1 Fighting the Spread of Infection in the NICU Environment Megan E. Denham, MAEd, EDAC SimTigrate...

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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

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HOW DOES INFECTION SPREAD?

COLONIZEDor

INFECTED HOST

PatientsHCWsVisitors

CONCEPTUAL FRAMEWORK FOR THE CHAIN OF TRANSMISSION

COLONIZEDor

INFECTED HOST


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)

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WHAT ROLE DOES THE NICU ENVIRONMENT PLAY IN PREVENTING THE SPREAD OF HAIs?

COLONIZEDor

INFECTED HOST


CHAIN OF TRANSMISSION INTERVENTIONS MODEL

COLONIZEDor

INFECTED HOST


HAI

Human Reservoirs




EXTERNAL SOURCE


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



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AIRBORNE TRANSMISSION (Viruses, TB)

COLONIZEDor

INFECTED HOST


Air Chain of Transmission Interventions Model

COLONIZEDor

INFECTED HOST


HAI

Human Reservoirs




EXTERNAL SOURCE


Transmission event


HVACFiltration


VentilationFiltration

DecontaminationIsolation






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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

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WATERBORNE TRANSMISSION(Legionella)

COLONIZEDor

INFECTED HOST


Water Chain of Transmission Interventions Model

COLONIZEDor

INFECTED HOST


HAI

Human Reservoirs




EXTERNAL SOURCE


Transmission event


Safe Plumbing PracticesDecontamination


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

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CONTACT TRANSMISSION (MRSA, C. difficile)

COLONIZEDor

INFECTED HOST


CONTACT CHAIN OF TRANSMISSION INTERVENTIONS MODEL

COLONIZEDor

INFECTED HOST


HAI

Human Reservoirs




EXTERNAL SOURCE


Transmission event

Cleaning StrategiesHand Hygiene

SurfacesPhysical Barriers


Cleaning StrategiesSurfaces

Physical Barriers

Hand HygieneTouchless SystemsPhysical Barriers

Cleaning StrategiesHand Hygiene

Touchless SystemsPhysical Barriers

Surfaces

Hand hygienePrivate rooms

Isolation


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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)


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Surface Material: Nonporous, cleanable, antimicrobial surface materials (e.g. copper)


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Physical Barriers: Spatial separation such as single-patient rooms, isolation and

privacy curtains


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Hand Hygiene Infrastructure: Strategic placement of alcohol rubs and sinks, and technologies to monitor hand hygiene compliance


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WHY ARE WATER AND AIR IMPORTANT IN THE CONTEXT OF CONTACT TRANSMISSION?

COLONIZEDor

INFECTED HOST


CHAIN OF TRANSMISSION INTERVENTIONS MODEL

COLONIZEDor

INFECTED HOST


HAI

Human Reservoirs




EXTERNAL SOURCE


Transmission event


BarriersFilters

Design Elements


DisinfectDecontaminat

eEliminate




Design Elements



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EVALUATING THE EVIDENCE

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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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PATHOGENS TABLE

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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!


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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


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• 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

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QUESTIONS?

1 Fighting the Spread of Infection in the NICU Environment Megan E. Denham, MAEd, EDAC SimTigrate...

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