controlling hospital acquired infection - …...stage 2 - a questionnaire survey on control of...
TRANSCRIPT
MARU
medical architecture research unit
CONTROLLING HOSPITAL ACQUIRED
INFECTION IN THE WARD ENVIRONMENT
Design and Management Recommendations
A research project for the Health and Care Infrastructure Research
and Innovation Centre
FINAL REPORT February 2010
2
Table of ContentsABSTRACT
ABSTRACT .................................................................... Error! Bookmark not defined.
ACKNOWLEDGEMENTS ............................................................................................. 6
BACKGROUND............................................................................................................. 8
The research team and steering group .......................................................................... 8
Programme ................................................................................................................ 10
REPORT STRUCTURE AND SCOPE ......................................................................... 11
1 THE RESEARCH AIM AND OBJECTIVES ............................................................ 12
Methodology ............................................................................................................. 13
2 LITERATURE REVIEW .......................................................................................... 15
3 QUESTIONNAIRE TO ACUTE NHS TRUSTS ....................................................... 25
Responses to the freedom of information questions ................................................... 26
Freedom of information summary ................................................................................. 30
4 STEERING GROUP INPUT ...................................................................................... 32
5 FOCUS GROUPS ..................................................................................................... 34
Findings .................................................................................................................... 37
Focus group summary ............................................................................................... 45
6 KEY FINDING AND DISCUSSION ........................................................................ 47
Variability of the estate .............................................................................................. 48
Decision making ........................................................................................................ 49
Patient priorities ........................................................................................................ 50
Wards and single bedrooms ....................................................................................... 51
Design and Management Decision Making Tool ........................................................ 55
Summary of recommendations .................................................................................. 59
Summary of areas identified for future research ......................................................... 59
7 CONCLUSION ......................................................................................................... 61
APPENDIX 1: Freedom of Information Responses ....................................................... 62
APPENDIX 2: Design Dilemmas of Guidance and Regulatory Compliance .................. 71
APPENDIX 3: Discussion sheets for focus groups ........................................................ 81
APPENDIX 4: Transcript sample (part 1 of Microbiologists focus group) ..................... 93
APPENDIX 5: Key points from the focus groups ........................................................ 116
REFERENCES............................................................................................................ 136
Tables
Table 1 Contributors ....................................................................................................... 6
Table 2 Research team and roles ..................................................................................... 8
Table 3 Steering group members .................................................................................... 9
Table 4 Project programme........................................................................................... 10
Table 5 Outline of the research methodology ................................................................ 13
Table 6 Freedom of information questions .................................................................... 25
Table 7 Identified drivers for capital spend ................................................................... 27
Table 8 Areas of divergence in reported capital spending ............................................. 28
Table 9 Original focus group discussion list ................................................................. 30
Table 10 Design dilemmas for infection control ........................................................... 32
Table 11 Categories for activity and evidence ............................................................... 35
Table 12 Order of discussion chosen by each group ...................................................... 36
Figures
Figure 1 Key drivers of the capital spend ....................................................................... 26
Figure 2 The relationship of CoI design decisions with other dimensions of hospital build
projects.......................................................................................................................... 55
4
Executive Summary
Background
Hospital infections cost the NHS around £1 billion per annum. It is well recognised that
failure to control infection has a significant impact on both the patient and the provider of
healthcare. It is generally recognised that hospital infection is a multi faceted problem,
hence, the control of infection can only be achieved by a combination of design and
management factors and not by a single identifiable factor.
Research question
What interventions are being made to improve the ward environment in acute Trusts and
do these changes improve infection control?
Methodology
A literature search and freedom of information request were used to identify the key
interventions being made by Acute NHS hospital Trusts on wards relating to infection
control.
Findings from the above formed the basis for discussion with uni-disciplinary focus
groups to ascertain the efficacy and decision making strategies.
Findings
Ten key areas were identified and explored in depth:
Curtains Staff change facilities Ward storage
Clinical hand wash basins at ward entrances
Sensor taps Cleaning method
Sluice room clinical hand wash
basins and macerators vs.
bedpan washers
Centralised ward equipment
decontamination
Single rooms
Flooring
There was consensus in the focus groups that these are the key areas of intervention. We
found that there is generally a lack of evidence to support Trusts in making choices in
each of the areas. Different Trusts are making different choices. These are based on the
constraints of existing sites, finances and managerial choice.
Conclusions
Creating an environment that is easy to clean, looks clean, is uncluttered and provides
ample opportunity for clinical hand washing contributes to the control of infection. Trusts
are striving to achieve this.
5
The out come of the research study is the production of a Design and Management
Decision Making Tool. The anticipated users of this product are hospital managers,
designers and estates and facilities staff.
6
ACKNOWLEDGEMENTS
The MARU research team would like to thank the Steering Group members, Focus
Group participants and all contributors for their invaluable direction and support, without
which the investigation would not have been possible. In particular, thank you to Guy‟s
and St Thomas‟ NHS Foundation Trust for hosting the focus group meetings and to
Yvonne Fortune for co-ordinating the arrangements. To Salford Royal NHS Hospital and
in particular Anne Symons at Balfour Beatty NBHJV for arranging the Design Dilemmas
workshop.
Table 1 Contributors
Phil Astley Prof Colin Gray Phil Nedin
Toby Banfield Mike Hall Simon Neville
Peter Bennett Delilah Hesling Rachel Northfield
Dave Bentley Stuart Hobson Richard Paley
Paul Bradley Peter Hoffman Pat Rae
Sylvia Bradley Rob Hornby Phil Reader
Mark Buckle Joe Houghton, Mary Reid
Sheena Carmichael Thusitha Ierera Simon Richards
Verite Reily Collins Dr David Jenkins Ellie Richardson
Franko Covington Maeve Keaney Prof Herbert Robinson
Helen Crisp John Kelly Sally Rosenthal
Martina Cummins Lionel Kirkbride Moira Rough
Tony Dolding Freda Kosmin Keith Slater
Phil Eagles Marc Levinson Karen Sorensen
Jochen Eggert Lindsay McCluskie Jeff Soutar
Dr Alireza Eshaghi Craig McDade Anne Symons
Natalie Firminger Jacqui McDonald Ian Tempest
Suzanne Fisher Jan Middleton Benita Tucker
Tracey Flynn Michael Middleton David Tucker
Peter Forshaw Robert Montgomery Chris Ward
Prof Gary French James Moore Pete Waring
Christel Garton Wendy Morton Linda Waskett
Rosemary Glanville Saud Muhsinovic Sinclair Webster
Andy Gleaves Kieran Mullan Richard Winterbone
This study has been funded by HaCIRIC, the Health and Care Infrastructure Research
and Innovation Centre, a collaboration with Reading University lead by Professor Colin
Gray, and the teams involved with HAI research at Loughborough University and
University College London Hospital. We are grateful to Imperial University and
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Professor James Barlow and the HaCIRIC team for arranging the peer assists at the early
stage of the proposal which helped us shape the focus of the study, and for the support of
the EPSRC whose annual reviews both positively appraised and supported our progress.
A personal thanks to all MARU alumni who have supported us throughout the year and
in particular to West Suffolk Hospital NHS Trust and Papworth Hospital NHS
Foundation Trusts, as well as East Midlands Strategic Health Authority for supporting the
lead researchers NHS secondments, and lastly, thank you to Philip Eagles, alumni and
Director of Estates at Bedford NHS Foundation Trust whose MSc dissertation was the
inspiration for the original study proposal.
8
BACKGROUND
Hospital Acquired Infection (HAI) is a complex problem but existing research suggests
that it is not being approached in holistic, co-ordinated and coherent way. The importance
of design is crucial in infection control and there is a need for a better understanding of
the interaction between design factors to tackle infection control. This pilot research
study has been completed reviewing the key infection control design issues in acute ward
areas. It seeks to understand the complexity of infection control and design by exploring
the impact of diverse factors in the hospital environment. Through literature searching,
examination of capital spending on infection control improvement measures, steering
group and focus group meetings a range of evidenced and non-evidenced based
interventions have been identified.
The idea for this research study was developed from a Masters dissertation (MSc
Planning Buildings for Health) “Adapting the Existing Health Care Estate to Minimise
Healthcare Associated Infection”, written by Philip Eagles, Director of Estates at Bedford
Hospital NHS Trust. This dissertation attempted to map some physical environmental
interventions against reducing infection rates but concluded that such reductions were
achieved by multi factorial interventions including clinical, behavioural and physical
environmental changes.
The research team and steering group
A multidisciplinary team of healthcare built environment experts was assembled and
worked from the MARU (Medical Architecture Research Unit) office at London South
Bank University, Papworth NHS Foundation Trust, SHA Estates (Midlands division) and
Guy‟s and St Thomas‟ NHS Foundation Trust.
Table 2 Research team and roles
Research team: Research Roles
Phil Astley Principal Investigator
Rosemary Glanville Co-Investigator
Dr Herbert Robinson Co-Investigator
Jacqui McDonald Senior research fellow
Robert Montgomery Senior research fellow
Mark Page Senior research fellow
Karen Sorensen Senior research fellow
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Table 3 Steering group members
Steering Group:
Professor Colin Gray Academic Director, HaCIRIC project
Helen Crisp CHKS Ltd (Caspe Healthcare Knowledge Systems)
Phil Eagles Head of Estates , Bedford Hospitals NHS Trust
Anne Symons Senior Design Officer, Balfour Beatty NBHJV
Rachel Northfield Project Director, Children‟s hospital project, Cambridge
University Hospitals NHS Foundation Trust
Sinclair Webster HOK Design
Ian Tempest WS Atkins plc
And the research team as detailed above
The research team were supported by a multi-disciplinary steering group who provided
guidance on the pilot as it progressed. This group provided various inputs with regards to
dilemmas that they were facing relating to infection control and the design of acute care
refurbishments and new buildings.
10
Programme
The study was carried out over an 18 month period. The study was managed through a
process of regular research team meetings and steering group meetings at key points.
Table 4 Project programme
Year 2008 2009 2010
Month S O N D J F M A M J J A S O N D J F
Research
team
meetings
Steering
group
meetings
Literature
search
Freedom of
information
(FoI) request
Analysis
from FoI
data on
control of
infection
(CoI)
interventions
Interim
report
Focus groups
Analysis of
focus group
data
Final report
11
REPORT STRUCTURE AND SCOPE
Following the abstract, acknowledgements and the background of the research study this
report is organised into 7 sections:
Section 1: Details the research study aim, objectives and methodology.
Section 2: Presents the literature review focusing on key themes relating to
the control of infection (CoI) and hospital buildings.
Section 3: Details the Freedom of Information (FoI) process, questions asked
of acute NHS Trusts, the responses received and the analysis of the
responses.
Section 4: Presents the steering group input, including their recognition of
design dilemmas.
Section 5: Details the focus group methodology, key themes identified for
discussion, the discussions and summarises the outcomes from
each theme.
Section 6: This is the discussion section and pulls together all of the strands of
the research study, presenting a design and management guidance
tool, recommendations and areas for further research.
Section 7: The research study conclusions.
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1 THE RESEARCH AIM AND OBJECTIVES
The aim of the study was to develop design guidelines to identify and implement control
of infection measures in briefing, design development and construction stages and in
managing the operation of hospital facilities.
