New Threats Offer Opportunity To Improve Infection Controls

Germ containment has long been a sticky issue in hospital design. Now, because of patient deaths related to "sick building syndrome," outbreaks of SARS and fears of more incidents of bioterrorism, infection control is beginning to get the support it has long deserved.

One trend is toward stricter standards for heating, ventilating and air conditioning systems, says James F. Case, director of health care design for Swanke Hayden Connell Architects, New York City.

That’s a good thing, says Paul Gloriod, a principal with FKP Architects Inc., Houston. Even under ordinary circumstances, "air quality needs to be improved significantly," he says.

Eugene Bard, of Bard, Rao + Athanas Consulting Engineers, Boston, says the "new world" of terrorism is changing the way engineers approach the design of HVAC systems. "Since 9/11, every emergency room we do is isolated, HVAC-wise," he says.

No Waiting Room. Emergency department at Ball Memorial Hospital has a hotel-style check-in counter for triage, but no waiting room–an area long considered an infection-control nightmare. (Photo courtesy of Cardinal Health System)

Pandemics are not the only motivation for separating emergency rooms. At Ball Memorial Hospital in Muncie, Ind., the strategy behind the design of its year-old emergency department was to improve day-to-day care. ER "waiting rooms are an infection-control nightmare," says Karla Kirby, Ball’s administrative director for emergency services.

That’s why the hospital built its emergency department without a common waiting area. Instead, the department has a check-in area, similar to a hotel. Patients then go straight to a private room to wait. There are no curtained-off treatment areas.

Even beyond the ER, "a single room is a great opportunity for a safer health care experience," says John R. Pangrazio, principal of Seattle-based NBBJ and president of the American Institute of Architects Academy of Architecture for Health.

A proposal in the draft of the 2006 Guidelines for Design and Construction of Hospital and Health Care Facilities, just out for comment, recommends only single-patient rooms for all new hospitals. Pangrazio thinks it inappropriate to go that far in the guidelines. "But that doesn’t mean I don’t believe in the single-patient room," he says.

Single Safety. Trend in new construction is for private rooms. (Graphic courtesy of Ellerbe Becket)

Studies show that private-room patients heal more quickly. Their attitudes are better and there are fewer germs transferred between patients. And though a single-room hospital has a higher first cost, it is likely to cost less to operate. "And that’s where the real costs associated with health care are," says Pangrazio.

For example, a move from one level of care to another, such as a single to a double room, costs about $750 and takes four hours of nursing care, he says.

The new way of thinking about ventilation goes beyond the ER. For Denver Children’s Hospital, just starting construction, an entire patient floor is designed to be converted into an "isolated" SARS ward "at the touch of a button," says Bard.

On a more mundane level, Gloriod suggests interstitial mechanical floors, instead of fan rooms on each floor. That keeps service and maintenance personnel completely separate from patients, he says.

A research effort, called Project ER1, is an example of taking isolation to an unprecedented extreme (ENR-AR Special Report 5/31-Spring 2004, p. 10).

In the Project ER1 scenario, the ER has all the bells and whistles of infection control, including ventilation control, self-decontaminating surfaces with an ionic-silver impregnation, ultraviolet germicidal irradiation, decontamination showers and more. Sinks would even have high-velocity water spouts to "neutralize" bacteria in drains.

Future Vision. Curbside showers, isolated emergency room entries (left) could help handle disasters involving infectious agents. graphics courtesy of HKS, INC.

The patient environment is a "smooth membrane," so it doesn’t harbor germs. All equipment comes and goes with the patient, says David R. Vincent, a senior vice president of HKS Inc., Dallas, which is involved in the project.

"ER 1, which represents a paradigm shift, is at least ten years ahead of its time," says Vincent. But designers can apply some of its principles right away, he adds.

Architects know that design efforts to aid hospitals from spreading germs can be neutralized if the clinicians don’t wash their hands. To encourage good hygiene, architects spend much time discussing the placement of sinks and disinfecting gel dispensers, says Pangrazio.

At the end of the day, "hand-washing could arguably be the number one culprit for causing nosocomial infections," agrees Gloriod. "We have hand washing down" in the codes, he laments, but that "still doesn’t force anyone to do it."