Combating Healthcare Risks

Healthcare Spaces – Safety

As healthcare facilities grapple with the daunting challenges posed by healthcare-associated infections (HAIs) and antimicrobial resistance (AMR), controlled environments go a long way in enhancing patient safety…..

By Dr Lallu Joseph

The complexity and inherent risks of healthcare settings demand meticulous attention to controlled environments. These environments have a critical role of in enhancing patient safety, mitigating healthcare-associated infections (HAIs), which are infections acquired during the process of receiving healthcare treatment, and combating antimicrobial resistance (AMR), the ability of microorganisms to resist antimicrobial treatments.

Healthcare facilities are battlegrounds against disease, but they also pose significant risks. The World Health Organisation (WHO) sheds light on this paradox, estimating that 1 in 10 patients in developed countries experience harm while receiving care. In the US, the Agency for Healthcare Research and Quality (AHRQ) reported harm to patients at a rate of 25.1 per 100 admissions in 2013. Furthermore, the Institute for Healthcare Improvement (IHI) reveals that medical errors are the third leading cause of death in the US, trailing only cancer and heart disease.

Controlled environments within healthcare facilities are designed to mitigate the risks associated with HAIs and AMR. These environments regulate temperature, humidity, air pressure, and quality to create optimal conditions for patient care and recovery.

HAIs epitomise the risks within healthcare facilities. Defined as infections acquired during the process of receiving healthcare treatment, HAIs have devastating consequences, including prolonged hospital stays, increased healthcare costs, lost wages, and death. The Centres for Disease Control and Prevention (CDC) estimates that HAIs cost over ten billion dollars annually in the US alone. The global scale of HAIs is staggering, with millions affected each year, highlighting that no healthcare system is immune.

The threat of AMR is magnified within the context of HAIs. In 2019, the WHO identified AMR as a top global health threat, exacerbated by the COVID-19 pandemic through the overuse of antibiotics and disruptions to infection control practices. AMR causes 1.27 million direct deaths per year and is associated with 4.95 million deaths annually. Significantly, AMR disproportionately affects children under five, underscoring the urgent need for effective infection prevention and control measures in healthcare settings.

The Crucial Role of Controlled Environments
Controlled environments within healthcare facilities are designed to mitigate the risks associated with HAIs and AMR. These environments regulate temperature, humidity, air pressure, and quality to create optimal conditions for patient care and recovery. For example, burn units require temperature controls up to 32°C and relative humidity up to 95% to facilitate patient recovery. Ventilation and filtration systems are tailored to specific needs, including the prevention of air-borne microorganisms and hazardous substances, through the use of pre-filters, fine filters, and HEPA filters.

The creation of controlled environments demands a collaborative approach involving healthcare providers, architects, designers, and facility managers from the early design phase. This proactive strategy not only enhances patient safety and satisfaction but also reduces long-term operational costs. The Infection Control Risk Assessment (ICRA) process is central to this effort, involving a comprehensive assessment of potential hazards and the implementation of design and operational strategies to mitigate infection risks.

The ICRA process encompasses several critical steps, including the identification of hazards, assessment of who might be harmed and how, evaluation of risks, and the development of action plans. This interdisciplinary effort ensures that healthcare facilities are designed with optimal infection control measures in place, from ventilation systems to the layout of patient care areas.

Guidelines and Standards for the Design and Operation of Key Areas/ Activities:

Central Sterile Supply Department (CSSD): It’s critical in ensuring the sterility of surgical instruments and equipment. The CSSD operations are divided into decontamination, assembly, and sterile processing stages. The use of ethylene oxide (ETO) gas sterilisers, which require special handling of ETO gas to prevent exposure, highlights the need for dedicated spaces with direct exhaust systems to safely manage and dispose of ETO gas and its by-products.

Intensive care units (ICUs) and isolation rooms are given particular attention, with recommendations for air pressure, filtration, and room design tailored to the needs of critically ill or infectious patients.

Air Quality and Pressure in Different Hospital Zones: The guidelines specify the use of pre-filters, bag filters, and HEPA filters in the air handling units (AHUs) to remove particles of varying sizes from the air, significantly reducing the risk of airborne transmission of infections. Different zones within the hospital are maintained at varying air pressures (negative, neutral, or positive) depending on the function of the area and the vulnerability of patients to infections. For example, positive pressure is used in rooms for immunocompromised patients to protect them from airborne pathogens, while negative pressure is utilised in areas where containment of infectious agents is critical.

Room Design and Material Specifications: The layout and materials used in patient care areas are meticulously specified to facilitate cleaning and minimise infection risks. Surfaces in high-risk areas have to be smooth, impermeable, and seamless to prevent the accumulation of dust, germs, and moisture. The use of cavity sliding doors is discouraged in clinical areas due to the challenges in maintaining a sterile environment. Similarly, specifications for flooring, walls, and ceilings are provided to ensure they are easy to clean and maintain, further reducing the risk of infection.

Flow of Patients, Personnel, and Materials: Unidirectional flow is recommended in operating rooms (ORs), the CSSD, and laundry areas to minimise cross-contamination. The arrangement of wards and the placement of beds are designed to support the segregation of clean and dirty areas, enhancing the overall hygiene and safety of the environment.

Waste Management and Environmental Controls: Guidelines for the management of medical and regular waste include the segregation of clean materials from waste removal and specific recommendations for the storage and handling of waste to avoid contamination.
Special Considerations for ICUs and Isolation Rooms: Intensive care units (ICUs) and isolation rooms are given particular attention, with recommendations for air pressure, filtration, and room design tailored to the needs of critically ill or infectious patients. The aim is to provide safe, controlled environments that protect both patients and healthcare workers from the transmission of infectious agents.
These guidelines reflect a comprehensive approach to hospital design and operation, prioritising patient safety, infection control, and the creation of a healing environment that minimises the risk of Surgical Site Infections (SSIs) and the transmission of infectious diseases.

Summing Up
The imperative for controlled environments in healthcare spaces is clear. As healthcare facilities grapple with the dual challenges of HAIs and AMR, the importance of meticulously designed and maintained controlled environments cannot be overstated. These environments are essential not only for patient safety and recovery but also for the overall efficacy and sustainability of healthcare systems worldwide. Through continuous innovation, collaboration, and adherence to best practices in design and operation, healthcare facilities can significantly reduce the risks associated with care delivery and pave the way for safer, more effective healthcare solutions.

(The author is Executive Director, Sree Renga Hospital, Chengalpattu, TN, India |Board Member, ISQua | Board Member, ASQua and Principal Assessor, NABH | Chair – Quality Professionals Wing, CAHO)