Today's hospitals are operating in an increasingly complex and challenging environment. Factors such as the weakened economy, cuts in Medicare reimbursement, and the growing uninsured population are whittling away at already paper-thin operating margins.

At the same time that hospitals are seeking ways to economize, they must make investments to improve patient care, maximize revenues, and remain competitive. Throughout the United States, hospitals are competing against each other for paying patients that are in need of the most lucrative procedures. The rise in specialty or “boutique” hospitals, the growth in capital projects, and investments in both clinical and information technologies are testaments to this trend.

Opportunity: Infection Control

Infection control presents a significant opportunity for hospitals to both reduce costs and gain a competitive edge in the marketplace. According to the Centers for Disease Control and Prevention, healthcare-associated infections (HAIs) account for an estimated 1.7 million infections and 99,000 associated deaths each year. These infections add an estimated $5 billion to the nation's annual healthcare bill.1

In an effort to reduce HAIs and enhance patient safety, Medicare has ceased reimbursing healthcare facilities for the increased costs of treating certain preventable infections.2 Compounding the issue, many private insurers have expressed their intentions of following suit. Since hospitals are now responsible for absorbing the added costs of treating these patients, it is in their best interest to reduce HAIs.

In addition to reducing costs, infection control presents the opportunity for healthcare facilities to increase revenue. With the consumer-driven healthcare movement in full swing, patients are becoming educated consumers when it comes to the care that they choose for themselves and their families.

“I received a call from a patient who was shopping around for a total hip replacement and his criteria for choosing a hospital was based on the facility's infection rates,” says Maureen Spencer, MEd, RN, Infection Control Manager at the New England Baptist Hospital in Boston. “We are seeing more educated consumers who are petrified of acquiring infections.”

Consumers also have more access to information as they “shop around”-many states have implemented, or are in the process of implementing, HAI public reporting mandates enabling consumers to view a hospital's infection rates via the Internet. As a result, facilities that implement innovative infection control practices and reduce infection rates can differentiate themselves from competing institutions and attract patients.

Challenges to effective infection prevention

Studies have shown that surfaces in healthcare facilities-from countertops to privacy curtains-serve as fomites, which are inanimate objects capable of harboring and transmitting infectious disease causing organisms, including Methicillin-resistant Staphylococcus aureus (MRSA), which is responsible for 63% of hospital-acquired staph infections.3

Recent findings on contamination of healthcare surfaces include:

  • MRSA survives for 11 days on a plastic patient chart, more than 12 days on a laminated countertop, and nine days on a cloth curtain.4

  • In an investigation of contaminated room door handles in a university hospital setting, 27% of door handles were contaminated by MRSA or methicillin-sensitive Staphylococcus aureus (MSSA).5

  • In a hospital culture survey, 42% of hospital privacy curtains were contaminated with Vancomycin-Resistant Enterococcus (VRE) and 22% with MRSA.6

Take for instance a countertop in a waiting area. Someone comes along with contaminated hands and touches it, leaving behind organisms. Then the next person comes along and touches it, and the next and the next. Every person who comes along has the potential to leave behind organisms and become contaminated with the organisms from those who have touched the countertop before them. Not only does the person who touched the countertop become contaminated, but that individual also has the potential to spread the organisms throughout the facility by touching other objects in their environment, increasing the risk of cross-contamination.7

Recently, the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) issued new guidelines that point to role of environmental surfaces in the spread of HAIs, noting: “MRSA contaminates the patient's environment (e.g., overbed tables, bed rails, furniture, sinks, and floors), and exposure to this contaminated environment has been associated with acquisition of MRSA.”3

To reduce the spread of MRSA, SHEA/IDSA urge healthcare facilities to:

  • Ensure cleaning and disinfection of equipment and the environment

  • Develop and implement protocols for cleaning and disinfecting environmental surfaces

  • Pay close attention to cleaning and disinfection of frequently touched (“high-touch”) surfaces in patient-care areas (e.g., bed rails, carts, bedside commodes, doorknobs, and faucet handles)