Objectives:
To identify areas with the greatest risk of infection, and the patterns and sources
of infection in hospital environments.
To explore the role of different stakeholders in facilities planning and their impact
on design decisions.
To examine the impact of organisational drivers on key design and management
factors and its influence on the transmission of infection and control measures.
To evaluate the impact of design on clinical, facilities management and
behavioural practices and to develop an audit tool to formulate control measures.
Boundaries of the research:
During the study it became clear that it would be better to focus on specific areas in
hospital environments. The research was therefore limited to acute hospital ward settings
as this is where the greatest focus is in relation to hospital acquired infection and its
control. It was also decided to exclude areas of interest with a lot of guidance and
legislation such as Legionella, Aspergillus, theatres, intensive care areas,
decontamination of theatre instruments and endoscopes. This is because it was unlikely
that the research would have added anything new to the existing body of knowledge.
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Methodology
The methodology outlined in figure 1 consisted of various research approaches to address
the study aim and objectives. This includes:
Stage 1- a literature review to identify key themes relating to design and management
factors affecting infection control,
Stage 2 - a questionnaire survey on control of infection interventions, based on the
£300,000 received by most NHS Trusts from Capital Challenge monies in 2006/07, using
the FoI route as a research tool.
Stage 3 - focus groups to bring together experts from a wide range of fields to share
expertise and debate current issues to bring a fresh and synergistic approach to tackling
this difficult issue.
Research team meetings were held at least monthly throughout the study. Steering group
reviews were held at the end of each stage.
Table 5 Outline of the research methodology
The research study limitations were:
1. This research study was limited to acute ward areas, though the principles are
transferable to other clinical settings.
2. Areas with strong Department of Health guidance were excluded from the study
as it was felt unlikely that there would be anything new to add to the existing
body of knowledge e.g. Legionella.
Literature
search
Questionnaire
to acute Trusts Statistical
analysis of
responses
Focus groups
Exploration of
emerging themes with
multidisciplinary
experts
Content analysis of
the focus groups
Design
Guidelines
Relevance to
different groups
and stages of
construction
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3. It was recognised that opportunity could have been taken to ask the focus groups
to rank the subjects for discussion. This would have given insight into the
variations within and between uni-disciplinary groups.
4. The swine flu out break did impact on the number of people present in the focus
groups. This did not reduce the value of the discussions held and was mitigated by
sending the results out to all invited focus group members for comment.
The limitations of the research study are not major and do not compromise the value of
the evidence found or the Design and Management Decision Making Tool developed.
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2 LITERATURE REVIEW
This section of the research report reviews the literature relevant to the research study.
The description of how the literature searches were carried out is followed by a précis of
the quality of information found. This section then goes on to detail the subject areas and
review the literature consulted during the study.
The literature search was carried out using journals, books, the NHS Space for Health
web site (formally known as the Knowledge and Information Portal), the NHS Evidence
web site and internet search sites including Alta Vista, MedLine, PubMed, Ovid and
Google Scholar.
The sources used in this review have been identified across a wide spectrum of published
material. The available literature subject to academic peer review was found to be
limited. However, a substantial body of relevant governmental guidance and good
quality „grey literature‟ provided useful knowledge, essential information and context to
underpin the study.
„Grey literature‟ lies outside the academic, peer review process, but it is presented
frequently in professional journals, reports, and other publications, which have a high
reputation for accuracy, reliability and relevance within the fields within which they
circulate. Some of this material is considered very carefully before publication (papers
presented at conferences, for example) and is subject to open criticism and debate. Some
of the literature found originates from experience and sources outside the UK.
The research team recognise that control of infection (CoI) is a multi faceted problem that
cannot be addressed by focusing on a single measurable factor (Eagles, 2008).
The research team, guided by the steering group, carried out a targeted literature search,
which initially focused on the general literature relating to the design of wards and CoI in
hospitals. The search was then expanded, based on the investigation of CoI, towards the
design and management of the environment associated with:
• Location, planning and design of bed spaces and arrangement of beds
- Bed spacing
- Single bedrooms
• Clinical practice drivers
• Engineering services in acute hospital buildings
- Heating and ventilation
- Clinical hand wash basins and taps
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• Facilities management
- Hard FM (including surface finishes)
- Soft FM (including fabrics and cleaning methods)
- Storage
- Centralised decontamination of ward furniture
- Staff changing facilities
These were added to the review following the FoI request responses as they
appeared to be issues for NHS Trusts.
The meta analyses by Ulrich et al (2004) and Phiri (2006), of the literature on evidence
based design, were used as the baseline for the literature review. In the study “The role of
the physical environment in the hospital of the 21st Century: a once in a life time
opportunity” over 600 studies were reviewed in a report commissioned by the US Center
for Health Care Design (Ulrich et al 2004). In parallel, a study commissioned by the DoH
in the UK “Does the physical environment affect staff and patient health outcomes; a
review of studies and articles 1965-2005” (Phiri, 2006), reviews evidence based literature
before 2005. This latter document includes a section on infection control which looks at
evidence based studies on healthcare acquired infection (HAI) from both airborne and
contact routes. It is assumed that all evidence based studies relating to the built
environment and CoI, prior to 2005, have been identified in these documents.
Mayhall (2004) gives a comprehensive list of HAIs in the book 'Hospital epidemiology
and infection'. The implications for surveillance, prevention and control of infections in
patients and health care workers are clearly considered. Although the book is now some
six years old, it is still a useful reference for those seeking to understand what is meant by
HAIs.
A recent National Audit Office report (2009) reiterated the Health Act 2006 (Department
of Health, 2006a) that:
“infection control must be everyone‟s responsibility, from clinicians, cleaners and
ancillary workers to patients and relatives”
It is noted that although there is no specific mention of the designers, construction firms,
maintenance or capital projects teams, these teams and organisations have responsible
parts to play in the processes of infection control.
The relationship between the built environment of acute hospital care - its design,
engineering, construction and maintenance – and the control and management of HAI is
best explained in Infection Control in the Built Environment (NHS Estates, 2002). This
document is also known as Health Facilities Note 30 (HFN30) and precedes the
extensive work on CoI published since 2002. It is currently being rewritten for the
Department of Health (DH) by the Central Office of Information. Meanwhile, an
updated version of this has been produced for Scotland (Health Facilities Scotland,
2007a). The opening statement in the guidance sets the scene:
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“If the burden of health care associated infection is to be reduced it is imperative
that architects designers and builders be partners with health care staff and
infection control teams when planning new facilities or renovating older
buildings”.
HFN30 is one of the most relevant documents within the literature review as it covers
several of the themes for investigation in the research study. These themes include bed
spacing, isolation rooms, single bedrooms, ventilation, basins, storage, finishes, changing
and cleaning. HFN30 (2002) also discusses the various stages of a capital-build-project
from initial concept through to post-project evaluation, and highlights the major CoI
issues and risks that need to be addressed at each particular stage to achieve “designed-
in” CoI. The DH has also provided some evidence based guidance in Health Building
Notes and Health Technical Memoranda to assist this process. These are discussed in the
relevant sections of this review.
Development of policy and practice relating to CoI in Scotland has placed the built
environment more centrally in its CoI guidance to hospitals. This guidance is set out in
HAI-SCRIBE (Healthcare Associated Infection System for Controlling Risk in the Built
Environment) (Health Facilities Scotland, 2007a). Within this guidance, a system is
described to identify, assess and clarify the management of potential hazards and risks in
the built environment in four stages: addressing the site strategy, the planning and design
stage, construction and/or refurbishment activity and the operation of the buildings. Each
stage has a specific set of questions to be addressed, which are wide ranging and require
the use of high level planning concepts concerning the planning choices to be made. For
example, it is recommended that the design, layout, engineering and other features of the
building should not only respond to the health care procedures and services to be
provided, but also include assessments of the risk of incidence and spread of HAI that
could result from the design and layout of the healthcare facility.
The planning, design and operational questions raised by HAI-SCRIBE (Health Facilities
Scotland, 2007a) include themes explored in this study: for example, curtains separating
patients, the location of wash hand basins, ease of cleaning, and storage facilities.
However, although the need for sufficient isolation facilities in managing HAI is raised,
the ratio of single bedrooms and isolation rooms needed is not touched on. A further
problem for planners and designers is that HAI-SCRIBE is not well co-ordinated with the
Scottish version of HBN 30 (Infection Control in the Built Environment Facilities Note
30: Version 3) (Health Facilities Scotland, 2007b) as discussed above. This is an
illustration of the uncertain place occupied by the built environment in the development
of thinking and policy making around the reduction and management of the HAIs.
Following the introduction of the Health Act 2006 Code of practice for the prevention
and control of Health Care Associated Infections (DH, 2006b) the design and
maintenance of the built environment is required to establish systems to prevent HAI.
This built on earlier requirements for the integration of the built environment within the
strategy towards CoI. For example, the requirement for the patient environment to be
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well maintained, clean and safe does consider the involvement of infection control nurses
(and matrons) in refurbishment and new build projects (DH, 2004b). The need for
coordinated processes has been reiterated in „Going further faster II: applying the
learning to reduce HCAI and improve cleanliness‟. This document contains a complete
package of measures proposed for involving everyone in a health care organisation (DH,
2008a). Four areas are identified for action, as noted in DH (2008a):
• People: training, skills, behaviour.
• Processes: systems and procedures – including bed management and cleanliness.
• Practices: individuals, clinical, organisational – including cleanliness and
isolation.
• Performance: policies, procedures and standards – including the commissioning
and provision of a clean environment.
It is noted that the prevention of HAIs is not included in the key features of a desirable
environment in the guidance document 'In-patient care. Health Building Note 04-01:
Adult in-patient facilities' (DH, 2008b), which seems to be an important omission.
Location, planning and design of bed spaces and arrangement of beds
Bed spacing and the possibility for cross infection is recognised as a variable in the
incidence and control of HAI and have been subject to considerable debate (for example,
Hawkes, 2004; NHS Estates, 2002; Scher, 2003). The assumption that bed spacing and
separation is likely to influence cross-infection is widely held, but it is not universally
supported within the thinking and practice of bed-space planning and design (DH,
2004c). The limited research evidence about patient separation and HAI is inconclusive.
The most influential work on standards for ward design and bed spacing is the guidance
given by NHS Estates (2002). These standards were first promulgated in the second
edition of Health Facilities Note 30 (NHS Estates, 2002) and subsequently reiterated in
“Ward layouts with single bedrooms and space for flexibility' (NHS Estates – May 2005).
It relates to new-build schemes and major reconfigurations of existing wards.
The HFN30 guidelines state explicitly that the primary driver for change in ward design
is CoI. The aim is to include within ward design sufficient flexibility of multi-bed ward
space and single bedroom spaces to enable sufficient, effective separation of patients
when controlling occurrences of HAI, and the consequent potential for cross-infection.
However, this factor in bed spacing and ward design is only one, and not necessarily the
most important criterion, in the location, planning and design of bed spaces. The current
guidance of 3.6m is not attributable to an over-riding concern with CoI, but results from a
complex of considerations including cost of space provision, patient and bed handling,
levels of staffing and patient observation ( NHS Estates, 2002). Further research is
indicated before conclusions can be drawn about the efficacy of these guidelines in
relation to CoI.
