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Barbara J. Huelat: Healing Our Healthcare

Cleanable Benefits that Matter
By Barbara J. Huelat, FASID, AAHID, EDAC, IIDA

We expect a healthcare environment to be a safe place where we can receive diagnosis, therapy, surgery and medicine that will improve our health outcomes. This is where we go when we, or our loved ones, are sick and in need of healing. These places of healing must meet this expectation of being [safe].

Safe healthcare places and spaces is not a new concept. Florence Nightingale, the founder of modern nursing who served in the Crimean War, wrote, "It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm." She gave specific advice about materials that would promote cleanliness: "The best wall for a sick-room or ward that could be made is pure white non-absorbent cement or glass, or glazed tiles..." ("Notes on Hospitals," 1863 edition.)

This principle of "first, do no harm," goes back even farther in time to Hippocrates, who is often called the father of medicine. He advised his fellow physicians to "have two special objects in view with regard to disease, namely, to do good or to do no harm." ("Of the Epidemics," 400 B.C.E)

So, before healing can begin, we must mitigate harm. We must ask, are our healthcare facilities safe? Can these environments cause harm? And most importantly for a designer's role in healthcare design, can design improve safety? Can design truly create healing environments?

Design has played a major role in changing the look of today's hospitals. Articles about new facilities and design fill magazines and celebrate beautiful atrium, comfortable furnishings, delightful patterns, sculpture and art that create inviting spaces. But are they safe and how clean are they?

Today one of healthcare facilities' major concerns is "hospital-acquired infections" or "healthcare-associated infections." "Healthcare-associated infections (HAIs) are infections that patients acquire during the course of receiving healthcare treatment for other conditions," according to the Centers for Disease Control and Prevention (CDC) definition.

These infections are caused by ugly bugs that lurk in the crevices of beautiful materials throughout the facility. They come by air, droplets and direct contact. They are spread from person to person, hitching a ride on hands, shoes and equipment that is carried from place to place. Keeping a facility clean is a serious and growing problem for those who manage the risks of [Infection Control]. Consider the following facts regarding the safety of our healthcare environments.

• World Health Organization estimates more than 1.4 million people worldwide are impacted by infections in hospitals.
• Cleaning, disinfection and sterilization saves lives and improves patient outcomes.
• Between 5 -10% of patients in the developed world acquire one or more healthcare-associated infections.
• CDC estimates approximately 1.7 million healthcare-associated infections occur annually in U.S. hospitals and are a factor in nearly 100,000 deaths each year.
• Healthcare-associated infections are found in hospitals, extended care facilities, nursing homes and rehab centers.
• Pathogens transmission occurs via hands of healthcare workers who are inadvertently contaminated during patient care activities.
Contaminated surfaces are sources of pathogens that contaminate workers' hands.
• Providing patients with a safe environment requires a high level of compliance with hygiene policies, cleaning, disinfection of medical equipment, specification of cleanable environmental surface and good design.

Healthcare institutions deploy armies of "environmental services" (ES) personal to irradiate bacteria that pose a threat to patients, residents and other occupants. Today's environmental services staff uses evidence-based cleaning practices that integrate a systems approach cleaning protocol for both terminal cleaning and spot cleaning. This approach reduces contaminates up to 63 percent when following the Centers for Disease Control checklist for the systems approach for terminal cleaning. However, despite rigorous hygienic protocol, hospital-acquired infections continue to result in a significant loss of life and cost the U.S. healthcare system an estimated $45 billion annually.

Design can contribute to a [clean] healthcare environment in four primary areas:
• Material Specification
• Material Details
• Lighting
• Human Factor

What makes a material selection appropriate for a clean healthcare environment? Ideal surface materials for cleaning are those that are smooth, non-porous, homogenous, and seamless. In addition, we want them to be durable, cost effective, easy to maintain and, of course, beautiful. Surface materials must be specified as appropriate to the functional use of the area. For example, the surface material of a wood wall as used in a public space may not be appropriate in a patient care area. Likewise, a homogenous sheet vinyl specified for a surgical suite may not be appropriate for a patient room.

Few materials meet all these criteria; therefore it is the designer's challenge and responsibility to specify appropriate surface materials for specific locations and functional criteria. Paramount in designing for functional criteria is the risk of HIAs. In areas where the patient or resident are physically compromised, the risks are much greater. These areas include ICU, immune suppressed patient care areas, medical surgical patient spaces, dialysis, infusion, and places where there are populations of the very young, frail or elderly. High-risk areas require a greater attention to the specification of highly cleanable surface materials.

Environmental Services' cleaning protocol has identified several unique areas where bacteria growth is a concern. ES refers to these special areas as "high-touch" areas which require special cleaning attention. These areas have been identified in evidence-based studies of contamination swabs - cultures identified "hot spots" where bacteria was prevalent. ES has identified front and sides of beds, sinks with surround, TV remotes, phone cradles, nurse call devices, tabletops, bedside tables, over-the-bed tables, doorknobs, drawer interiors, cabinet hardware, handrails, wall areas around wall-mounted equipment, light switches and armchair covers. These high-touch areas also require special attention by designers to make appropriate material selection. High-touch areas need to be non-porous, seamless, homogenous and easy to clean.

Appropriate material selection in high-risk and high-touch areas does not totally satisfy the design responsibility. The transition, termination and the joining of materials must support ES cleaning protocol. This is where design detailing comes into play. A beautiful solid-surface seamless wall must also have a smooth transition to the floor base to successfully mitigate bacteria. Likewise, a seamless floor must have a seamless transition to adjoining floors and wall base.

