MRSA Interviews


Is the root of the current MRSA proliferation traceable to hospital design and facilities management? Elit Kane investigates.

Three Feature Articles include

1 HAI Infection Control The designer's bug HD August 2004

Is the root of the current MRSA proliferation traceable to hospital design and facilities management? Elit Kane investigates.

The hospital super-bug crisis is now worse than ever with over 700,000 patients each year picking up infections on the wards - a staggering seven times as many as previously predicted by the Department of Health.

Out of these, 20,000 cases involve Methicillin Resistant Staphylococcus Aureus (MRSA), which is three times the previous estimate. The government points its finger at hospital hygiene, particularly the washing of hands by staff. But with bloodstream infections accounting for only part of the total toll, it seems there is not enough Government focus currently on other ways in which infections can be acquired?

Majorie Nicholson at Fenchurch Environmental Group says poor ventilation systems are a common culprit in the spread of bacteria, including MRSA. "Research has established that mechanical ventilation systems not only support fungal growth but, because of their role in delivering air throughout a building, can be a major means of dispersing these micro-organisms to occupied areas." This is a severe hazard to infection control demonstrated by a case referred to by Nicholson: "Two people died of Aspergilliosis and many others where infected in a Newcastle hospital a few years back." Aspergillus, the cause of the infection, entered the hospital via open windows and ventilation systems, having been released into the atmosphere as a result of nearby demolition work.

The implication is that buildings themselves could be responsible for the growth and dispersal of organisms and in the case of hospitals, undo much of the work that is done by infection control teams. The problem continues worldwide with a recent outbreak of MRSA in Thailand, attributed to the lack of germicidal ventilation.

Breathing Easy?

The message from forward-thinking engineers is that without ventilation stratification, there is no way of isolating infection. Hospital engineer Carl Ryton suggests the use of self-adjusting air ventilation for each bed space, to filter, isolate and remove the infection. "Air stratification would isolate germs which come from the human body and move them upwards. If you have ventilation above the bed, it brings the germs back down to the public area." As the number of people in the room is increased, the ventilation must also increase in order to counteract the possible germs. The system should be able to adjust itself accordingly, and all in all this should result in a 40% reduction in infection, says Ryton.

Buildings could be responsible for the growth and dispersal of organisms and undo much of the work that is done by infection control teams

But improving ventilation systems is only part of recognising the wider design issues involved in the prevention of MRSA. The role of surfaces, arrangement of furniture and even the use of taps and door nobs can all play an influential role in the spread of bacteria. Hospitals have much more to change in terms of design according to healthcare designer Graham Cooper, who points out that private finance initiative (PFI) buildings are being built irrespective of the MRSA problem, due to the removal of potential for isolation in some areas. Cooper says: "The difficulty is that we are now producing larger scale hospitals and with that we increase the risk and rate of infection."

The answer, suggests Cooper, is to go back to earlier designs: "Wards can be isolated much more easily with the pavilion design that was used in the days of Florence Nightingale. Rooms were not built on top of each other like they are today, so if there was a problem in a particular ward you could just isolate or close it down. "We need to avoid large monolithic buildings and dissolve the hospital into a 'village cluster' - building health in the community." But taking into consideration the factor of space, time and the economic value of multi-storey hospitals, set against the tight budgets of the NHS wallet - it seems we are far from achieving such a drastic change in the time needed, despite the present risks posed by MRSA.

Don’t Touch!

Other changes, perhaps more simple to achieve, include improving circulation: "We should be reconsidering public access so that wards are serviced by two routes - one for patients and one for the public - to ensure that patients are not intermixed with possible germ areas." General tidiness can also contribute to maintaining a safer environment, in addition to design interventions such as easy-clean curved skirting.

A recent announcement from the British Cleaning Council (BCC) has also stated that luggage and belongings, plus the sheer number of visitors at each bed, is making wards harder to clean and helping to fuel the growth of MRSA. Paul Pierce, chair of the BCC said: "In the days of the matron there were strict visiting times and patients did as they where asked, allowing cleaners to get on with the job in hand. Now there is no time when a ward can be properly cleaned without interruption."

Cooper makes suggestions as to the ways in which clutter can be reduced: "Fixtures need to be reassessed and obstructions removed to make cleaning easier. Floor mounted chairs that flip up when not used would also help to meet this ends." Finally, if people refuse to wash hands after using the toilet then why not replace taps to reduce the spread of germs? "Infra-red taps and switches would enable us to take the touch element of infection away." Why stop there? Automatic toilet doors, disposable towels and infra-red toilet flushers would all do a lot to prevent the spread of infection where bacteria can thrive.

PFI buildings are being built irrespective of the MRSA problem, due to the removal of potential for isolation in some areas - Graham Cooper

Even the materials used in flooring and walls can be a major breeding ground for MRSA. Peter Mileham, managing director at wallcoverings firm Liquid Plastics, points out how infections can be combated through changing the materials used in surfaces. "We all know that dust will adhere to walls, so it seems reasonable to assume that any surface, irrespective of which plane it is in, can become contaminated. Therefore, assuming MRSA survives long enough, anyone then touching a contaminated surface will themselves become contaminated and pass the risk on to others with whom they come into physical contact with." An issue, then, that pushes hygiene to the top of the agenda, where it arguably should have been all along.

Recent plans by Health Secretary John Reid to appoint modern matrons to maintain cleanliness standards suggests a tacit admittance that hospitals have not been as clean as they should have been (although the PEAT visits have forced improvements). The increase in cleaning costs since outsourcing emerged as a model could also be a culprit, with costs rising at double the rates of general inflation, according to a recent report by the Building Cost Information Service (BCIS). So if hospitals are not spending a substantial amount of their budget on cleaning, they are likely to be getting dirtier, increasing the risk of infection, particularly if nurses continue to neglect hand washing.