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The debate about single bedrooms (including isolation rooms) for patients in NHS
hospitals is substantial and long-standing, and the discussion of HAI has become
fundamental to this debate (Dowdeswell et al, 2004; ; Lawson and Phiri, 2004; Phiri
2006, Ulrich et al, 2004, Xia, 2009).
The research conducted by Dowdeswell et al (2004) makes broad conclusions which
include that:
1. rates of cross infection are reduced when patients are placed in single bedrooms
2. single bedrooms can be effective in improving standards of hand hygiene
3. single bedrooms permit more efficient cleaning and decontamination programmes
Other research reports evidence that single bedrooms make a useful contribution to the
management and control of HAI, because they can be used for isolation purposes
(Dowdeswell et al, 2004, Scottish Government, 2008); and treatment of patients with
HAI is more effective when these patients are nursed in single bedrooms (Dowdeswell et
al, 2004). In an overview of the single bedroom debate, Xia (2009) concludes that despite
there being problems of insufficient single bedroom capacity and availability, single
bedrooms have proved to be effective in the management and control of MRSA. The
latest NHS guidance gives recommendations for the design of bed spaces to include
sufficient single bedrooms for the management of the incidence of HAI (DH, 2006),
however 'sufficient' is not defined.
Currently, an evaluation of the performance of a 24 single bedroom ward is being
conducted at the Hillingdon Hospital Trust, in West London. The first objective of this
evaluation is the effectiveness of this configuration of patient separation for the control of
HAI (Hillingdon Hospital Trust, 2007). Earlier research had indicated the potential for
reductions in cross-infection through the use of single bedrooms, but more research is
required to demonstrate the impact on actual infection rates (Phiri, 2006).
Single bedrooms may be effective in the control and management of HAI, but actual
performance is also highly dependent on the associated staff behaviour and hygiene
control methods (Moore, 2009). This demonstrates the symbiosis between design and
practical operation of hospital buildings.
Clinical practice drivers
The clinical practice drivers surrounding the CoI are well known. These have been
subject to some considerable research and documentation (Bissett, 2007; Coia et al, 2006;
Department of Health 2003, 2006a, 2007a, 2007b, 2008a, 2008c; Fairclough, 2006;
Gould, 2005; Healthcare Commission, 2008; Pratt et al, 2007; et al). The Department of
Heatlh guidelines have been developed from the principles of CoI and relate to the
appropriate management of clinical equipment, instruments, hand hygiene and practices
involving patient intervention (DH, 2007b, 2008a, 2008c). The key interventions for
practice are detailed in the 'Saving lives' document (DH 2006a) which requires the
auditing of practice to ensure minimum standards are met. These relate to a range of
- 20 -
activities including: antibiotic prescribing; cannula insertion and rate of change; insertion
of catheters, peripheral and central lines; and clinical hand washing.
Much less understood are the variables within the planning, design, engineering and
management of the built environment which impact on clinical practice. There is
relatively little attention paid to this in the literature. There is very little discussion
relating to the shifts in the design, organisation and management of buildings that could
support changes and improvements in clinical practice and the CoI. There are some
mentions of design factors in the literature relating to hand hygeine.
Hand hygiene plays a central part in the CoI (DH, 2006a, 2008c). Much of the literature
on hand hygiene focuses on behaviour, culture, education and hand hygiene practice
amongst clinicians and nursing staff ( Bisset, 2007; Chen and Chiang, 2007; Collins and
Hampton, 2005; Cooper, Wisenor and Roberts, 2005; Fairclough, 2005; Lam, Lee and
Lau, 2004; Nazarko, 2007; Preston, 2005; et al). In all of these articles only two make
any reference to the physical environment. Preston (2005) in her article on aseptic
technique comments on the requirement of elbow or foot operated taps to negate the
recontamination of hands by touching taps to turn them on and off and to adjust
temperature. Lam, Lee and Lau (2004) state that proper design and convenient location
of clinical hand wash basins can improve compliance with hand hygiene protocols. Their
work was related to a neonatal intensive care unit in Hong Kong but is still relevant to all
clinical settings.
Hall and Horsiey (2007) evaluate the principles and practice of hand hygiene in the
control of clostridium difficile. Their investigation concluded with recommendations
applicable to staff, patients and visitors. The best way to combat the spread of
clostridium difficile by people is clinical hand washing with soap and water; gels and
hand rubs are ineffective against this pathogen. This is reiterated in the DH publication
clostridium difficile infection: how to deal with the problem (2008c).
Engineering services in acute hospital buildings
Engineering services are a crucial feature in the functioning of buildings. The principles
and practices of CoI rely to a considerable extent on the installation, control and
management of water supplies and treatment of wastes, heating and ventilation, air
pressure control in various forms of isolation rooms (DH, 2002).
Guidance on specialised ventilation and isolation rooms is available (DH, 2007; NHS
Estates, 2002), but there are few references to CoI and the relationship of these facilities
to the design, engineering and management of the building services which support such
facilities. The DH has developed detailed technical advice on safe hot and cold water
systems, drinking water, hygiene systems and the control of Legionella (DH, 2006c & d).
- 21 -
The Health Technical Memorandum 64 (DH, 2006d) contains advice on sanitary
assemblies and fittings, but with little reference to CoI, and sensor taps, which are subject
to debate amongst building professionals (Health Estate Journal, 2009).
HAI-SCRIBE (Heath facilitiesScotland,, 2007a) is very detailed in the considerations
required for heating, ventilation, vacuum supply, lighting, water, and drainage. All of
these elements are required to be thought about in relation to the CoI.
One of the few research based articles is about the role of architecture and engineering in
CoI. The study in Brazil, by de Castro Bicalho (2006), investigates the physical barriers,
air-flow control, the organisation of workflows, and the choice of finishes and materials
relating to CoI. In the specification of materials, it is recommended that careful
consideration should be given to their performance in CoI and, in particular, the water
retention and impermeable properties of materials in walls, floors, ceilings and counters
to reduce the transmission of micro-organisms (de Castro Bicalho, 2006).
Facilities management
The performance and maintenance of surfaces is an important consideration in design,
construction and in the maintenance and management of buildings.
LSI Architects (2009) have described their overview of CoI measures designed into a
recently opened 22-bed infection control escalation ward refurbishment project. These
measures included cleanable wall finishes, lighting, interstitial blinds and vinyl floors
with attention to the skirting detail.
Within the field of facilities management, the work of Liyanage and Egbu has highlighted
the importance of the management of hospital facilities (including domestic services) in
the management and control of HAI (Egbu, Liyanage et al, 2004; Liyanage and Egbu,
2004; Liyanage and Egbu, 2008). Their research examines the risk of inadequate facilit ies
management as a source of HAI and the need for improved measures of performance in
this field. These issues are recognised by the Department of Health and the National
Patients Safety Agency (NPSA). They have produced guidance, specifications and
cleaning manuals (DH, 2008c, NPSA 2007, 2009). The NHS healthcare cleaning manual
was updated in 2009 (National Patient Safety Agency) and gives full details of the
expected cleaning regimes and does detail some methods including the use of micro-fibre
cleaning systems. This document is complemented by the National Patient Safety
Agency (2007) National specifications for cleanliness, which has audit tools to complete
so that NHS Trusts can be assured of the cleanliness of their premises. It is noted that
neither of the NPSA documents comment on the expectations of the built environment in
supporting these cleaning processes.
Micro-fibre cleaning systems have been the subject of some investigation in relation to
CoI. While correct hand hygiene practices remain fundamental, the micro-fibre systems
- 22 -
appear to offer higher levels of cleaning performance in high-touch areas than other,
conventional cleaning techniques (Nursing Times, 2009).
The study by Whitehead et al (2007) argues that the perception of cleanliness is
influential on the behaviour of staff and patients and, consequently, on the CoI regime.
This particular study points to the possibility that the 'appearance' of cleanliness should
be a design criterion integrated into the design approach to CoI.
Research in the USA has demonstrated the important problem of persistence of bacteria
commonly found in hospitals on walls, flooring and upholstery. One of the conclusions
drawn is that the specification and selection of materials to be used in surfaces should
include considering both the performance of the application in use and its performance in
disinfection (Lankford, 2006).
The properties of flooring in relation to CoI are considered in HFN 30 (NHS Estates,
2002) and HAI-SCRIBE (Health Facilities Scotland, 2007b). Both detail the requirement
for smooth impermeable surfaces for floors and appropriate skirting. HAI-SCRIBE states
the right angle joints between walls, floors and ceilings should have coving for ease of
cleaning. This document also details that surface joints should be kept to a minimum, and
where they do exist, that they should be sealed effectively.
The anti-bacterial properties of materials are also considered in Airey and Verran, 2007
and Practice Greenhealth (no date), and anti-microbial surfaces using copper as a
component of surface finishes (for example door furniture) are discussed in the Health
Estate Journal (2008) and the Journal of Hospital Infection (Airey and Verran, 2007).
Whether antibacterial surfaces/coatings do impact on microbial loadings in clinical areas
is unclear. HFN 30 recommends that CoI is integrated into the design and construction of
patient lockers and wardrobes associated with ward design (NHS Estates, 2002). There
are, however, no published recommendations for the specific incorporation of
antibacterial surfaces/coatings into ward design or furniture at present.
Despite the discussion of CoI as a consideration in bed spacing specification and single
bedroom provision, separation and privacy for patients in the NHS is usually achieved
through the use of curtains and (to a lesser extent) the use of fixed partitions. The
literature on bed spacing and CoI shows little or no connection with considerations
concerning the planning, design, installation and management of curtains and partitions
as a feature of patient separation. The NPSA cleaning manual (2009) details how
frequently curtains should be changed, the HAI-SCRIBE document asks if curtain track
are dust traps and if curtains can tolerate the required laundering temperatures.
A small study by Trillis et al (2008) showed that contamination on curtains could be
picked up on the hands of those who touched them. The study reviewed 50 curtains and
did include curtains from isolation rooms. The conclusion at the end of the study was
that curtains pose a low risk as the quantities of contamination passed from curtain to
hand were small and with appropriate clinical hand washing the risk was eliminated.
- 23 -
They did recommend the use of antibacterial coated curtains though they had not tested
these as part of their study.
Behaviour and cleanliness have been a focus for the National Audit Office‟s (NAO)
investigation into HAI (NAO, 2009). The report found that lack of clutter and tidiness
improves compliance with hand hygiene practice. The report also points to the need for
design and building management to pay more attention to adequate storage space for
equipment, instruments and materials.
HFN 30 (DH, 2002) provides guidelines for specific storage for cleaning equipment and
materials, laundry and clinical waste. Some specific sizes of storage areas are detailed in
HBN 04-01 (DH, 2008b) and the 'Clostridium Difficile infection: how to deal with it'
document states that the ward environment should be uncluttered (DH, 2008c). The
Scottish HAI-SRIBE document (Health Facilities Scotland, 2007b) calls for the
'satisfactory' storage provision for all items including mobile equipment not in regular
use, linen, laundry, waste, sterile stores, domestic cleaning equipment and patients
belongings. No journal articles were found relating to ward storage facilities.
Huang et al, 2006) conducted research into the contamination of surfaces and furnishing
and measured the time which pathogens remain on the surfaces of patient charts (11
days), table tops (12 days) and curtains (9 days). The research concluded that irregular
surfaces play a part in the retention of pathogens and that these environments should also
be de-contaminated as part of the containment of an outbreak of MRSA (Huang et al,
2006).