Drawbacks of active hygiene practices

All hospitals rely on “active” hygiene practices to prevent HAIs. While these practices-including handwashing and the use of disinfectants-are widely regarded as the most effective ways to reduce the risk of infection in the healthcare environment, HAIs continue to spread. 8,9,10

The main reason that active hygiene practices are ineffective is that they require action on the part of an individual. Healthcare workers must remember to wash their hands every time that they come in contact with a surface, but an estimated 60% of workers do not wash their hands while on the job.11 Cleaning staff must spray on disinfectants and leave the surfaces wet for the amount of time recommended by the manufacturer (anywhere between 10 and 30 seconds) in order for it to be effective, but studies have shown that routine cleaning does not always remove pathogens from contaminated surfaces.10

“We've known that dirty hands transmit disease from one patient to another for over 150 years yet we continue to do it,” says Ella S. Franklin, RN, CRC, Director of External Partnership Relations, Research and Development, ER One Institute @ Washington Hospital Center. “In addition, the microorganisms themselves have become more resistant because of the number of antibiotics that we are using. It's not only that they are in our environment, but they are also more difficult to treat.”

There is no way to actively reduce organisms on every single hospital surface at all times. Healthcare workers, patients, and visitors touch thousands of surfaces each day -light switches, door handles, faucets, patient gowns, chairs, elevator buttons, toilet seats, food service trays, pens, and so forth-so the environment will continue to be contaminated by a variety of microbes.

While healthcare facilities must continue to improve compliance with active hygiene practices since they are our first line of defense against HAIs, we must also implement new solutions that can provide secondary protection against microbes.

A silver-based solution

Healthcare facilities, designers, and architects are seeking new ways to design “passive” infection prevention measures into healthcare environments. One method that is gaining in popularity due to its efficacy, safety, versatility, and cost-effectiveness is the use of products that incorporate silver-based antimicrobials.

Real-World Examples

Hospitals across the U.S. have found ways to design silver-based antimicrobial treated products into their healthcare facilities to maintain cleaner, more hygienic environments. Some have incorporated products into existing facilities, while others have worked with architects and designers to incorporate treated surfaces into new building projects.

St. Rita's Medical Center, Lima, Ohio

St. Rita's Medical Center learned of silver-based antimicrobial treated products as they were embarking on, what they called “The Medical Center of the Future”-a $130 million expansion project that expanded the facility's campus to over 53 acres and increased its buildings by an additional 40 percent. In keeping with evidence-based design, they sought out ways that design could impact patient care, and infection control was one of their top priorities.

To determine where they could best use silver-based antimicrobial treated products, they conducted an observational study of a nursing unit to evaluate where nurses spent their time, what surfaces they touched and how often. They then collaborated with the project's architects and designers to identify products that would best meet their needs.

As a result, they've protected a variety of “high-touch surfaces” with the silver-based antimicrobial throughout their new 10-story patient tower. From the kitchen all the way through the patient rooms, all door handles, door push plates, grab bars, faucets, and faucet handles have been treated.

New England Baptist Hospital, Boston

New England Baptist Hospital (NEBH) was in the process of building a new pre-surgical holding area and recovery room when they learned of silver-based antimicrobial treated products. They proceeded to install treated doorknobs, door push plates, bathroom faucet handles, grab bars and stainless steel counters throughout the new facilities,

According to Maureen Spencer, MEd, RN, Infection Control Manager at NEBH, the decision to use the products was a “no-brainer”: “These are high-volume areas where one patient after another is sitting on the same chair and lying on the same stretcher while they wait to go into the operating room, which makes it a very conducive environment for cross-contamination,” says Spencer. “We were putting hardware into the facilities anyway, so if there was a product available to reduce microbial load why wouldn't we use it? That's the least we can do to ensure that we don't have MRSA and VRE in the environment before surgery.”

ER One Institute & Washington Hospital Center

ER One is an initiative launched by Washington Hospital Center (WHC) to design and demonstrate the concepts, features and specifications for the emergency room of the future. As part of this initiative, ER One is evaluating silver-based antimicrobial treated surfaces for the reduction of microbial contamination in the environment.

