing is needed to alert for risks as they happen. However, most settings do not have the budget to test more, which opens up a space for innovation, for products that monitor and detect water contamination in real time. An example would be utilisation of remote monitoring devices attached to pipe work to constantly monitor water flow and temperature.
“From a research profile, we’re always trying to engage with industry... if they have new ideas that would help healthcare... we try to scientifically trial them in wards...Without innovation, you can’t enhance orgo forward with better healthcare.”
Innovation: cleaning
We need better surfaces that are easier to clean, and we also need better products for cleaning them. And we need to develop better methods to clean the hospital surfaces effectively.
Although the cleaning and decontamination solutions from industry vary, there is a niche for automated whole-room disinfection and decontamination. For example, robots are available that can move around, scan patient rooms and calculate the optimal cleaning cycle. These automated decontamination technologies may utilise means such as hydrogen peroxide vapour (HPV) or UVC radiation to disinfect rooms. However,these have pros and cons. HPV is good at killing pathogens from heavily contaminated surfaces, but a cycle can take up to 5-6 hours of cleaning time.UVC on the other hand can kill moderate levels, but cycles are very short(minutes) and can be used to target surfaces. However, all technologies are improving and advancing.
Education
Better knowledge and support around cleaning is needed because the people who do the cleaning are often short term entry-level cleaning staff on their way to another role. Training — and empowerment allowing operatives to understand why their role is so important — are crucial to ensure cleaning products are used correctly.
Conclusion
However we build and whatever materials we use, we need to ensure that the water is safe, surfaces are easy to clean, or self-clean, and that we have good quality air.
Monitoring is the key. When we think about new hospitals, Hospital 2.0 and futuristic design, we need to start thinking of future technology alongside material innovation and routine validation, the way forward points to real time data, in-line monitoring, biosensors and real-time feedback.
References
1. www.linkedin.com/company/new-hospitalprogramme/about/
* Role of Dr Ali and the Healthcare Infection Society (HIS) insolutions to address the ‘New Hospitals’ landscape:
In his additional current role as guest editor of the Journal of Hospital Infection, a HIS journal, Dr Ali is chairing a special issue: “Infection prevention risks associated with healthcare water systems and wastewater disposal – considerations for planning of hospitals for the future”.This issue will curate high-quality original research, innovations, solutions and clinical perspectives into the planning, building and infection control aspects for future healthcare buildings.
Also in response to the NHP, ahead of the Hospital 2.0framework, Dr Ali and colleagues, in partnership with the HIS, as part of the HIS's “Water safety in healthcare” course, are developing training aimed to prepare and inform all key members of the scientific, medical, IPC and estate scommunities.