'Clostridium Difficile infection: how to deal with it' (DH, 2008c) details the
decontamination procedures during and after an out break of Clostriduim Difficile. This
includes the thorough cleaning of the internal ward area including all ward furniture and
equipment. No published literature was found relating to the regular decontamination of
ward furniture and equipment in centralised or local facilities. Eagles (2008), in his
dissertation, does detail the centralised equipment decontamination facility in his case
study of an NHS Trust.
The requirement for the provision of changing facilities for staff is eloquently detailed in
the article by Nye, Leggett and Watterson (2005), who also note that uniforms are a
potential source of cross infection in the clinical setting. A news article in the Nursing
Standard accused hospitals of breaking the law by not providing adequate changing
facilities for staff (Stephenson, 2005). This does not appear to have been substantiated as
there is then no comment in the literature.
The only research found relating to staff changing facilities was the work by Yu et al
(2007), which was undertaken in China. The study was undertaken to investigate 128
ward in 26 hospitals and looked at why severe acute respiratory syndrome (SARS) spread
on some wards and not others. One of their key conclusions was that the provision of
staff changing facilities at ward level helped to reduce the risk of nosocomial (hospital
acquired) outbreaks of SARS (Yu et al, 2007).
- 24 -
As these were the only articles found on the subject of staff changing facilities this could
be an indication of the low priority this facility has become for NHS Trusts.
The relationship between the performance of the built environment in relation to CoI is
under-developed in the mass of literature relating to infection control. The literature
that was found was predominantly government guidance and „grey literature‟. There is
very little academic research on the elements reviewed. This is possibly due to the fact
that the majority of research is carried out by doctors, nurses and academics who tend to
focus on the infections, transmission routes, treatments and preventative measures in
clinical practice.
This relative lack of strength of published evidence led the research team to believe that
the research study was worth pursuing as it could develop knowledge in this field and
enhance the published evidence base.
- 25 -
3 QUESTIONNAIRE TO ACUTE NHS TRUSTS
The literature search was followed by a Freedom of Information (FoI) request to all acute
NHS Trusts relating to how they spent the £300,000 capital money made available to
most NHS Trusts to make improvements relating to infection control in 2006/07. There
were some challenges in using FoI as a research tool to collect data. These are
summarised below:
It was slow work finding the FoI addresses as there is no central database.
Some addresses were wrong which impacted on the response rate.
There was some confusion over funding in question (capital or revenue) as more
money was issued in the next financial year - so some responses had to be
rejected.
Questions needed to be objective to ensure reply.
Responses came back in various formats which made collation very slow.
Some responses were very generalised, others very specific which made analysis
difficult.
The requests for information on capital spending were sent out to 160 acute NHS Trusts.
There were 124 replies of which 13 did not receive funding. There was some confusion
over the money in question as the following financial year a similar sum was made
available to NHS Trusts to carry out deep cleaning – this money was revenue money and
so it was not spent on structural changes. The NHS Trusts who responded in relation to
the wrong money were re-contacted and asked to answer the questions in relation to the
earlier money. Some did but others declined.
The FoI route yielded a 77% response rate. The questions asked are detailed in table 5.
Table 6 Freedom of information questions
1. Did the Trust bid for the HAI capital monies available?
2. How was it spent – were there any deviations from their original plans?
3. Who was involved in the decision making?
4. With more time would the Trust have done anything differently?
5. Has the Trust undertaken any infection control related facilities improvements
subsequent to the initial money?
- 26 -
Responses to the freedom of information questions
• Did the Trust bid for the HAI capital monies available?
The assumption had been that all NHS Trusts had been required to put in detailed bids for
this allocation of money. The responses showed that most NHS Trusts did have to put in
detailed bids, whilst a few either did not have to bid at all and were just given the money
or they only had to outline how they would be spending it. There were 13 NHS Trusts
who said they did not receive any money – these were mostly specialist NHS Trusts with
very low infection rates.
• How was it spent – were there any deviations from their original plans?
NHS Trusts have invested the funding grants allocated to reflect different priorities. From
the survey responses it was apparent that the work carried out was concentrated in key
sites. These were ward areas, including bathroom renovations and sluice room upgrades,
as well as general refurbishment, Critical care, Endoscopy units, Cleaning facilities plus
equipment, and general items such as teaching aids.
One NHS Trust used the money to partly fund the purchase of an additional building
which then gave them room to increase the spaces between beds. All other responses
related to changes within existing buildings.
Figure 1 Key drivers of the capital spend
31.5
19
15.5
5
0.75 0.45
27.8
0
5
10
15
20
25
30
35
% of total capital spend
Changes in Thinking Backlog maintenance
Technological Innovation Behaviour
Changes in Guidance Solutions to Design Issues
Other
- 27 -
Table 7 Identified drivers for capital spend
Drivers Percentage of
Total capital
spend
A Backlog maintenance (needed doing anyway) 27.8%
e.g. – Refurbishments
– Flooring upgrades
– Replacement commodes and macerators
– Replacement furniture (patient chairs and bed
tables)
B Changes in guidance 5%
e.g. – Endoscope decontamination
– Tracking of surgical instruments
C Changes in thinking 31.5%
e.g. – Requirement for more isolation facilities
– Removal of carpets from clinical areas
– Closed storage areas
– Wall tiles no longer acceptable
– Centralised cleaning areas for ward furniture and
equipment
– Addition of clinical hand wash basins in sluices
D Technological innovation 19%
e.g. – Bio-Cote® antimicrobial coating using silver ion
technology
– Micro-fibre
– Disposable curtains
– CoI IT tracking/ monitoring systems
– Ultraviolet cleaning systems
– Hydrogen peroxide cleaning systems
E Behaviour 15.5%
e.g. – Additional clinical hand wash basins (including at
ward entrances and in sluices)
– Floor signage
– Teaching materials and displays (including talking
frames and audio messages in the lifts)
F Solutions to design issues 0.75%
e.g. – HEPA filter radiator vacuum cleaner
– Addition of doors to separate wards (automatic)
There were a number of NHS Trusts who reported deviations from their original plans.
These were due to under estimation of cost, inability to gain access to areas to carry out
work and time scales.
- 28 -
A summary of the key drivers identified for the work undertaken is shown on the graph in
figure 1. Table 6 shows examples of what was in the categories. It would be interesting to
know if this is a reflection of capital spending in general. It was not within the scope of
this study to investigate this further.
The most frequent individual interventions identified were new clinical hand wash basins
and sensor taps (9%), refurbishment of showers/bathrooms and toilets (6%), creation of
additional single bedrooms with en-suite toilet/bathrooms (5%), replacement of
commodes (4%) and the creation of centralised equipment decontamination areas and
additional equipment (3%).
The reported action of adding of clinical hand wash basins into sluice rooms appeared
unusual to the research team. They expected that sluice rooms would be designed to have
a clinical hand wash basin. The relevant guidance was checked, Health Building Note
04-01 (DH, 2008a), and there was no mention of a clinical hand wash basin being
required in a sluice room.
It was apparent that NHS Trusts were making different choices and some were doing the
complete opposite to other NHS Trusts. Though the numbers in these areas were very
small, it was of interest to the steering group, all of whom had experienced issues in these
areas. The areas of divergence are summarised in table 8.
Table 8 Areas of divergence in reported capital spending
CoI Activities
A Curtains
– Replacement curtains with anti-microbial properties
– Replacement of curtains with disposable curtains
– Replacement of curtains with screens
B Sluice
– Replacement of old macerators with new
– Replacement of old bedpan washers with new
– Replacement of old bedpan washers with new macerators
C Cleaning methods
– Micro fibre
– Dry air systems
– Vapour technology
– Hydrogen peroxide
• Who was involved in the decision making?
The Director for Infection Prevention and Control (DIPC), estates manager,
housekeeping manager, matrons and capital projects team members were all represented
in responses Only a few NHS Trusts mentioned that they had used the services of
- 29 -
architects or designers. This was probably because most of the works were small
changes in many places such as elbow taps being changed for sensor taps in specific
areas.
• With more time would they have done anything differently?
This was seen as a subjective question and therefore most declined to respond as they are
not required to do so under the FoI legislation. Of those who responded almost all said
that they would not have done anything differently but would have appreciated more time
to plan. The bids were asked for in December with the money released in February and
having to be spent by the end of that financial year. This had not been such an issue for
NHS Foundation Trusts as they were allowed to carry the funds forward to the following
year.
• Any infection control related facilities improvements subsequent to the initial
money?
All the responses indicated that they had continued to improve facilities in relation to
infection control through their capital projects or refurbishment schemes. Some of the
responses were very generalised whilst others listed specifically what they had been
doing. The interventions that were mentioned are similar to the list of original
interventions in response to question 2. This demonstrated that the initial interventions
were not one off's and are being repeated.
- 30 -
Freedom of information summary
Using the FoI route as a research tool was very rewarding. Useful and insightful data was
obtained which provide the basis for the next stage of the project. The full data collated
is shown in Appendix 1.
The process was not without its problems. The formatting of the material provided
varied widely, making collation very difficult. The manner in which NHS Trusts chose
to respond was variable too. Some NHS Trusts gave highly detailed replies whilst others
gave high level overviews which made the analysis of the data less straight forward.
From the data collected it was apparent that the reasons for the work carried out, fell into
the broad categories of backlog maintenance, changes in guidance, changes in thinking,
new technologies, behaviour and design issues.
It is clear from the activity in the NHS Trusts and the literature review that there is not
always published evidence underpinning their actions. In the case of clinical hand wash
basins in sluice rooms the activity was not included in the DH guidance for sluice rooms.
The team felt that the areas with little or no evidence in the literature should be explored
further. The key topics chosen for further debate at the focus groups are detailed in table
9.
Table 9 Original focus group discussion list
Subject for discussion Reason for choice
Curtains – standard fabric, anti-bacterial
fabric, disposable or remove and replace
with screens
There is a lack of evidence in the literature
regarding curtain choice. From the
questionnaire results it is clear that there are
a range of solutions to this.
Clinical hand wash basins at ward
entrances
Activity – no evidence in the literature
Clinical hand wash basins in Sluice/ dirty
utility
Activity – no evidence in the literature
Macerators vs. bedpan washers Mixed evidence and mixed activity
Sensor taps Activity – no evidence in the literature
Changing facilities for ward staff Mixed activity – limited evidence
Centralised ward equipment
decontamination areas
Activity – no evidence in the literature
Flooring (vinyl in all clinical areas and
coving instead of skirting)
Activity – little evidence
Ward storage (quantity and method) Little evidence – mixed activity
Choice of cleaning method Mixed activity – little evidence
- 31 -
Areas excluded from further investigations were endoscopy and surgical instrumentation
tracking as the actions taken were in response to recent well documented guidance. Also
excluded were actions which were not directly related to design. These included IT,
replacement commodes, furniture and teaching aids.
Once the data was collated and the trends apparent, the results were shared with the
steering group for their opinion.
- 32 -
4 STEERING GROUP INPUT
The steering group met 3 times during the project (see table 3). The first meeting was at
the start of the project to agree and approve the methodology of the research study. The
second meeting followed the completion of the FoI request analysis and is detailed
below. The third meeting was at the conclusion of the study to assist with pulling the
strands of the study together.
