The focus on patient safety and the magnitude of healthcare-acquired infections (HAIs) demand that design professionals become well versed in knowing where risks occur, how they occur, and what they can do to reduce or minimize them. For many years, the primary goal has been to reduce the institutional appearance of hospitals—to make them less threatening through the careful selection of interior finish materials; the use of furniture with wooden frames and woven upholstery fabrics (as opposed to vinyl); and the introduction of texture, water features, artwork, and vibrant color. Materials selected for this purpose have to meet fire codes and be durable and easy to clean.

Since such an array of products that meet these general requirements is available, designers have usually not had to go beyond the specifications and manufacturers' printed literature to feel confident in their selections. Occasionally a call to the technical department about whether one product versus another is the best choice for a given situation is required. For example, hospitals often have moisture problems associated with both on-grade concrete slabs and below-grade slabs. This results in problems with many types of resilient flooring, which can lead to substantial risk—and possible litigation—for contractors, architects, and designers.

The situation today is quite different. The goal for design professionals needs to be enhancing patient safety; however, designers cannot necessarily rely on manufacturers' claims and recommendations as in the past because new environmental threats exist. The study by Lankford, et al. (2007), summarized by Leib and Rohde (2007), points out that manufacturers are sometimes out of touch with the cleaning agents and methods actually used by hospitals and that manufacturers' recommended cleaning processes may not result in eradicating pathogens. Nor can designers rely on an antimicrobial label to feel confident that these products will prevent the growth of pathogens (disease-causing germs).

The antimicrobial controversy

There is considerable ongoing debate about the appropriateness and effectiveness of products enhanced with antimicrobial properties for use in hospitals. Types of products currently being marketed include paint, upholstery and cubicle drape fabrics, ceiling tile, patient gowns, door handles, solid-surface material (used for countertops), as well as coating that can be applied to a variety of surfaces. Carpet with antimicrobial preservative has been available for a number of years. The debate or discussion is occurring between infection control specialists, microbiologists, and hospital facility managers who want to know whether such products are effective, safe, and worth the additional cost. Certainly, the ideal would be a variety of products that extinguish pathogens on contact. This would do much to solve the current infection-control crisis in hospitals, at least in terms of pathogens transmitted from environmental surfaces by contact. So kudos to manufacturers for trying to make this work.

The issue, however, is that antimicrobial agents come under the jurisdiction of the Environmental Protection Agency (EPA) Federal Insecticide, Fungicide, and Rodenticide Act, as opposed to public health products such as antiseptics and germicides, sterilizers, disinfectants, and other sanitizers also regulated by the EPA and the Food and Drug Administration.

The EPA requires data to support claims of efficacy against specific microorganisms as well as labeling that details the safe and effective use and also hazards associated with the product. Manufacturers are prohibited from making a public health claim for any product unless it has been approved and registered by the EPA or is exempt from registration (Kaiser Permanente 2006).