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Fighting the Spread of Infection in the NICU Environment
Megan E. Denham, MAEd, EDACSimTigrate Design Lab, College of ArchitectureGeorgia Institute of Technology
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LEARNING OBJECTIVES
1. Identify the 3 primary mechanisms of transmission for HAIs through the NICU environment
2. Identify common approaches to interrupt the chain of transmission through the NICU environment
3. Recognize NICU design components that can mitigate the risk of infection
4. Explore the gaps in the current evidence and illustrate how multidisciplinary collaboration can bridge those gaps
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• At any given time, ~1 in 25 hospitalized patients in the US have at a healthcare-associated infection
• Patients admitted to ICU rooms in which the previous occupant had MRSA and VRE showed a 40% INCREASED RISK of acquiring those infections
• There was more than a 2 FOLD RISK of acquiring C. difficile in ICU rooms in which the previous occupant had this infection
HAI OVERVIEW
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
CONCEPTUAL FRAMEWORK FOR THE CHAIN OF TRANSMISSION
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
HAI
Human Reservoirs
Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers)- airborne/droplet
Environmental sources and reservoirs of pathogens
RESERVOIR or SOURCE IN THE HOSPITAL
EXTERNAL SOURCE
Transmission event Transmission event
Transmission event
Reservoir – Place (human or environmental) where organisms reside and multiplySource – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument) 5
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3 MECHANISMS OF TRANSMISSION
I. Air– Pathogens release into air, we breathe them – Pathogens released into air, land on surfaces
II. Water– Contaminated water lands on surfaces– Contaminants become aerosolized, we breathe them
III. Contact– Direct Contact (skin to skin)– Indirect (touch a contaminated surface)
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
CHAIN OF TRANSMISSION INTERVENTIONS MODEL
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
HAI
Human Reservoirs
Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers)- airborne/droplet
Environmental sources and reservoirs of pathogens
RESERVOIR or SOURCE IN THE HOSPITAL
EXTERNAL SOURCE
Transmission event Transmission event
Transmission event
Reservoir – Place (human or environmental) where organisms reside and multiplySource – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument)
BarriersFilters
Design Elements
Opportunities for interventions through the built environment
DisinfectDecontaminat
eEliminate
Hand hygieneOther barriers
IsolationDesign Elements
Hand hygieneIsolation
Design Elements
Hand hygieneOther barriers
IsolationDesign Elements
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
Air Chain of Transmission Interventions Model
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
HAI
Human Reservoirs
Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers)- airborne/droplet
Environmental sources and reservoirs of pathogens
RESERVOIR or SOURCE IN THE HOSPITAL
EXTERNAL SOURCE
Transmission event Transmission event
Transmission event
Reservoir – Place (human or environmental) where organisms reside and multiplySource – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument)
HVACFiltration
Opportunities for interventions through the built environment
VentilationFiltration
DecontaminationIsolation
VentilationFiltration
DecontaminationIsolation
VentilationFiltration
DecontaminationIsolation
Hand hygieneIsolation
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I. Ventilation: Replace contaminated air with fresh, clean air
II. Decontamination: Technologies such as Ultraviolet Germicidal Irradiation (UVGI) to kill bacteria in the air
III. Filtration: Trap pathogens in filters while letting clean air through
IV. Isolation: Separation to prevent cross-contamination
AIRBORNE TRANSMISSION OPPORTUNITIES FOR INTERVENTION
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
Water Chain of Transmission Interventions Model
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
HAI
Human Reservoirs
Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers)- airborne/droplet
Environmental sources and reservoirs of pathogens
RESERVOIR or SOURCE IN THE HOSPITAL
EXTERNAL SOURCE
Transmission event Transmission event
Transmission event
Reservoir – Place (human or environmental) where organisms reside and multiplySource – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument)
Safe Plumbing PracticesDecontamination
Opportunities for interventions through the built environment
Safe Plumbing PracticesDecontaminationDesign Elements
Safe Plumbing PracticesDecontaminationDesign Elements
Hand hygieneIsolation
Safe Plumbing PracticesDecontaminationDesign Elements
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I. Safe Plumbing Practices: Maintain optimal water temperature, adequate pressure, eliminate dead ends
II. Decontamination: Kill bacteria with chemicals (chlorine), super-heating water, or technologies such as UVGI or copper-silver ionization
III. Filtration: Point of use filters
IV. Design Elements: Electronic faucets, sink design, and proper care of decorative water features
WATERBORNE TRANSMISSION OPPORTUNITIES FOR INTERVENTION
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
CONTACT CHAIN OF TRANSMISSION INTERVENTIONS MODEL
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
HAI
Human Reservoirs
Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers)- airborne/droplet
Environmental sources and reservoirs of pathogens
RESERVOIR or SOURCE IN THE HOSPITAL