The second steering group meeting was the forum for presenting the responses to the FoI.
It became apparent from the discussion that there were issues and dilemmas being faced
(table 9) regarding the key points drawn from the FoI request.
From the steering group the following design dilemmas were identified:
Table 10 Design dilemmas for infection control
New build vs. refurbishment There are different issues posed by the type
of building project. Refurbishments tend to
be more restrictive in relation to what is
possible to change to achieve infection
control design requirements
Variable age of the estates and size of sites
Different aged buildings require different
solutions to infection control issues and this
is the same for different sized sites
Choice without substantiating research
evidence
There are numerous products on the market
purporting to be antimicrobial resistant but
there is little research evidence directly
relating to the realities of hospital
environments
Differing views of infection control teams
There appears to be some subjectivity in
decisions made by infection control teams –
probably due to „choice with out
substantiating evidence‟
Affordability vs. risk Some solutions are more expensive than
others, NHS Trusts have to keep within
budgets and have to „cut their cloth‟
accordingly
Preventing problems for the future Trying to predict what will be problematic
in the future is difficult.
Incorporating new technology
– Developments are so fast that designs
can be out of date before construction is
complete
– How is the design brief kept flexible to
accommodate late changes?
- 33 -
There is a dichotomy between the statutory, mandatory and compliance with infection
control principles. DDA and building regulations can conflict with CoI guidance.
An example of this was given by one of the steering group who shared a case study
regarding the placement and height of clinical hand wash basins in clinical areas (see
Appendix 2).
In the case study there were requirements for clinical hand wash basins in numerous areas
for a variety of infection control reasons. A problem arose when the building officer
insisted that they all be positioned at the accessible height in line with the DDA. The
case study details how, by discussion access and detailing who would use which sinks for
what purpose, compromises were made in order to keep the building functional for the
users.
Infection control measures are not „mandatory‟ and can be subjective. They are,
however, extremely important to NHS Trusts. The steering group felt that stakeholder
inclusion resulted in sensible local decision making on CoI design issues.
The insights from the steering group helped to set the scene and the discussion points for
the focus groups.
- 34 -
5 FOCUS GROUPS
Stage three of the study consisted of a series of facilitated focus groups. Focus group
methodology brings together an informal group of people who share common
characteristics, to discuss or share their experiences about a specific topic or problem.
They are a useful research tool to identify a wide range of experiences around specific
topics and to collect data to address the research aim and objective.
The disciplines chosen were microbiologists, control of infection nurses, facilities
managers, estates and capital planning managers and architects and designers as all of
these groups have been involved in the decision making and planning of the capital
spending for control of infection interventions in stage 2. It was decided to hold uni-
disciplinary focus groups as previous experience in the team had shown that this allowed
individuals to speak more frankly and openly about the issues they faced than would be
elicited in a multi-disciplinary group. It was agreed that multidisciplinary discussions
could be held following the initial focus group meetings, if required.
It was also noted that none of the NHS Trusts in stage 2 had patient representation on
their decision making groups, which may have been due to the time constraints rather
than the intention to exclude them. The research team and steering group agreed that
there would be value in seeking the view of patients or patient representatives as part of
this research. The Patients Association, a well established national patient group, was
contacted and a focus group was convened from their members. This meeting was held
after the other focus group meetings for control of infection nurses, microbiologists,
designers, facilities managers and estates managers. The patients group were asked to
review and comment on what had been raised in those focus group meetings.
Participants in the five uni-disciplinary focus groups were acknowledged experts in their
field, selected through the knowledge and contacts of the research team and steering
group. All were contacted by email and asked if they would be interested in attending
focus group meetings based on pre-selected dates. At least two members of the research
team attended each focus group.
Attendance at the focus groups was variable as the dates coincided with the swine flu
outbreak which caused particular issues with the microbiologists group. Attendance
ranged from four to thirteen per group.
All of the focus groups were audio taped except the patient group at which only notes
were taken. Notes were also taken by the members of the research team present. The
audio tapes were transcribed by a professional company (see sample of a transcript in
Appendix 4). The combination of the transcriptions and the notes formed the summary
of the discussions (Appendix 5).
At each focus group the discussions were based on the key themes from the findings of
the stage 2 of the research and the literature search. The key themes were presented and
- 35 -
members invited to discuss the issues and give their professional views based on their
own experiences and knowledge.
Table 10 shows the matrix used to identify areas for further exploration. It is not possible
to judge the no evidence/ no activity element as we do not know what we do not know. It
was also not possible to judge from our enquiries where there is evidence but no activity.
Table 11 Categories for activity and evidence
+ Activity -
-
E
v
i
d
e
n
c
e +
Evidence and activity
Evidence but no activity
No evidence but activity
No evidence and no activity
The analysis of the responses to questions 2 and 5 of the FoI request, in stage 2 of the
study, provided themes and areas where work had been focused. There were also a
number of divergences identified. The findings from stage two and interventions with no
clear evidence base found in the literature in stage one, formed the basis for discussions
at uni-disciplinary focus groups in stage three.
To assist the focus groups a pack of summary sheets was provided containing the list of
subjects to be discussed and a section for each subject with some questions to consider
and a small summary table of the evidence, or lack of evidence, found. These can be
found in Appendix 3. Each group was asked to decide the order in which they wished to
discuss the topics/issues – to ensure they addressed what was most important to them (see
table 9).
All of the focus group discussions were lively and proactive with some strong views
expressed which are captured in the summary of discussions (Appendix 5).
- 36 -
Table 12 Order of discussion chosen by each group
No Topics/issues Control of
infection
nurses
Designers Microbiologists Facilities and
housekeeping
managers
Estates
managers
Patient
representative
group
1 Curtains 1 1 2 1 1 1
2 Flooring 2 2 3 2 2 5
3 Clinical hand wash
basins at ward
entrances
3 3 4 3 3 6
4 Sluice rooms –
clinical hand wash
basins and
macerators vs.
bedpan washers
4 4 5 10 5 7
5 Sensor taps 5 5 6 9 4 8
6 Changing facilities
for ward staff 6 8 7 8 7 9
7 Centralised ward
equipment
decontamination areas
7 7 8 7 8 10
8 Single bedrooms/
patient isolation* 8 6 1 4 6 4
9 Ward storage 9 9 9 6 9 2
10 Choice of cleaning
method - - 10 5 10 3
* Following the focus groups with the designers an additional item „ single bedrooms/
patient isolation‟ was added to the list.
The designers were very keen to discuss the subject of single bedrooms and it proved to
be a popular discussion point in the subsequent meetings. All groups were asked if there
were any other key issues they wanted to discuss but this was the only change/ addition
requested by any of the groups. To keep the discussion points to ten in total the sluice
room became one topic – where the merits of having a clinical hand wash basin in the
sluice and the divergence of macerators or bed pan washers were discussed.
When choosing the order to discuss the topics the infection control nurses chose to just
work through the list in the order it was presented. Other groups made clear choices as
shown in Table 10, the patients group prioritising ward storage and choice of cleaning
method far higher than the estates and microbiologists. The microbiologist's top choice
was single bedrooms which they were very passionate about.
The list of topics was not put together in any specific order. The groups were asked to
prioritise the order in which they wished to discuss the topics, which resulted in a
collective decision. What could have been a useful exercise was to ask the individuals to
rank the list to show their personal preference. This could have given useful comparisons
within each group and between the groups in terms of level of importance attached to
various topics.
- 37 -
Findings
An experienced facilitator with research experience was appointed for the focus groups
and as a consequence all of the groups were good humoured with open and honest
discussions. The key findings with respect to the various topics are as follows:
1. Curtains
Both the control of infection nurses and microbiologist stated that they were equivocal
about the benefits of disposable curtains, antimicrobial coated curtains and standard
fabric curtains. The microbiologists argued that material surfaces do not generally
harbour micro-organisms and that there is no evidence that they distribute organisms
They felt this was a low risk issue in terms of infection control.
Through the discussions with all of the groups it was evident that numerous NHS Trusts
have changed some or all of their curtains to disposables. The strongest reasoning for
this change was evident in the facilities management focus group. A number of people in
the facilities management group were delighted to have changed to disposable curtains.
They felt that disposable curtains were easier for staff to handle as they come in boxes,
easier and faster to change, and are all in one colour throughout the NHS Trust so there
are no concerns regarding matching patterns or issues with differing hem lengths where
some curtains have shrunk in the wash. This is an example of the type of problem they
were dealing with before the change to disposables. None of their issues related to
infection control other than the frequency of changing the curtains.
The estates focus group commented that fast change hooks and track were available for
fabric curtains which reduces the manual handling issues if you choose fabric curtains.
Disposable curtains were not favoured by designers as they are block colours and quite
limited in choice of colour if you want to avoid transparency. Designers preferred fabric
curtains as these can be used to enhance the interior design of ward areas. However the
discussions had no root in infection control.
The reported frequencies of routinely changing disposable curtains were interesting.
Fabric curtains are generally changed to be laundered every three to six months. There
were reports of disposables being changed between 6 months and a year at the focus
groups. This rationale appeared to be due to cost as disposable curtains are expensive to
purchase and to dispose of.
One NHS Trust reported that they had changed to disposable curtains but they were
having frequent patient infections. As a result the curtains were regularly changed and
the cost of the new curtains and the waste costs were not sustainable. It is interesting to
note that this NHS Trust is now in the process of changing back to fabric curtains.
- 38 -
The patients group felt that there should be appropriate information available to NHS
Trusts so that they could make informed decisions regarding what choice of curtains
would be suitable for them.
There was also much discussion regarding window dressings and the problems associated
with horizontal and vertical blinds, interstitial blinds (between glass panes), external
blinds and disposables. It appears that there is no standard solution to this issue and it is
being tackled by different NHS Trusts in different ways.
There are some NHS Trusts that are trying to move away from traditional curtains
altogether. This is achieved by using the design of cubicles and single bedrooms to
negate the use of curtains or utilising new technologies such as glass that can be switched
from transparent to opaque and back as required.
2. Flooring
There was consensus across the groups that there is a requirement for smooth impervious
floor coverings that do not trap dust. The finish needs to be easy to clean and maintain for
its life time.
The life time of the flooring needs to be long (years) as it is logistically difficult and
costly to close wards to replace flooring frequently.
It was felt that although carpet can look good, reduce noise and in some cases accelerate
recovery (when learning to walk again) it is not a practical solution in acute ward areas.
It does not tend to look good for long, and rarely responds well to being cleaned with
bleach based products, which are required if there is any spillage of body fluids.
Carpets are too difficult and costly to maintain in the clinical environment and there is
anecdotal evidence of carpets harbouring infection and being the causal factor in not
getting an outbreak under control. Vinyl, linoleum or marmoleum are commonly used in
practice and generally recommended. The latter two are sustainable options but are
difficult to 'seal' to prevent absorption of fluids and subsequent staining.
Wet areas such as bathrooms, shower rooms and toilets require a non-slip surface. There
are reports of the dimpled versions being difficult to clean as they gather grime in the
recesses and the high friction versions shredding micro fibre mops, hence these are also
difficult to clean. There is no definitive solution to this.