“There is valid research that says this technology decreases the bio-load on surfaces,” says Ella S. Franklin, RN, CRC, Director of External Partnership Relations, Research and Development, ER One Institute @ Washington Hospital Center. “In 2003, we launched our own trial of silver-based antimicrobial treated paint in one of our units and we still have surfaces that are cleaner than a control surface.”

Based on the success of this trial, the facility has taken the next step and designed four rooms in their extended emergency department called “the treated rooms” where they have employed an aggregate of eight different ER One compendium ideas that they believe will provide a cleaner environment for patients and staff, including the use of silver-based antimicrobial treated surfaces. These surfaces include door hardware, bathroom hardware and hand washing sink plumbing fixtures. They are currently conducting a 24-month study to determine the effectiveness of these treatments.

Studies have shown that surfaces treated with silver-based antimicrobials significantly reduce microbial contamination. A recent study published in the Journal of Hospital Infection found stainless steel surfaces coated with a silver-based antimicrobial significantly reduced Staphylococcus aureus. The researchers concluded that surfaces constructed of stainless steel with silver-based antimicrobial coatings have the potential to reduce Staphylococcus aureus rates in healthcare facilities.12

Surfaces embedded with or coated with silver-based antimicrobials provide an effective counterpoint to “active” hygiene solutions because they combat microbes 24 hours a day/7 days a week with absolutely no human intervention required. They do not take the place of handwashing and disinfectants, but serve as an additional line of protection for surfaces in between cleanings.

“While nursing units and patients' rooms get cleaned every day, there are other areas of a hospital with high-volume patient exposure that are only cleaned once a shift,” says Spencer. “Embedded antimicrobials enable us to provide added protection where we can't clean in between each patient.”

How It works

Silver has long been recognized for its antimicrobial properties. Throughout history it has been used to purify drinking water, treat medical conditions and prevent the spread of disease. When most of us think of silver in medicine, it conjures up the image of silver nitrate drops used in the eyes of newborns to prevent eye infections.

Silver-based antimicrobials are “smart” materials, which means they only release antimicrobial properties when microbes are present. When microbes come in contact with a treated surface, silver ions are released on demand to the surface of the product to kill the organism. The silver is released at a slow and steady rate, providing protection for the life of the treated product. In fact, bacteria can survive up to 20 to 40 times longer on some common materials that don't feature antimicrobial protection versus a surface treated with silver-based antimicrobials.

Let's go back to the countertop example mentioned above, but this time the countertop has been treated with a silver-based antimicrobial. Someone comes along with contaminated hands and touches it, leaving behind organisms. In this case, the silver ions in the countertop immediately begin fighting the organisms so that by the time the next person touches the surface, the level of organisms on the surface has been reduced. So instead of the countertop harboring the full load of organisms from the last five, 10, 20 people who have touched it, it is harboring - and transmitting - far less organisms, reducing the risk of cross-contamination.

Safety

Silver is known as “nature's antimicrobial” because it is a naturally occurring element. According to a leading manufacturer, silver-based antimicrobials are less toxic than table salt and less irritating than talcum powder, and they are one of the few technologies approved for food and water contact. They have even been approved for use in invasive medical devices, such as central venous catheters.

In the fight against HAIs, one of the greatest concerns that we face is antibiotic resistance, so the idea of an “antimicrobial” automatically raises red flags. But silver antimicrobials function quite differently from antibiotics-attacking and eliminating microbes in three ways: inhibiting respiration in the cell wall, inhibiting cell reproduction, and interrupting cell metabolism. This tri-modal effect reduces the possibility of “super bugs” or antibiotic-resistant strains of bacteria.

“If we can modify the patient care environment in such a way as to reduce the levels of pathogenic microorganisms, we will attack the problem of healthcare-associated infection in two ways. First, we will decrease the transmission of disease from patient to patient and caregiver to patient, and secondly, we will avoid the need for additional antibiotics by interrupting the spread of disease,” says Franklin.

