The Environment Network – Designing and Building for Infection Prevention by Elise Maynard

Event write up from 8th October 2021 meeting, Goodenough College, London

The event was opened by Dr Elaine Cloutman-Green who explained about the aims and objectives of the Environment Network.  It covers both water and air healthcare based testing and monitoring, environmental audit, surface testing and decontamination.  The network is self-funded and run by a group of dedicated volunteers.

Infection prevention and the built environment: The Good, the Bad(Time Consuming) and the Ugly. Dr John Hartley, Great Ormond Street Hospital.

The Good – providing a built environment that promotes infection prevention, promoting patient and staff safety and comfort and minimising costs.

The Bad (time consuming) – lack of knowledge and resources, getting competent contractors, commissioning, maintenance and training.

The Ugly – the consequences of failure e.g. infection, reputation, stress.

John then explained these in relation to a positive pressure ventilated lobby – the resources to facilitate these is enormous and if they fail, the consequences are immensely costly and disruptive.

Dr John Hartley

Building a new hospital – complications and lessons learnt. Dr Christine Peters, Queen Elizabeth University Hospital.

Christine is a Clinical Microbiologist and she explained about the impressive £800 million new hospital in Glasgow.  There were initial problems with ventilation in the bone marrow transplant unit and further problems have led to an ongoing inquiry.  There is a fresh opportunity to improve practice and design. The infection control and microbiology departments had not been involved in any of the designs – not even for the infectious disease unit.  She described a number of areas which were not compliant:

  • The dialysis unit water points were not fed from a specialist supply.
  • The BMT unit did not have protective isolation provided.
  • Theatres had shared preparation rooms with reversed ventilation and the doors were not closing properly.
  • Sinks were near the patients’ heads in the anaesthetic rooms.

Water taps were stripped and cultured and found to be highly contaminated.  A Legionella risk assessment undertaken prior to the hospital opening had found numerous issues e.g.  dishwashers were plumbed incorrectly and when removed, left dead-legs.  Drainage was equally horrendous and items such as syringes were found in the U bends.

The air handling units had water systems attached which leaked and were also liable to condensation.  Other issues were poorly fitted flooring, non-compliant sinks, pigeons in the plant room, fungi in the water tanks etc. etc.

Christine queried as to where learning is communicated, what about root cause analysis?  Commissioning/Validation needs clinical teams involved, with sufficient time and resource and clear handover systems.  Derogations also need clear definitions as they can be used inappropriately.

Dr Christine Peters

What to do with your environment when re-design is not an option? Martin Kiernan, University of West London.

We have relied on old knowledge for too long!  Martin discussed ventilation and how to improve it – learning is still not being implemented even at this stage of COVID-19 learning:

  • CO2 meters are useful.
  • Air filters may help reduce microbial contamination.
  • There are not enough isolation facilities, and unlikely that there is sufficient room.
  • Screens may have an effect against droplets, but good ventilation is far more important.
  • There is evidence to demonstrate that full length curtains may assist.

The risk from water has been well know for many years, linked to poor design. Martin asked whether washbasins and sinks always required?  Splashing is a known risk and poor drainage is common. Human activity is key in the use of washbasins, such as; poor handwashing, cleaning items, draining bags, disposing beverages etc.  He asked how can improvements be made, are items cleanable?  How should they be cleaned and are the components compatible? Can we prepare a patient zone safely?  Equipment cleaning knowledge is poor but we can communicate better and learn from others – measure whether cleaning and other interventions work as consistency of cleaning is intermittent.

Martin Kiernan

Staphylococcus capitis, the new kid on the environmental block? Dr Derren Ready, UK Health Security Agency

This is a Gram-positive coagulase negative coccus, neonates are particularly susceptible and there has been a recent increase in incidence.  There have been sporadic outbreaks since the 1990’s but it took hold in 2012 in France and is resistant to many antibiotics, it has since spread worldwide.  There is  a need to determine an environmental sampling framework and share lessons learned from decontamination practices amongst neonatal units.

Derren described some methods which are currently under development and the preliminary efficacy data.  Neonatal incubator designs are not conducive to thorough cleaning and Derren showed images of visible contamination.  Positive samples were also found on a stethoscope, incubators, handles, blanket and an equipment trolley recess as well as a milk warmer, computer mouse and monitor control knob.  Similar results have recently been obtained from a different hospital site.  Derren explained that the data is very preliminary but it is already clear that it is very difficult to disinfect equipment and procedures need to be optimised.

Dr Derren Ready

How do risk assessment and governance support new build safety? Elise Maynard, Elise Maynard Associates LLP.

Elise discussed the various Legislative and guidance documents which are applicable to water safety for all buildings and how they should be applied at the design and concept stages especially for new healthcare buildings – this should include any CQC registered facility, including primary care and dental facilities.  She advised that there a number of new British Standards which have been written by a team who are actively involved in water management – these include:

  • BS 8680:2020     Water quality. Water Safety Plans. Code of Practice
  • BS 8580-1:2019 Water quality, risk assessments for Legionella control. Code of practice.

And due to be released early 2022:

  • BS 8580-2           Water quality, risk assessments for Pseudomonas aeruginosa and other waterborne pathogens. Code of practice.
  • BS 7592               Sampling for Legionella bacteria in water systems – Code of practice (revision).

The process of risk assessment and the associated hierarchy of control is to remove or minimise the likelihood of harm.  Elise showed examples of Contamination, Amplification, Transmission, Exposure and Susceptibility within new build designs and explained the costs of getting this wrong.

Elise Maynard

What role does education play in supporting infection prevention and control teams in managing the built environment? Dr Lena Ciric, University College London.

Lena is an Associate Professor in Environmental Engineering.  The environment includes air, water and surfaces and environmental cleaning should remove pathogens, but how is this defined?  She advised that disinfectants may not always get to all surfaces and many cleaning staff feel undervalued and under-resourced and are not told why they are performing tasks.  Monitoring cleaning can be done visually or by more sensitive detection methods including microbiological monitoring.  Air and water are more complex and often require estates involvement, there is often a disconnect in design and use, changes over the years and out of date schematics.

She described a study at GOSH where they mimicked contamination onto a bedrail and subsequently sampled 44 surfaces for a week.  The data showed widespread transmission with evidence of cleaning and re-inoculation, the clinical areas being worst.  This evidence was used to educate the staff in a very visual manner.  She advised to teach people “Why?” and relate it to their tasks and job environment.  Infection control is everyone’s task and it requires a holistic approach including collaboration.

Elaine closed the meeting by explaining the plans for 2022:

  • Secure funding for next year’s meeting
  • Membership survey
  • Launch the website
  • Recruit further stakeholders for the committee
  • Inputting into strategic groups

She also recommended an excellent course – Building Blocks for Clinicians, which will help you get the building you need for your patients and staff. They have an expert faculty including architects, construction professionals, built environment academics and clinicians.   The course runs over 2 days and is fun and interactive.   The pandemic has clearly demonstrated the value of clinician lead design. They will give you the tools to put this into practice. 

All the talks and case discussion frameworks will be uploaded shortly, followed by some videos of the speaker sessions where available

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