The finishing detail where the flooring meets the wall was raised as an issue. Some prefer
to run the vinyl up the wall, giving the added benefit of wall protection, others prefer
coving and capping. The more joins and joints there are the greater the risk of a gap
which acts as a potential reservoir for infection. One microbiologist was of the same
mind as Florence Nightingale and called for an elimination of corners. In the estates
focus group one member cited a case where there was an opinion that the floor finish in a
- 39 -
side room was poor. There were however 17 corners in the room, with 17 seals, so this
was never going to be an easy floor to lay and finish well. The focus groups felt that
these need to be considered when areas are designed.
There were also reports of issues with retrofitted inset floor designs - either decorative or
instructional (e.g. clean your hands, way finding etc). It was felt that this interrupts the
integrity of the original flooring material and can lead to gaps and lifting of sections
where water gets underneath. However, it was noted that if these are fitted as part of the
initial flooring laying they appear to be better as their welds are more likely to stay intact.
Our recommendations for designers is that the method of cleaning needs to be matched to
the floor surface and finishes chosen or visa versa, to ensure that cleaning methods and
regimes will be suitable for the finished product. The number of facets, therefore corners
and seals should be kept to a minimum.
It was also noted that light coloured floor finishes are preferred as it is easier to see when
they are dirty. The high volume of traffic across ward floors was also noted and how
rapidly the floor becomes dirty after cleaning. The patient group wondered about the use
of protective overshoes as a solution to this.
The microbiologists wondered if it would be possible to get flooring to work harder by
being technologically responsive to being clean or dirty. Suggesting either a colour
change vinyl that indicated when it had been cleaned or a coated vinyl that glowed when
it was contaminated.
3. Clinical hand wash basins at ward entrances
There was overall agreement that there should be clinical hand wash basins at ward
entrances as an infection control measure, though initially the microbiologists appeared
to be against them. It transpired that they felt they would be audited on clinical hand
washing at these sinks and they were not necessary for doctors to use. Their feeling was
that there should be more sinks closer to the patients. However after a lengthy discussion
they did agree that they were beneficial for general use but needed to be designed so that
more than one person could wash their hands at a time. It was also felt that there should
be basins at the exits to wards too. All of these facilities should be designed to prevent
water spillage on the floor and should have hooks and or shelves where bags and items
being carried could be set down to enable efficient clinical hand washing. The clinical
hand wash basins should be clearly visible to those passing but be positioned in such a
way as to prevent damage from ward traffic, beds and wheelchairs etc.
Generally it was felt that hand driers are too noisy for use in ward areas, but they could
be considered at the ward entrances.
The estates managers focus group reported conflict with building control and the
application of DDA, where they were forced to install clinical hand wash basins at
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wheelchair height that would be used by staff who were standing. The message from the
group was that this can be avoided with a good access policy which identifies who the
users will be. This was also reflected in the case study from the steering group (see
section 4, page 40 and Appendix 2). One NHS Trust reported putting two clinical hand
wash basins in at the ward entrance, one at each height.
Two groups mentioned the possibility of using CCTV to monitor usage of the clinical
hand wash basins. The patient group went further suggesting that entry to the ward
should only be gained if people were seen to wash their hands.
The microbiologists liked the thought of utilising RFID (Radio frequency identification)
to track staff and see when they went close to clinical hand wash basins. The RFID
system would not let you know that they had washed their hands but could still be useful.
The microbiologists could envisage this technology being useful to track patients‟
movements within the wards too.
4. Sluice rooms – clinical hand wash basins and macerators vs. bedpan washers
There was consensus that there should be clinical hand wash basins in sluice rooms in
addition to equipment washing sinks. This clinical hand wash basin should be positioned
adjacent to the exit from the sluice room . The placement of a clinical hand wash basin in
the sluice room is not in the guidance.
There was again consensus on the debate on macerators versus bed pan washers, with
macerators being heralded as more reliable, efficient and the best option for infection
control.
5. Sensor taps
It is noted that the general trend is towards sensor taps as they look good, are easier to
clean and prevent cross infection due to the „no touch‟ technology. It would seem that
some designs are more successful than others and the key to success is to get the water
flow and temperature right.
There were some issues mentioned regarding cold water to clean teeth with when sensor
taps have been installed. Some NHS Trusts have retained traditional patient bathroom
taps to overcome this.
The microbiologists were also very keen on sensor flushes for toilets as this further
reduces a contact point for cross infection. They were also impressed with designs
incorporating sensor lights and doors that open with sensors. All of these design choices
negate the need to touch items and therefore reduce the risk of cross infection.
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6. Changing facilities for ward staff
This subject was strongly supported as a requirement for wards. There was a minimum
requirement of one changing area per floor mentioned and the preference was for local
changing areas. These should be of adequate size and of „swimming pool‟ changing room
standard to ensure they are attractive places which would encourage use. Current practice
can be no changing facilities and staff are changing in toilets.
It was noted that there were various reports on uniform policies, doctor‟s uniforms and
the laundering of uniforms on site. However, there seems to be a variety of arrangements
across the country. The ideal would be for all uniforms to be laundered by the NHS Trust
as this ensures that they are washed at the appropriate temperatures to kill bacteria.
It was not clear from the discussions how much risk there is in staff laundering their
uniforms at home. There was a general agreement that staff should not be seen in
uniform outside hospitals.
7. Centralised ward equipment decontamination areas
There were mixed reactions to this idea or way of working. Many of the discussions
were around the management of such a system and the segregation of dirty and clean
equipment, the requirement of additional furniture but less equipment if managed in a
library manner.
There were discussions in most of the groups regarding the logistics of centralised
decontamination areas. The practical elements of transporting „dirty‟ furniture from the
ward to the facility and transporting clean items back. Some NHS Trusts have a shrink
wrap system for their cleaned items. The separation or management of routes for clean
and dirty items is a key consideration in the implementation of this type of system.
A particular issue is the space required to set up a ward equipment decontamination
system which precludes some NHS Trusts from setting up a system. This is because
space is required for the storage of the dirty items coming in, for the cleaning and drying
to take place and for the storage of the items once they have been cleaned before they are
dispatched back to the wards. One group discussed off site decontamination as a solution
but this requires a larger increase in furniture and equipment stock.
An additional benefit of a centralised system is that the equipment can be assessed,
maintained and if required replaced on a regular basis. Few hospitals have a regular
inspection, maintenance and replacement system in place for ward equipment and
furniture.
The main consensus was that there should be a facility to decontaminate furniture and
equipment, this should be centralised but could be local. Key drivers in this decision
would be space availability and cost of cleaning equipment and personnel.
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8. Single bedrooms / patient isolation
It was clear from the focus groups that the requirement for single bedrooms is
multifaceted. The more single bedrooms you have the better you can address privacy and
dignity issues, and accommodation can be used more flexibly in gender terms enabling
greater bed occupancy. For infection control the segregation of patients, the separation of
relatives at visiting time and the ability to clean the area thoroughly when the patient is
discharged are all benefits. Isolation rooms are required to manage infectious patients.
Isolation rooms need a lobby as detailed in the HFN 30. The air flows in these rooms
should be mechanically managed and extracted air filtered before it is expelled from the
building.
Design issues for single bedrooms were that they should all have en-suite facilities and
adequate space for equipment and bed type, including extensions. There needs to be
careful management of air flows to ensure air from the rooms does not circulate into
shared areas (corridors etc.).
There was clear frustration from the microbiologists who had experienced the abuse of
single bed rooms, finding them used as store rooms or offices. Space is usually as a
premium in NHS Trusts and only good design, planning and management will ensure the
appropriate use of single bedrooms.
There was no clear outcome regarding the efficacy of 100% single bedrooms, but there
were comments on the number of bathrooms that are created if all are en-suite and how
much additional cleaning work this created. This was from the microbiologists and the
housekeeping focus groups.
It was also mentioned that where there is not enough space to introduce more single
bedrooms some NHS Trusts are putting doors on multi-bed bays to give an element of
containment. There are also a couple of NHS Trusts who have removed a bed from a 6
bedded bay and put in a shower room with WC, together with a clinical hand wash basin
in the bay for staff use and doors on the bay entrances. This assists with containment –
patients do not need to leave the bay to use the bathroom and provides facilities for staff
to wash their hands whilst in the bay.
Doors on the multi-bed bays are generally sliding, sensor activated and comprised of
toughened glass.. This gives maximum visibility into the bays. The sliding action
minimises air disturbance which helps to reduce contamination and the sensors mean that
nothing has to be touched for entry or exit.
One of the comments from the microbiologists was that even when patients are in
isolation rooms the doors are often left open. It could be possible to use the door types
being retrofitted to bays in the single bedrooms. This would ensure that doors were not
left open but that access was straight forward.
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9. Ward storage
All groups were in agreement that 'adequate' ward storage is essential. Experience from
the groups was that this is not often the case. The focus groups design recommendations
included that storage should be closed or sealed preferably behind glass to prevent
contamination but to enable supplies to be easily seen. Storage should be to the ceiling or
have sloped tops to prevent dust gathering on top. Static items should be stored off the
floor to prevent contamination and facilitate cleaning. Shelving should be mobile or
sliding to maximise space and facilitate cleaning. It should be designed to accommodate
what needs to be stored including drip stands, hoists, stores, linen and waste.
Management of storage was raised. Stores should be kept to a minimum so if they do
become contaminated there is minimal loss when contents are discarded. „Just in time‟
deliveries were recommended. Technological changes for materials management are
continuous. Ensuring the design brief is flexible enough to accommodate late changes is
essential to ensuring facilities have the most up to date system.
10. Choice of cleaning method
This section was not discussed by the designers as they felt they had little knowledge of
the subject. It was also not discussed by the control of infection nurses due to lack of
time.
The patients‟ focus group said this is the topic that they have the most calls about, usually
relating to general cleaning and its frequency.
Through the discussions it was clear that there are issues of access to get areas clean.
There is constant pressure on beds in all areas. With hospitals striving to meet
government targets including 4 hour A&E waits, 18 week treatment from referral times
and 2 week cancer referral times, this is unlikely to change. This pressure restricts the
time available to clean bed areas between patients as well as day to day cleaning. The
extra time required to carry out a „terminal‟ clean when an infectious patient has left a
single bed room is often problematic to bed managers. How this constant pressure and
conflict will be managed has to be considered when facilities are designed.
The microbiologists commented on management of cleaning stating that methods should
be kept simple to ensure compliance. They mentioned that open visiting on wards
restricts frequency and access for cleaning. They also felt it important to value cleaning
staff who have an unpleasant and poorly paid job. Valuing staff and giving them specific
areas of responsibility helps them to develop a pride in their work.
It is also important to have cleaning schedules for all equipment, furnishings and all
areas. The microbiologists sited an occasion where an outbreak of infection was due to
contact with the nurse call equipment in shared bathrooms. When it was investigated it
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was found that the equipment was not being cleaned as no one had direct responsibility
for doing it.
Some design issues came out of the discussions. The microbiologists felt strongly that
wards need to be designed for easy cleaning and to look clean. The facilities and
housekeeping management group expressed the need for local separate storage areas for
top up supplies e.g. paper towels, soap, toilet tissue, detergent and disposable curtains if
used.
Certain cleaning methods require design input. Micro fibre reusable systems need
laundry services with strict clean and dirty separation. Hydrogen peroxide vapour
requires that areas to be cleaned are physically sealed off to contain the process. Not all
hospitals have the required space or design to implement the range of cleaning methods
available.