The joining and transition of surface materials is the likely area where soil and bacteria will settle. It can also be an extremely difficult area to clean. Cleaning equipment and even mop cleaning may move soil and even grind particles into any open crevice. Transitions between materials are often of slightly different heights which can leave an open gap. Gaps much like seams should be eliminated in high risk and high touch areas. This is an important area for designers to detail integral cove base and welded seam between flooring materials.

Transitions between wall and floor materials are a bit more challenging. The vastly different composition of surface materials makes integral seaming more difficult, often resulting in caulking the seams and joints. Most caulking is considered a temporary application that needs ongoing inspection to confirm that the joint is still properly sealed.

Sinks and the surrounds are both a high-risk and high-touch challenge. Bacterial growth has been linked to these wet areas for many years. In the past plastic laminate countertops, drop in rimmed sinks, with separate cut backsplash was standard. This type of design has been linked to mold and bacterial growth. Today's standard is solid-surface that is seamless with integral bowl sinks and post form backsplash to eliminate any possible crevice for bacteria to grow. This detail along with touch-free faucets has greatly mitigated bacterial risk from wet areas.

Functional and task lighting is essential for clean design. The very base of cleaning protocol of the healthcare environment is to support the ES team with good visibility of spaces and places that require cleaning. The team must be able to easily see and identify soiled areas.

Task lighting must be located at the cleaning site, especially in wet areas and other high-risk areas. Task lighting varies from area to area, and the designer needs to follow the guideline for appropriate light levels that support the function and the ambiance as well as the light levels for cleaning the area. These are typically two different lighting levels. As healthcare environments must be designed to be non- institutional as possible and yet still provide staff the ability to perform complex visual activities, lighting is a prescriptive solution that fulfills both the functional and aesthetic criteria.

Design that integrates human engineering of good ergonomics supports successful cleaning outcomes by ES staff. For example, high-touch areas should be located within the standard reach of the ES staff. In addition, design must also support the cognitive function of cleaning. It must look and be obvious and intuitive. Therefore high-touch areas need to be clearly identified, well designed, well lighted, without crevices, without open seams, and without acute angles which make it difficult to penetrate with standard cleaning equipment. Meeting these criteria makes it obvious and intuitive to be clean.

Human factor combines all four areas which impact design for cleaning. A successful case study example for ER One at MedStar Washington Hospital has combined these factors to produce improved outcomes in bacteria mitigation, patient satisfaction, staff satisfaction, and business case.

The material specification featured environmental surface material, solid surface.  This product was carefully specified for the properties of ease of cleaning, non-porous composition, and seamless abilities, the elasticity of the product to mold and bend, aesthetics and compatibility to seam with other materials.  These product capabilities made the material ideal to use in the high-risk area of the emergency department and the high-touch zone of the patient room.  The applications that we designed provided surfaces that were easy to clean, plus the hygienic benefits to protect against growth of infectious agents and chemicals and the durability of an ED environment used 24/7.  

This surface material was used in high-touch zones of wall cladding, handrails, bumper guards, video wall, lighting details, casework, art features, light switch cover plates, countertops with integrated sink bowls and table tops.  

The solid surface materials were detailed to eliminate acute angles, open gaps, crevices and seams.  Design with the material further allowed use of radius corners and curved edges, making the surface, safe & aesthetically pleasing.  

Solid surface wall materials could be planned to marry up with integrated floor base without creating any crevices.  All joint conditions could be seamed.

Lighting supported all task areas.  For example, light sensors went "on" over each hand-washing sink.  This increased cleaning visibility in these wet areas as well as intuitively alerting the need for hand washing.  Solid surfacing in the translucent panels allowed us to backlight the walls featuring color kinetic lighting and patterning.

Human factors were addressed within the patient room. High-touch components were featured within a color contrast horizontal band around the room.  This allowed the placement of "sharps containers" glove boxes and other often used items within a "high-touch strip."  The high-touch strip provided the ES staff a "clean priority" indicator.

Incorporating solid surface materials as described provided a high quality, clean environment that improved the business case by design. A recent review with the facilities management team indicated that the ES staff was able to provide a terminal clean between patients in 10-15 minutes.  Previously in the standard ED patient room, it took 30 minutes to clean.  The team further indicated they felt the room was ten times cleaner. It was clean by design. 

Healthcare design is a challenging.  It requires a blend of the arts and sciences to keep the hospital environment safe, clean, beautiful and patient friendly.  However, meeting this challenge improves outcomes and can be personally rewarding.

-- A Visual Reference for Evidence-Based Design, J. Malkin, Center for Health Design, Concord, CA, 2008.
- "Control and Mitigation of Healthcare-acquired infections: designing clinical trials to evaluate new materials and technologies," HERD 2011 Fall, I. Sharpe
- "Hospital and Clinic Cleaning Guidelines," Minnesota Technical Assistant Program, University of Minnesota
- "Patient Room Cleaning Protocol," Infection Control Today, Virgo Publishing 11/30/09.
- "Practice Guidance for Healthcare Environmental Cleaning" from the American Society for Healthcare Environmental Services (ASHES)
- "Room for Improvement," Environmental Services, G. Buntrock, Health Facilities Management
- To Err is Human, Building a Safer Health System, L. Kohn, J.M. Corrigan and M. Donaldson, Editors, Institute of Medicine, National Academy Press, DC, 2000
- "Lighting Prescriptions: Balancing Clinical and Aesthetic Needs in Hospitals," D. Fong, J. Losnegard, Health Facilities Management


Barbara Huelat
Design Principal
Huelat Parimucha Ltd. / Healing Design
635 South Fairfax Street
Alexandria, Virginia 22314
P: 703.838.8414

Design Principal
Huelat Parimucha Ltd. / Healing Design
635 South Fairfax Street
Alexandria, Virginia 22314
P: 703.838.8414