EXTERNAL SOURCE
Transmission event Transmission event
Transmission event
Cleaning StrategiesHand Hygiene
SurfacesPhysical Barriers
Opportunities for interventions through the built environment
Cleaning StrategiesSurfaces
Physical Barriers
Hand HygieneTouchless SystemsPhysical Barriers
Cleaning StrategiesHand Hygiene
Touchless SystemsPhysical Barriers
Surfaces
Hand hygienePrivate rooms
Isolation
Reservoir – Place (human or environmental) where organisms reside and multiplySource – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument)
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I. Cleaning Strategies and Technologies
II. Surface Material
III. Physical Barriers
IV. Hand Hygiene Infrastructure
CONTACT TRANSMISSION OPPORTUNITIES FOR INTERVENTION
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Cleaning Strategies and Technologies: Targeting surface contamination with better cleaning adherence, and augmenting with terminal cleaning technologies (UVGI, HPV)
CONTACT TRANSMISSION OPPORTUNITIES FOR INTERVENTION
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Surface Material: Nonporous, cleanable, antimicrobial surface materials (e.g. copper)
CONTACT TRANSMISSION OPPORTUNITIES FOR INTERVENTION
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Physical Barriers: Spatial separation such as single-patient rooms, isolation and
privacy curtains
CONTACT TRANSMISSION OPPORTUNITIES FOR INTERVENTION
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Hand Hygiene Infrastructure: Strategic placement of alcohol rubs and sinks, and technologies to monitor hand hygiene compliance
CONTACT TRANSMISSION OPPORTUNITIES FOR INTERVENTION
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
CHAIN OF TRANSMISSION INTERVENTIONS MODEL
COLONIZEDor
INFECTED HOST
PatientsHCWsVisitors
HAI
Human Reservoirs
Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers)- airborne/droplet
Environmental sources and reservoirs of pathogens
RESERVOIR or SOURCE IN THE HOSPITAL
EXTERNAL SOURCE
Transmission event Transmission event
Transmission event
Reservoir – Place (human or environmental) where organisms reside and multiplySource – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument)
BarriersFilters
Design Elements
Opportunities for interventions through the built environment
DisinfectDecontaminat
eEliminate
Hand hygieneOther barriers
IsolationDesign Elements
Hand hygieneIsolation
Design Elements
Hand hygieneOther barriers
IsolationDesign Elements
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EBM AND EBD: COMPARATIVE APPROACHES
Evidence Based Medicine Evidence Based Design
• Integration of best research
evidence with clinical expertise and
patient values
• Quantitative: rigorous clinical
studies with hypothesis testing
• Focus: patient
• Ideal: randomized controlled trial
• Highly “standardized”
• Continuously evolving
• Integration of technical expertise
and organizational/patient values
with the best research evidence
• Qualitative: informed by research
studies, based on ideas
• Focus: patient and organization
• Ideal: experiential
• Avoids “one-size-fits-all” approach
• Continuously evolving
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Elevator
Inpatient
Hemodialysis
Tile
Floor*
Ventilation systemAntimicrobial surfacesCleans*
Critical Emergency department
Room
Shower*
Sink*SurfacesSanitary
DisinfectionTable*Toilet*
UpholsteryHospital wards
Inpatient acute careInterior design
Layout
Light Fixture
Fabric
IsolationQuarantine
FaucetFixture
SurveillanceFurnishings
Ventilation
Human factors engineering
Water fountainWindow*
WorkstationCohorting patients
Inpatient rehabilitation facilityIntensive care unit
Incubator
Construction
Patients’ rooms
Wall
ColonizationContaminationRenovation
Cleaning
Disinfect*
Copper
LightingPaint
Ultraviolet irradiation
Medical Waste disposal
Long term acute careDécor
Engineering
Cost-benefit analysis
Infection ControlDecontamination
MeSH Design Medical
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EVALUATING THE EVIDENCE:DETERMINE IMPORTANCE
HVAC components had moderate to heavy contamination pre-UVGI installation
All HVAC cultures negative at 6 months post
Surface and air samples had moderate to heavy contamination pre-UVGI installation
All surface cultures negative at 6 months post
74% of throat cultures were positive for pathogens such as Pseudomonas aeruginosa and Klebsiella pneumonial pre-UVGI installation
55% of throat cultures were positive at 6 months post
44% of throat cultures were positive at 18 months post
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The quantity of evidence needed to declare something is safe…
…the evidence needed to declare something poses an
unnecessary risk!
EVALUATING THE EVIDENCE
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Not yet widely adopted…
UVGI to clean surfaces:Lots of evidence that it reduces contamination
BUT
Not enough evidence that it reduces infection
WHY?
Not enough evidence to determine ROI
EVALUATING THE EVIDENCE
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EVALUATING THE EVIDENCE
• But we don’t have sufficient evidence to say with confidence that a single component of the BE reduces infection
• There is evidence that there are many interventions to reduce contamination
• There is evidence that reducing contamination reduces the risk of infection
UVGIHPVCu
DANGER OF INFECTION
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CONCLUSIONS
• Modes of transmission well understood• Impact of design on proxy marker well
understood, but not on clinical endpoints• Design interventions based on evidence, best
practices and values• Collaboration, often and early, essential• Many gaps to address