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Focus group summary
Apart from the addition of single bedrooms to the discussion topics all of the groups were
keen to discuss the issues highlighted by the responses to the FoI requests to acute NHS
Trusts. Single bedrooms were highlighted in these responses but were initially excluded
as there is a reasonable evidence base for the provision and their use.
A recent National Audit Office report (2009) reiterated the Health Act 2006 (Department
of Health) that “infection control must be everyone‟s responsibility, from clinicians,
cleaners and ancillary workers to patients and relatives” but it is difficult to judge if this
approach is being adopted. Design solutions are responding to this statement. With
clinical hand wash basins at ward entrances, in sluices and no touch taps all visitors and
staff are encouraged to wash their hands and minimise cross infection.
The methods of cleaning, curtain choice, flooring and skirting choice are open to
interpretation. As long as cleaning is thorough, curtains are changed regularly, flooring is
smooth and impervious, the risk of cross infection from these items are low.
The provision of staff changing facilities seems to be of questionable value particularly if
the NHS Trust is not laundering uniforms for staff. However infection control teams
would welcome in house laundering of uniforms as this would ensure that they are
washed at the right temperature and promote changing on entering and leaving the
premises. The general design recommendations from the groups to support this process
was that pleasant changing rooms should be provided either centrally to the hospital or
locally to the wards.
Ward storage and management of supplies are key infection control design and
management issues. Keeping ward areas free from clutter reduces contamination and
allows thorough cleaning. The way storage is designed and what is stored needs much
consideration and must incorporate the principles of infection control.
The decontamination of ward equipment and furniture (including mattresses) is a
requirement but is logistically difficult in large numbers of existing hospitals. The space
and specification of such cleaning areas (drains in floors, adequate ventilation, etc) make
them difficult to retrofit. The additional staff, stock of furniture and equipment is an
additional financial burden. Consideration should be give to creating these areas in
refurbishments and new builds.
The extent and use of single bedrooms is still a cause of much debate. NHS Scotland has
a requirement that all new hospitals will now be 100% single bedrooms. New builds are
in progress in England with 90 to 100% single bedrooms. There is evidence that placing
infectious patients in single bedrooms is an effective measure to combat spread of
infection. There are additional drivers for the single bedroom approach which include
improved sleep and rest, greater privacy and dignity, and flexibility of accommodation.
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With single bedrooms there are not the gender restrictions which occur with multi-bed
bays.
Key infection control principles of cleanliness, tidiness, no dust traps, clinical hand
washing between patients and procedures, together with the containment of known
infections must be incorporated into the designs of ward areas.
It is evident that some decisions have been made under the auspices of infection control
but really meet different needs; curtains are a specific example of this.
At the end of each focus group meeting the groups were asked if they had found the
session useful. All said that it was useful, some said they had learned a few things from
the discussions and the patients and microbiologists said that they really appreciated
being asked their opinions.
There were also comments from the housekeeping focus group that they were not always
invited to the design meetings and when they were it was usually too late in the design
process to influence anything. They felt that this could be improved.
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6 KEY FINDING AND DISCUSSION
This research study has highlighted a number of themes that are important for the
effective and efficient environmental control of infection in inpatient ward areas. This
section discusses the findings from these themes based on the FoI actions and focus
group outcomes and compares it with the literature, analysing what is being done, why
and who is or should be involved in the decision making.
The methods of gathering data via the freedom of information process and discussions
with uni-disciplinary focus groups worked well. The data gathered was valuable and has
given insight into the issues and practices in NHS Trusts in relation to control of infection
and design.
There was consensus in the focus groups regarding the topics for discussion and no one
strongly disagreed with any of the issues presented which arose from the FoI requests.
This was reassuring and demonstrated that the findings from the FoI request were a good
indicator of the issues regularly faced by NHS Trusts. The major areas of interest from
the spending of the £300k were taken forward for discussion at the steering group and the
focus groups. There are potential barriers to achieving best practice in design relating to
infection control. These include: organisational, managerial (and behavioural responses
in operation) and care, these are noted through the discussion.
The aim of the study was to develop design guidelines to identify and implement control
of infection measures in briefing, design development and construction stages and in
managing the operation of hospital facilities.
The study has identified, against the first 3 research study objectives:
1. areas of greatest risk, identified as the ward, and where people are most
concerned for the control of infection
2. the role of different stakeholders in facilities planning and their impact on design
decisions
3. the impact on organisational drivers on key design and management issues and its
influence on infection control measures, the choices available, the potential
constraints and how decision makers may overcome these barriers
A Design and Management Decision Making Tool has been developed from the
identified themes in the research study to inform decision-making and help address
design dilemmas. Finally a series of recommendations are made that including future
research focus.
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The variety of responses in relation to infection control principles are organised into 4
key areas:
Variability of the existing estate
Decision making and stakeholder representation
Patient‟s priorities
Wards and single bedrooms (10 investigated interventions)
Variability of the estate
The research study identified that work carried out by NHS Trusts was driven by a range
of issues including backlog maintenance, changes in thinking, technological innovation
and influencing behaviour. All NHS Trusts are unique in relation to their age, size and
design. Also, the design of wards within each NHS Trust is often different, as the estate
is developed over time. This means that the issues faced concerning infection control and
the suitable solutions are varied. Only one NHS Trust used the money to partly fund the
purchase of an additional building the stated purpose of which was to give them room to
increase the spaces between beds. The research team assert that this accounts for the
array of strategies implemented. It is also recognised by the research team that the
drivers for capital spending is an area that warrants further research.
The choice of solution for the design intervention will be dependent on the age of the site
and constraint of the design of the ward layout. The constraints of the existing estate in
terms of its configuration and layout are organisational issues. This restricts where you
can put things like additional en-suites, single bedrooms, clinical hand wash basins or
additional facilities such as staff changing rooms and centralised decontamination areas.
Certain options are not viable in some settings. For example, the use of hydrogen
peroxide vapour decontamination in open bays is only possible if the whole ward is
empty and sealed off. However single bedrooms are well suited to this method of
cleaning.
Where budget constraints also dictate the extent of possible estates improvement,
stakeholders might prioritise those design interventions that are informed by stronger
existing evidence base e.g. the position and accessibility of wash hand basins. NHS
Trusts might find that existing layout constraints conflict with statutory DDA compliance
and non-statutory infection control guidance, e.g. equipment handling informing bed
spacing, clinical hand basin heights in single rooms.
All of the information from the FoI requests related to refurbishment of existing estates.
It could be argued that this dilutes the strength of the evidence and that it is only
applicable to refurbishments. However there were a number of representatives from
recently built facilities at the focus groups. When the key issues were discussed their
experience was similar, suggesting that the key issues and principles for the control of
infection to be considered are the same whether it is new-build or refurbishment. The
difference is that there is often a wider choice of solutions with a new build.
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Decision making
There are financial constraints faced by NHS Trusts. They have to make tough decisions
and stay within their budgets and this can limit the choices available. Decisions are often
based on risk to the patient and to the NHS Trust which can be difficult with a
generalised lack of documented evidence as support.
Notable too, are the unsubstantiated claims of new products aligned to current trends to
meet the control of infection.
Ensuring that the design and fabric of the building make cleaning easy, prevent dust traps
and accumulation of dirt and grime, is essential. Supporting this with design that reduces
the number of surfaces that need to be touched, corners to trap dust and are awkward to
clean and clinical hand wash basins at strategic points all have huge benefits. To get this
right the correct stakeholder representation is required in the design process. The answer
to the question in the FoI request “who was involved in the decision making?” was
uniformly the same. The key people involved were the infection control leads, facilities
staff and estates staff. However it appears from the focus groups this is not generally the
case for capital works in NHS Trusts. There seems to be a lack of regular and timely
consultation with infection control, housekeeping services and facilities.
It is evident from the research study that the £300k received by acute NHS Trusts was
spent in a variety of ways. The purpose of the money was for acute NHS Trusts to
implement structural measures that would assist with the control of infection. It is clear
that a significant proportion of the monies were spent on improving ward
environments. The research team identified that this was because the ward area is where
in-patients spend the majority of their time and so it is where they are most vulnerable to
contracting HAIs. Therefore this is where the biggest benefit to patients could realised.
The decisions on how the money would be spent were made in the same way in all
Trusts. The infection prevention and control team, estates managers and facilities
managers were all involved. The notable missing stakeholders were patients. The
research found, through the focus group, that representation of patients would probably
not have influenced the outcome of the spending but would have strengthened the
decision making process.
NHS Trusts were time constrained when the capital challenge funds were released late in
the financial year. However, in the FoI request, the majority of NHS Trusts said that they
would not have spent the money any differently even if there had been more time. The
research study concludes that with key stakeholder involvement it is possible to make
robust design decisions in short time-scales. It was noted though that only a few NHS
Trust specifically mentioned that they used an architect. This implies that the decision
makers were all 'in-house'. This is an interesting dynamic to note; it appears that the
short time-scale and in-house team work was a successful combination. The research
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team recommend that NHS Trusts should foster in-house team work to enhance their
capital projects.
The research team also recommend that to ensure CoI is embedded in the design the
relevant CoI principles need to be clearly stated at the commencement of each project.
NHS Trusts need to implement an informed “common sense” approach to infection
control when refurbishing or building new facilities. Consideration must be given to how
the CoI principles impact on each element and area of the design. Once identified the
CoI principles and areas of impact should be documented to prevent them being lost in
the design process.
Stakeholder engagement and management are vital to the issues being raised and
addressed in the most appropriate and timely manner. This engagement provides better
informed decision making and avoids conflict between design and management issues.
Staff working directly in the ward appear to be rarely asked for their opinion or views on
what the issues are and yet they are best placed to be aware of what is relevant to the day
to day management of the area. The research team recommend that stakeholders are
involved in the design process from the beginning and at regular intervals throughout the
process. The use of uni-disciplinary focus groups could be used for this as people may be
more inclined to speak openly and honestly in this setting.
The Design Dilemmas case study found that coordination of the design considerations by
all the stakeholders could determine an agreed hierarchy of design options for clinical,
public (including staff) and patient spaces. The study has proposed how these could lead
to a best „optimised‟ (not standardised) solution for statutory compliance (sometimes
with locally agreed derogation with Building Control) that could omit the need for very
expensive duplication of resources and equipment (final table Appendix 2). This
collaborative working is recommended by the research team both at the design stage and
in the construction stage (as in the case study). This should lead to favourable outcomes
and improved infection control measures built in to the fabric of the clinical area.
The tracking of any changes and rationale for any should be documented through the
iterative process of the design. Other management and stakeholder issues may appear
more pressing and important and in some instances they may be. But any proposed
changes that that compromise the CoI principles must only be made in consultation with
the CoI teams. Working in this way will prevent conflict, potential cost and overrunning
of projects as reworking of design and potentially construction due to issues in relation to
CoI will be negated.
Patient priorities
Patient care is the centre of the control of infection agenda and is the priority on wards.
To hear the patient group‟s voice in the decision making would install local confidence
and ensure that a Trust is able to communicate that the control of infection in the built
environment means something broader than cleanliness programmes (and similar
initiatives). This requires the integration of thinking and practice around the design and
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management of the built environment that surrounds acute hospital care. The research
team recommend that patients are involved in the design process.