The Working Environment

A different approach taken by CABE (The Commission for Architecture and the Built Environment) who, on the day the Health Secretary announced 15 new hospital development projects, urged them to consider the role and importance of hospital design as a way to improve the performance and morale of staff in the NHS, which in turn, effects their attitude to hygiene and infection control. After all, giving nurses more soap won't improve hygiene if they are demotivated - thus design can solve problems at both the staff morale level as well as the practical level when it comes to control of MRSA.

Sunand Prasad, Commissioner for CABE, said in CABE's 2003 statement on 'Healthy Hospitals': " Being involved in part of the service you are delivering is an important part of cultivating care for things like hand washing. Putting nurses in a better environment would encourage them to care more."

Addressing the design side of the problem, Darryn Kerr, chief engineer for NHS estates says that both ventilation and isolation are two of their main priorities at the moment: "Our target is to have a refreshed version of HTM2025 'Ventilation in Healthcare' available by November 2004 with the full update for spring 2006 dependent on research programmes and their outcomes. In addition we are also working on new guidance on isolation facilities".

The clinical solutions to the MRSA problem has received much work, including the appointment of infection control directors, the introduction of matrons and shortly, the use of alcohol-based rubs to make the process of hand cleansing easier. But even if the problem lies within hospital infrastructure rather than working practices, litigation will surely raise its ugly head just as high - with costly, time-consuming consequences. This together with its growing media profile will make it an issue the Government may prefer to keep swept under the mat. However hospitals themselves may have no choice but to now finally eradicate the problem using any means necessary.

2 MRSA action plan may neglect building design HD July 2004

The hospital super-bug crisis is far worse than was thought, the Department of Health (DOH) has recently admitted. Over 700,000 patients each year pick up infections on NHS wards - a staggering seven times as many as previously predicted by the DoH.

Out of these, 20,000 cases involve MRSA; three times the previous estimate. The recent announcement by the Health Protection Agency (HPA) that bloodstream infections have increased by 3.6% in England over the last year has led some to argue that infection control teams must build infection prevention into hospital design as well as clinical practice, as there are other ways of contracting MRSA than via touch.

Marjorie Nicholson, group communications manager at Fenchurch Environmental Group said that poor ventilation systems are a common culprit in the spread of bacteria: "Research has established that mechanical ventilation systems are a major means of dispersing micro organisms into occupied areas." This was recently experienced during an outbreak in a hospital in Thailand, which was attributed to the lack of a germicidal air conditioning system.

Improving ventilation systems is only part of recognising the wider design issues, according to healthcare designer, Graham Cooper, who avocated more dramatic design steps: "PFI buildings are being built irrespective of the MRSA problem simply because we have lost the art of isolation. The difficulty is that we are now producing larger-scale hospitals, increasing the rate of infection. He continued: We need to look into pavilion-style buildings with particular attention paid to circulation systems, infra-red devicesand the reduction of clutter to make cleaning easy."

Infections can also spread via surfaces, says Peter Mileham, managing director at Liquid Plastics: "We all know that dust will adhere to walls, so it seems reasonable to assume that such surfaces can be contaminated. Assuming MRSA survives long enough, anyone touching a contaminated surface will themselves be contaminated."

The DOH has announced its national target for MRSA: "(to) achieve year-on-year reductions in MRSA levels and future reductions in other hospital acquired infections", yet hospital design considerations seem noticeably absent in the recent 'action plan' released by Health Secretary John Reid for "cleaner, safer, hospitals."

Engineer Carl Ryton said the Government's response to such design risks is woefully inadquate: "The Government has no idea what spreads infection from one person to another. It's nothing to do with washing hands." He claimed: "There is no hospital in the UK that is hygienically clean, it will just keep getting worse. The only solution is to change the design criteria for hospitals altogether."

Doctors quoted by the website predicted that MRSA rates would increase. One doctor said: "All we need is for cleaners and nursing staff to be given the time to clean the wards and equipment as used to be done."

3 Superbugs new target for CABE health design campaign HD December 2003

CABE is advocating improvements in its mission to have hospital design "made a major part of the Government's campaign to combat cases of superbugs in hospitals." The organisation said in a statement that "emphasis must be placed on adequate ventilation on wards." Despite CABE's statement appearing fairly thin on technical specifics at this stage, it asserts: "design is central to both of these issues."

CABE Commissioner and leader of the Healthy Hospitals campaign Sunand Prasad, said: "we need to sort out issues of adequate ventilation on wards. The availability of fresh air at the right temperature is a critical factor in inhibiting bacterial growth. Therefore it is vital to get the design and maintenance of air handling equipment and systems right." He said that the safety of patients was a prime concern of the Healthy Hospitals programme: "It calls for improvements in the design of hospital buildings to make them safer places for staff, patients and visitors alike."

The Healthy Hospitals campaign has produced a glossy booklet that presents four concept designs for healthcare schemes by non-healthcare architects, designed to be voted on by the public on CABE's website The document also presents research, including CABE research, for example that found that 74% of nurses surveyed said the quality of hospital environments made a "significant difference when looking for a new job."

Prasad commented: "Well-designed wards are easier to maintain and CABE research show that patients get better quicker in them." He added to this that staff "need to take more ownership of their immediate environment and become more house-proud." Designer Graham Cooper was less than impressed by the Healthy Hospitals document, finding it rather limited, though he accepted its targeting nurses was worthwhile: "It's interesting as a dissemination exercise, but it's a missed opportunity. The designs are miles off target, and appear very large-scale. Solutions are not that easy, and there is nothing very specific."
A leading health architect told HD he was not concerned that CABE appeared to have deliberately avoided healthcare specialist architects, and said the impression was clear of CABE trying to get "bright young things" involved.


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