Infection Control Primer, Part I

Posted on May 9, 2013


If you start a discussion about infection control with a hospital administrator, hand washing is likely to come up—and hand washing is a proven method for clinical cleanliness.  However, from a design standpoint, hand washing is a micro-level tactic to combat the 900-pound gorilla that is infection prevention.  There are macro-level strategies that, if not employed, all the hand sanitizer in the world cannot make up for.

Infection control is intimidating, and I am by no means a germ expert.  As an architect, I am very attuned to hospital acquired infections (HAIs) and their impact on hospital reputations and financial performance.

When I was in school, I worked banquets in a hotel which was the premier place in town for wedding receptions, class reunions and Rotary functions.  We had the unfortunate luck of a small food poisoning situation.  It was quite a learning experience to see the Health Department pick the kitchen apart—before everything was thrown away and every square inch steam-cleaned.  The event wrecked our reputation and business for quite a while which, in effect, ended my summer job.  HAIs can have a worse impact on hospitals.

HAIs are a big, expensive deal, and should be tackled with as many checks-and-balances and safety redundancy as possible.  Codes and healthcare design guidelines provide a lot of direction, but let me illustrate, as simply and in as common language as possible, how I think about, and design to control infection.

Where Germs Are:  Things to Pay Attention To – Hospitals & Architects

  1. Surfaces Touched by Dirty Things.  Hands, feet, clothes, and the general public are considered sources of dirt and germs.  Wherever these go, germs go.  Make smart decisions about materials and areas that come into contact with hands, shoes and visitors:  admissions counters, windows, light switches and door hardware—things that may not get wiped down every day.  Furniture (waiting rooms and offices) and equipment (computer keyboards, remote controls or refrigerators in patient rooms) also harbor germs.
  2. Horizontal Surfaces.  The big ones to pay attention to are floors and shelves.  Shoes are dirty.  Shoes go almost everywhere in a hospital, so floors are filthy.  They need designed for frequent, easy and rapid cleaning.  Shelves, especially in storage areas, collect dust.  Dust collectors are a no-no in healthcare design.  Any crud in the air that does not land on something ends up on the floor.  Think about and minimize equipment (tvs, monitors), counters, storage—anything that does not often get cleaned and could hold dust and dirt.
  3. Systems Design.  Water and air are very necessary in a hospital.  Water and air can also transport bacteria, germs, mold, particulates very efficiently.  Plumbing and HVAC systems must be designed with appropriate filtration, temperature and humidity control, and chemical cleaning in place to avoid entire populations from being negatively affected.  How clean are the A/C grills and heating ducts in your own home, and you have 25?  A hospital may have 500.

Now that we know where the big culprits are for harboring germs, let’s look at five strategies to help avoid infection control problems.

Infection Control Prevention Strategies:

  1. Separation.  As effectively as possible, I use design to separate five things:  public from private; clean from soiled; food from everything else; weak patient populations from everyone else; and sterile from everything else.  For clarity, weak populations generally include children, elderly, and the immune-compromised (high acuity, cancer, post-surgery).  Separation means dedicated, and sometimes duplicated, spaces for each:  elevators, corridors, holding rooms, preparation areas.
  2. Smart Operations.  This is business operations, not surgery we’re talking about.  Careful thought must be given to the process flow, circulation, transportation, storage and cleaning of items, and how those intersect with care giving.  This is where Lean and Six Sigma come in.  If the clinical care is delivered in a way that frustrates separation, or makes effective cleaning impossible, little else matters.
  3. Clean / Sterilize.  Everything that can be cleaned in a hospital must be cleaned as often as possible.  Germs need to be eliminated, not merely moved around or worse, spread.  In departments, autoclaves, ultraviolet, chemical and steam.  Central sterile, instrument cleaning and surgical packing are key.  Technologies are advancing to where entire rooms can be cleaned by a UV laser.  High-traffic surfaces need attention every day.  And likewise in the kitchen, coffee bars and cafes—anywhere food is produced, housed or distributed.
  4. Design Detailing.  Utilize maintenance and cleaning-friendly details like coves and sloped surfaces.  Create the smoothest surfaces with the fewest seams possible.
  5. Materials Selection.  Selection of the most appropriate materials is important, which includes wall surfaces.  Material science advances have provided functional and attractive anti-microbial fabric options.  High-touch items like faucets and light switch cover plates incorporate anti-microbial metals into their manufacturing.  Specify heavy-duty, abuse and impact-resistant materials where appropriate.  Some surfaces get used hard; some surfaces get cleaned hard; some get both.

These five items work in concert; they are not either / or choices.  Without smart materials selection, detailing is virtually irrelevant.  If things are not cleaned and sterilized religiously, internal clinical management cannot do much.  If separation is not designed in, all the cleaning in the world will not save a hospital.


Where Germs Are:  Things to Pay Attention To – Hospitals & Builders