The Battle Against Healthcare-associated Infections
Image credit: Jeff Swensen
A cabinet handle, a handrail, a countertop—choose your weapon. Or choose all of the weapons. Doing battle with healthcare-associated infections (HAIs) is resulting in innovative methods to combat the dastardly bugs that are attacking patients after they’re admitted to hospitals and other healthcare facilities.
Infectious pathogens, which can declare residency in healthcare facilities and lead to serious patient health issues and deaths, are claiming patient lives at an alarming rate. These dangerous pathogens can exist on surfaces or hitchhike on medical instruments. The latest annual statistics published by the Centers for Disease Control and Prevention show that there were 722,000 reported HAIs in the U.S. in 2011; there were 75,000 associated deaths. That equates to an average of 205 avoidable deaths per day, a fact garnering more media attention as providers, insurers, and health review agencies at local and national levels are realizing the magnitude of this problem.
To put HAI statistics in perspective, let’s return to the 20th century and compare these numbers to fire injuries and deaths in healthcare facilities. Combined casualties from three catastrophic fires during all of the 1900s totaled 240 deaths. Those fires spurred improvements to codes for design and construction minimum standards in hospitals and nursing homes. Now compare the 240 combined deaths of the three fires cited above to the 205 deaths per day caused by HAIs. It’s a compelling case to find more innovative ways to eradicate the bacteria and viruses causing these acute illnesses and deaths.
To compound cost premiums associated with HAIs, reimbursements from insurers are increasingly reducing payments for infections contracted during patient stays. The most notable insurer taking this action is Centers for Medicare and Medicaid Services (CMS). As of October 2008, CMS began reducing payments to providers for costly services and readmission care for specific HAIs.
Vetting products for safety
Healthcare designers, building material and product manufacturers, and equipment and furniture industries are beginning to gain traction on this front within the physical environment of healthcare settings. Infection control leadership, clinicians, central sterile, environmental services, and other ancillary support teams have an uphill battle to reduce infection rates from surgeries and clinical procedures that involve invasive catheters, respirators, and medical equipment. Where product innovators and designers can support these employees is in the physical healthcare spaces that have been documented to harbor and spread HAIs.
Architects, interior designers, engineers, and equipment planners can make a notable impact by being educated on innovative products and materials that fight HAI pathogens on the front lines. The design team and others involved in specifying healthcare materials and systems must also do their research on the extensive testing and trials these products have withstood. Such products are required to go through rigorous testing for safety to humans and the environment, as well as long-term efficacy through strenuous cleaning procedures. The most notable due diligence steps to look for are:
Reliable research of chemicals and products implemented to verify safety for the end user and general public by having independent, third-party testing labs validate chemicals or minerals used in these products.
Known labs with a reputable track record are best.
- EPA registration or FDA approval regarding human and environmental safety
- Independent third-party lab testing that validates a product’s claims
- Clinical trials with a healthcare partner that have validated HAI rates before and after implementation of the product
- Reliable references from hospitals and other owners that have implemented these products with no adverse effect to people or the environment
- Owners’ policies on antimicrobial products and possible product bans, such as the lengthy list produced by Kaiser Permanente that was updated in December 2015.
What owners and healthcare operators cannot risk is an experiment with a new antimicrobial material that could be the next generation of asbestos. Most healthcare systems have established a vetting process for allowing new products into specifications for their facilities.
David Pone, system director of facilities operations for Riverside Health System in Newport News, Va., says, “I want the answer to these questions when we’re reviewing new products for our building finishes, maintenance products, or cleaning products: (1) Does the product actually do what the company claims it does? (2) Does the product maintain its efficacy long-term? and (3) What cleaning products or chemicals should not be used on this product that can negate its performance?”
When it comes to providing safety to the public and environment on his system’s medical campuses, Pone says that a product’s EPA registration for antimicrobial benefits is an essential prerequisite. “We accept the EPA registration credentials as a key part of our overall vetting process. I, however, want to see the supporting documentation of this registration. We will verify this ourselves before allowing new products—whether they’re finishes, equipment, or new cleaning products—in our buildings,” he says.
The case for copper
After lengthy research and independent lab testing, the antimicrobial copper industry was given the green light in March 2008 by the EPA to officially promote copper and certain copper alloys as proven antimicrobial materials. Antimicrobial copper and copper alloys, such as brass, bronze, and zinc, are available in a range of products for high-touch surfaces that include door and plumbing hardware, cabinet pulls, bed rails, grab bars, IV poles, computer keyboards, and over-bed tables.
Solid copper may present cost limitations for larger surfaces or may not be the preferred metallic color of choice for overall interior theming. The industry’s response to cost concerns has been to develop an assortment of copper alloys that have at least 58 percent of copper content for accomplishing the same long-term efficacy of continual microbe kill rates at 99.9 percent.
There are a number of healthcare-grade copper products from the hardware, plumbing, toiletry dispenser, medical equipment, and furniture industries that are now more affordable than when first introduced to the market.