Applications

Silver-based antimicrobials can be applied to virtually any surface or material that is used in a healthcare environment (table 1). For plastic or silicone surfaces and textiles (e.g., plastic countertops, light switches, upholstery, patient gowns), the silver is built into the material during the manufacturing process. For surfaces made of steel or aluminum (e.g., stainless steel countertops, faucets, door handles), the silver is applied to the finished product as a protective coating. The up-charge for the treatment is minimal; it is within the range of standard architectural/design elements. The only issue is that the range of vendors that provide these products is limited.

Silver-Based Antimicrobial Treated Products for Healthcare Facilities

Category

Product

Built In or Coated

Equipment

Touch Screens

Built in

Furniture

Armrests

Both

Furniture

Desks

Both

Hardware

Door Handles

Coated

Hardware

Door Push Plates

Coated

Hardware

Light Switches

Both

Hardware

Faucets

Coated

Hardware

Hand Railings

Both

Surfaces

Countertops

Both

Textiles

Upholstery

Built in

Textiles

Carpet

Built in

Textiles

Patient Gowns

Built in

Water Filtration

Water Hoses and Tubing Fittings

Built in

Conclusions

Infection control is crucial to both the health and safety of patients and the financial viability of healthcare facilities. Rather than reacting to pressures from regulatory agencies, private insurers and consumers, hospitals should be taking the lead to reduce infection.

While active solutions are necessary, we don't live in a perfect world with 100% compliance-and never will. There will be times when a healthcare worker forgets to wash his or her hands or doesn't fully disinfect a patient's bedrail. As we work to improve compliance with active hygienic practices, we must also seek out passive solutions that fill the gap and provide an added layer of protection for our patients. HD

Ron Connovich is the Director of Facilities & Construction Services at St. Rita's Medical Center in Lima, Ohio.

References

  1. Centers for Disease Control and Prevention
  2. Centers for Medicare & Medicaid Services
  3. Calfee DP, et al. Supplement Article: SHEA/IDSA Practice Recommendation Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:S62-S80.
  4. Huang R, Mehta S, Weed D, Price CS. Methicillin-resistant Staphylococcus aureus survival on hospital fomites. Infection Control and Hospital Epidemiology, 2006 Nov; 27 (11): 1267-9.
  5. Hosokawa S, Ole I, Kamiya A. Contamination of room door handles by methicillin-sensitive/methicillin-resistant Staphylococcus aureus. Journal of Hospital Infection, Volume 51, Issue 2, June 2002. Pages 140-143.
  6. Trillis F, Eckstein EC, Budavich R, et al. Contamination of Hospital Curtains With Healthcare-Associated Pathogens. Infect Control Hosp Epidemiol 2008; 29:1074-1076
  7. Boyce JM. Environmental contamination makes an important contribution to hospital infection. Journal of Hospital Infection, 2007 Jun; 65 Suppl 2:50-4.
  8. Doebbeling BN, Stanley GL, Sheetz CT. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. New England Journal of Medicine, 1992 Jul 9; 327(2):88-93.
  9. Guideline for Hand Hygiene in Health-Care Settings. CDC Morbidity and Mortality Weekly Report, October 25, 2002 / Vol. 51 / No. RR-16
  10. Carling PC, Von Beheren S, Kim P, Woods C. Healthcare Environmental Hygiene Study Group. Intensive care unit environmental cleaning: an evaluation in sixteen hospitals using a novel assessment tool. Journal of Hospital Infection, 2008 Jan; 68 (1): 39-44.
  11. Hand Washing: Time Well Spent. A Special to the Washington Post, August 5, 2008; Page HE05.
  12. Bright KR, Gerba CP, Rusin PA. Rapid Reduction of Staphylococcus aureus populations on stainless steel surfaces by zeolite ceramic coatings containing silver and zinc ions. Journal of Hospital Infection (2002) 52:307-309.

Healthcare Design 2009 November;9(11):46-54