INFECTION PREVENTION AND CONTROL
patients, and visitors, to deliver facilities in which IPC needs have been anticipated, planned for, and met.’ In other words, success requires a multidisciplinary
approach. Key to successful implementation is how this multidisciplinary approach can be achieved, which of course also requires input from several other stakeholders, importantly including manufacturers. Healthcare facilities are breeding grounds for AMR. As antimicrobial resistance spreads like a tsunami across a country, it is exploiting and highlighting the deficiencies in the built environment.
The role of the healthcare built environment The purpose of this article is to highlight some of the key areas requiring this multidisciplinary approach. It is not designed to be exhaustive,
Figure 3: The Confronting antimicrobial resistance 2024 to 2029 publication is part of a concerted Government drive to tackle the increasingly tough challenge of antimicrobial resistance.
but merely to try and highlight the opportunities, and why such a wide variety of skillsets are needed. The healthcare built environment will be considered under the following headings: 1 Current issues with the design, construction, and commissioning, of new healthcare facilities.
2 Water and wastewater systems. 3 Equipment, including sanitaryware – improving its design functionality, ease of decontamination, and incorporating innovation.
Figure 4: A brand new drug preparation room in an as yet unopened new healthcare facilty. Whilst this is HBN and HTM- compliant, it is not safe – splashing from the sink on to work preparation areas could result in patients acquiring infections. Consequently, the clinical handwash station was removed (see red box showing where the sink used to be). This room is now non- compliant, but safe.
Other developments which have a bearing on these topics include: n Hot-off-the-press guidance for water systems in healthcare in response to the mycobacteria contamination of Papworth Hospital – addendum to Health Technical Memoranda HTM 04-01 published on 27 August 2024.4
n The New Hospital Programme. n Worldwide deficiency in trained nursing and medical staff.
The latest healthcare facility to make the headlines for the wrong reasons is the new maternity hospital in Belfast. Due to extensive issues, including contamination of water systems, this £80 m building has been prevented from opening, and faces a potential multi-million pound bill to rectify. The matter would have been substantially worse had patients been admitted to the building and infections been contracted. In 2018 two key reports on the construction industry were released within months of each other – the Cole
report,5 in Scotland, and the Hackitt report,6 in England.
The publication of the Scottish report was driven by the walls in brand new schools collapsing – the subsequent enquiry examined other schools using the same construction technique, and at the same time looked at fire safety – it found major deficits in both systems. The Hackitt report was driven by the appalling Grenfell Tower incident. However, this was more than a report on high- rise buildings and cladding – the tragedy was a symptom of a much wider malaise within the industry, described by Dame Judith Hackitt as ‘a race to the bottom’. The report identified an absolute requirement for a
change in culture across the industry. Guidance and compliance – the mainstay of the industry, have a strong track record of failure across many sectors. The Hackitt report recommended a move to a risk-based approach, ensuring the requisite training and competence of all of those involved, and no longer blindly following guidance. It also introduced the concept of ‘occupant safety’. You might reasonably ask what this has to do with AMR? Correct design, construction, and installation practices are key to prevent AMR spreading through hospitals. To give an example – if wastewater systems are not installed correctly (i.e. burrs are left on cut drainage pipes), they will predispose to blockages, which in turn predispose to the dispersal of AMR. The idea that architects and design teams need only consult the Health Building Notes and Health Technical Memoranda to design a safe building is dangerously flawed (see Figure 4).
Implicit to this is understanding that ‘compliant’ does not equate to ‘safe’. The desire to be compliant should not be underestimated, even to the extent of undermining patient safety.
Derogations Derogations from compliance are seen as an area to be avoided, and understandably in some instances this is correct, as this has been used as a way to downgrade new facilities to save money. However a risk-based approach demands that there will be deviations from guidance where enhancements are required to improve patient safety (see Figure 4). Ideally all guidance should come with a user’s guide that provides an explanation of how to use it safely, its implicit limitations, and that enhancements (i.e. deviation from guidance is necessary and acceptable) are expected where a risk-based approach shows that safety can be improved. Although water and wastewater systems are inextricably
linked, it is predominantly the wastewater system which provides a superhighway for the movement of AMR throughout a healthcare facility, while simultaneously allowing it to escape within the building to reach patients. Hospitals have the perfect storm of a high concentration of AMR pathogens from unwell patients, antibiotic pressures, and a vulnerable population to infect when the pathogens come back out of the drains. More alarming is that AMR pathogens are not confined to the drain they are deposited in. There is movement of bacteria from one drain to another, via growth back and forth in the biofilm lining pipes, which has been implicated in outbreaks. Yet the drainage systems of hospitals resemble those in other domestic and commercial settings, without, however, cognisance of the heightened risk. The same organisms which threaten the end of the antibiotic era have taken up residence within the very fabric of buildings designed to protect the most vulnerable patients in society. Why should this be the case? The antibiotic-resistant organisms which we most fear naturally reside within the human gut. The large bowel of a human
40 Health Estate Journal October 2024
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