A modest investment of $1,000 to $1,500 per patient room or exam room can fund an upgrade of door levers, cabinet and drawer pulls, and sink handles for these most frequently touched surfaces. A more robust outfitting of patient rooms can run $7,700 to $15,000 per room, according to the Copper Development Association Inc. Its business case for a 420-bed facility, fully outfitted with antimicrobial copper on high-touch surfaces, projects a payback in less than a year. This is based upon the projected reduction of HAIs in a hypothetical facility that uses national averages of HAI incidents.
An independent study done by the Medical University of South Carolina confirmed that use of antimicrobial copper surfaces reduced the microbial burden by 83 percent on the six most highly touched surfaces.
The 43-month study concluded that “use of copper surfaces on commonly touched objects could provide a substantially safer environment.” One of the lead researchers, Michael Schmidt, further stated that “given that the average hospital-acquired infection in the U.S. conservatively adds an additional 19 days of hospitalization and $43,000 in costs, the use of antimicrobial copper surfaces warrants further study and optimization.”
Integrating metals into non-metallic surfaces
Copper oxide, also referred to as cuprous oxide, warrants its own category. This product is produced by a heating process combined with a chemical mixing procedure. One company has developed the use of copper oxide, which is mixed a minimum of 16 percent into product options, to use in high-touch surfaces to kill HAI pathogens, including mold and mildew. By integrating copper oxide into the base material of solid surfaces and plastic injection-molded products, copper oxide provides the pathogen-killer for high-touch surfaces where metallic surfaces may not be preferred. Product options include solid surface countertops, integral sink fixtures, shower pans, wall panels in clinical work zones, bedside tabletops, and over-bed tables.
Injection-molded plastic with copper oxide is used for such items as bed-rail covers, exam or patient chair arms, and corridor handrails. The injection-molded options have allowed healthcare facilities to retrofit existing patient rooms and furnishings independent of more costly room renovations and demolition-intensive projects. The cost premium is approximately $40 per square foot of surface. To outfit a patient room at the most highly touched surfaces can cost around $4,000 per room. Relative to the return on investment (ROI), the first HAI prevented will have paid for outfitting multiple rooms in avoided costs to the owner.
Silver and silver ions have been incorporated in a wide array of products, ranging from solid-surface counters and shower stalls to coatings in bandages. Small amounts of silver have been used in fabrics for cubicle curtains, hospital scrubs, and bed linens. Silver is a proven antimicrobial. It’s typically a more affordable heavy metal option compared with copper, because a smaller amount of content is effective.
There are concerns, however, that have been identified with some silver-based products that should be carefully vetted. One concern is the potential for the silver, as an additive, to leach out of the fabric or in products when used as a coating. If leaching occurs, the long-range efficacy will diminish with each washing cycle, which, in turn, can affect the environment.
Advancing the cause
A more recent breakthrough is an antimicrobial paint that was introduced to the public in February 2016. Paint is the most widely used finish for healthcare facility walls and is often used on trim, doors, and nonporous hard ceilings. The new paint product, with an EPA registration, employs a quaternary ammonium compound as its active ingredient and, according to lab tests, inhibits growth of common microbes and has the power to kill bacteria including staph, MRSA, and E. coli.
While not a common application in fixed lighting within healthcare facilities, due to the potential impact to humans, ultraviolet (UV) lighting is becoming a popular environmental services (EVS) weapon for the post-occupancy cleaning arsenals. There’s a wide range of UV lighting products that includes sanitizing robots; portable, handheld UV wand devices; fixed lights in trash receptacles; and even fixed UV lighting to kill airborne pathogens in supply air ducts.
Another innovative advancement for healthcare waste management is the pneumatic tube soiled linen and trash removal systems. This is a mechanized alternative to EVS staff pushing trash and linen carts to the loading dock. These systems’ contribution to reducing infectious pathogens in healthcare facilities is multi-fold.
According to Tim Keenan, administrative director of support services at St.
Anthony Hospital (Lakewood, Colo.), the pneumatic trash and soiled linen removal system installed in the facility has shown an impressive ROI with operational savings: approximately $5,000 per month in lease/usage fees versus the cost of approximately 2.5 full-time equivalents (used to designate a full-time employee’s typical work week) per month. The hospital will own this system after a 10-year lease payback plan. At that point, the operational savings will further increase, and only maintenance fees will apply.
As part of the overall plan to reduce infectious pathogens in the hospital, Keenan says, the spread of germs is contained to fewer locations with fewer people touching the soiled linen and trash. The use of this system also reduces odors on the units.
Ideally, healthcare facilities are clean, safe places where medical interventions and healing take place for the sick and ailing rather than battlefields for HAIs. With continual advancements in technologies and developments of safe and reliable antimicrobial products, there is light pouring into the infectious pathogen tunnel.
Sam W. Burnette, AIA, EDAC, is senior designer/principal at ESa (Earl Swensson Associates; Nashville, Tenn.). He can be reached at firstname.lastname@example.org.