The research study found that the patient requirement is for an environment that is easy to
clean, looks clean, is uncluttered and provides ample opportunity for clinical hand
washing. This echoes the work of Whitehead et al (2007) regarding importance of the
perception of cleanliness. It was interesting to note from the patients focus group that the
largest number of enquiries the Patients Association receive are regarding cleanliness
and what standards should be in place.
Wards and single bedrooms
From the research study findings and the literature it is evident that patients are most at
risk of contracting a hospital acquired infection in the place they spend the longest time.
In general terms this is in the ward area.
The single bedroom model is limited in the NHS with a few new-build projects planned
and emerging. The study found that some of the focus groups consider the provision of
single rooms and side rooms (distinct from higher performance Isolation Rooms with
ventilated lobbies) an important factor in the support of infection control prevention
although this study found limited literature on the efficacy of single rooms in relation to
the control of infection. It is unclear whether management of outbreak situations are not
just as well managed within the ward irrespective of the proportion of single rooms,
though logically it appears that single rooms should improve containment. This research
study asserts that the comparison of patterns of infection within Trusts and between
existing and newly refurbished wards would be a useful addition to the evidence base.
In the FoI responses some NHS Trusts were looking at architectural separation
techniques for the refurbishment of wards. It was mentioned that where there is not
enough space to introduce more single bedrooms some NHS Trusts are putting doors on
multi-bed bays to give an element of containment. There are also a few NHS Trusts who
have removed a bed from a 6 bedded bay and put in a shower room with WC, together
with a clinical hand wash basin in the bay for staff use and doors on the bay entrances.
This assists with containment – patients do not need to leave the bay to use the bathroom
and provides facilities for staff to wash their hands whilst in the bay.
The way patients are treated in terms of antibiotic, invasive procedures and isolated when
they are infectious are very important (DH 2006a, 2007a, 2007b). Equally important are
clean wards and precautions for clinical hand washing for everyone in the ward.
Supporting these activities is the design and fabric of the building.
The research found that a number of NHS Trusts used part of their funding to replace and
upgrade floors in ward areas. The literature states that the numbers of facets and corners
should be minimised and that the seals at these points must be effective i.e. flush, water
tight and with no gaps for dust to gather. Replacement flooring often has to go into areas
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that have not been radically altered. So if there were problems with multiple facets
before this is unlikely to change.
Clinical hand washing remains the most effective defence against CoI (NAO, 2009). The
research study found evidence that supports the location of clinical hand wash basins in
strategic places at the entrance of the wards (and there might also be consideration to the
exit), positioned prior to reaching the patient bed in single rooms or locally to bed bays
being beneficial. They should be visually obvious and their soap, paper towels and
shelving accessories appropriately positioned to prevent water spillage on the floor. This
links to the work of Lam et al (2004) who found that visible well stocked sinks encourage
clinical hand washing.
The introduction of sensor taps and toilet flush negates the need to touch things and
further reduces the risk of cross infection or recontamination. This takes the work of
Preston (2005) a step further, as her work recommended elbow or foot operated taps to
prevent recontamination of hands, it is realised that sensor taps were not readily available
at the time of her work. The focus groups were predominately in favour of sensor taps
for the reasons stated above. It seemed that the initial sensor taps produced were not
good at regulating temperature or flow; however these issues have now been rectified.
The FoI information and focus group discussion relating to clinical hand wash basins in
the sluice rooms gave a clear indication that they should be in the guidance as a key
requirement. The review of the literature found that this is not the case currently. The
research team recommend that this be added the HBN 04-01 (DH, 2008b).
From this research study it appears that macerators are generally favoured over bed pan
washers. The discussions and reasoning for this was based on the reduction of risk. With
bedpan washers there is the risk of residual contamination but with macerators the whole
product is flushed away. There was no literature found to support this.
There was much debate and discussion regarding the type of curtain solutions employed
by NHS Trusts. The FoI revealed, and focus groups confirmed, that NHS Trusts are
implementing different curtain options. Research by Trillis et al (2008) shows that
curtains can be a route for the transfer of infection on hands of patients and care givers
but the risk is low and is eliminated with appropriate clinical hand washing (i.e. before
and after patient contact). The microbiologists and control of infection nurses also felt
the risk of HAI from curtains was low.
The options available for curtains are fabric, antimicrobial coated curtains and disposable
curtains. The control of infection nurse and microbiologists were happy with the fabric
option but said that if the antimicrobial coated curtains were affordable NHS Trust should
go for these. The facilities staff were keen advocates of the disposable curtains as they
are much easier for their staff to handle and much faster to change. However, one NHS
Trust found that disposable curtains were not a sustainable option for them due to cost
and are changing back to fabric curtains. It is clear that the decision making on this issue
is not wholly driven by CoI measures.
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Generally the main point of storage is to do away with clutter, storage off the floor in
particular. However ward storage is not just about medications, infusion fluids,
stores/supplies and linen. Most ward areas have regular use equipment to be stored
including dressing trolleys, standing aids, drip stands etc. Storage solutions need to be
designed for the nature of what needs to be stored. These findings from the research
study reiterate the NAO (2009) report recommendation that more attention needs to be
paid to the adequate storage of equipment, instruments and storage.
There was no direct literature pertaining to the subject of centralised decontamination
areas for ward equipment and furniture. There are detailed requirements of the cleaning
regimes following an out break of Clostridium Difficile which include the
decontamination of all ward furniture and equipment (DH, 2008c). The FoI showed that
this was an area a number of NS Trusts were investing in. Some were increasing their
ward furniture and equipment stock to create a library system. This appealed greatly to
all of the hospital based focus groups and to the patients group. The hospital based focus
groups said that they were space constrained in their Trusts so were unable to implement
this process but they would if they could. Their only options were to provide adequate
places to clean mobile ward furniture and equipment locally to the wards or in empty
bays. It appears from these discussions that the ideal provision is a centralised service.
The research study investigated staff changing facilities. There was little research on the
subject. The study by Yu et al (2007) suggests that staff changing facilities can be
instrumental in preventing the spread of HAIs. It appears that the absence of evidence
has impacted on practice and many hospitals do not provide changing facilities; a matter
commented on by Stephenson in 2005. The FoI revealed that there is some change in this
trend with some hospitals providing new centralised staff changing facilities and others
providing localised changing facilities. Informal testimony from the focus groups
revealed that staff were changing on an ad hoc basis (if they changed at all) in WCs and
storage spaces. Central staff changing facilities are not believed to work as staff present
directly to the ward. The preference from the groups was for high specification, pleasant,
localised changing areas. The impression was that this would encourage better hygiene
practices from staff, especially if the hospital took on the laundering of staff uniforms.
The study found that there were a number of cleaning methods being employed by
different NHS Trusts. Ensuring that the design and fabric of the building make cleaning
easy, prevent dust traps and accumulation of dirt and grime, is essential. Supporting this
with design that reduces the number of surfaces that need to be touched, corners to trap
dust and are awkward to clean is a challenge to all NHS Trusts. Some existing layouts
are not suitable for some cleaning methods i.e. open bays are not suited to localised
hydrogen peroxide vapour decontamination. With flooring if there were a number of
corners cleaning methods need to be matched to the flooring and skirting choices or visa
versa in the design stage.
There is pressure on NHS Trusts to meet government targets such as the 4 hour A&E
waits, 18 weeks from referral to treatment and 2 weeks for patients suspected to have
- 54 -
cancer. This creates pressure on bed occupancy making it extremely difficult to close
ward areas for deep cleaning and for refurbishment. These management drivers conflict
with the infection control agenda even though they both impact on patient well being.
This is an area which is likely to remain an issue for the foreseeable future.
The research team have identified that further research should be carried out to evaluate
the whole life costings of CoI measures in design, including sustainability and savings
through the reduction of infections.
To ensure CoI measures are embedded in the design the research team recommend that
infection rates form part of the pre and post project evaluation as a value for money
measure.
In the longer term if CoI principles are embedded into the design there should be cost and
time benefit. These would relate to improved patient care with reduced rates of HAIs,
thus improving the health and well-being of patients, reducing medication costs and
potentially reducing length of stay in the ward environment. The ease of cleaning the
environment will reduce facilities costs.
CoI is a complex issue on its own. When combined with the complexities of hospital
buildings it becomes even more complex. Figure 2 shows the interaction of many of the
dimensions of building projects and their relationship with CoI in the design and
construction phases. Figure 2 clearly shows how tensions can arise due to the multiple
areas of input and areas for consideration. This helps to explain the dilemmas identified
by the steering group.
The study found that there is a general lack of, and in some cases, no evidence in the
literature relating to CoI issues and design. This could be due to the pace at which things
are changing, improving and developing. The research team assert that this study goes
some way to filling the evidence gap.
The key elements and choices discovered in this study have been collated to form a
Design and Management Decision Making Tool to assist anyone involved in hospital
building projects.
- 55 -
Figure 2 The relationship of CoI design decisions with other dimensions of hospital build projects
Design and Management Decision Making Tool
The study found that there are infection control principles to follow that are relevant to all
Trusts, but that these must be interpreted locally because of constraints within the layout
and age of the estate. The prioritisation of actions should be agreed with representation
by all stakeholders, although the study found from the focus groups this was not always
the case. Infection control is multifaceted and requires many things to be effective. It is
clear from the research study that it is not possible or desirable to have a “one size fits
all” approach. NHS Trusts will always have restrictions and limitations due to various
factors influencing their decision making, from site constraints to affordability. However,
there is no doubt however that investment in informed design can enhance infection
control in ward areas. The options appraisal chart on the next pages forms a tool to guide
Trusts, stakeholder representatives and designers when involved in Hospital construction
projects.
The toolkit sets out the main themes of the study to provide support for key management
and design recommendations appropriate to a Trust‟s local environment when planning
improvements to the ward for the control of infection. Within the CoI Design and
Management Guidance Tool, decision making considerations are set out with the aim to
overcome barriers to implementation and the choices available. The themes are listed
alphabetically for ease of use.
- 56 -
Control of Infection Design and Management Guidance Tool
Themes Outcome of research Infection control
considerations
Other positive
considerations
Negative
considerations
General observations
1 Centralised ward
equipment
decontamination areas
These are desired but
often lack of space
prohibits investment
Ward furniture and
equipment should be
regularly, toughly
cleaned
Gives the opportunity
to mend and replace
furniture regularly, can
be linked with a
library type system so
wards call for
equipment as it is
needed, this reduces clutter and storage
space required on
wards
Few Trusts have the
space to put in a
centralised cleaning
area, there also need s
to be an increase in
furniture stock to
ensure availability on
the wards
There are logistical
problems associated
with this model but the
outcome is worth
navigating these
2 Changing facilities for
ward staff
Clothing is low risk
but all risks should be
minimised
Ensures uniforms are
washed at the correct
temperature
May require staff to
have more uniforms to
ensure a clean one on
every shift – this could
be more costly
3 Choice of cleaning
method
Various methods in
use – micro fibre
appears a popular
choice
Method needs to leave
ward areas visibly
clean and should
reduce microbial load
without dispersing it in the air
Reduces the amount of
chemical products
being used, reduces
cost and risk of
allergies
Not all systems are
suitable for use in
every design of
hospital
4 Curtains No clear preference
mix oice. Mixture of actions
Low risk, fabric needs
to be washed at high
temperature,
antimicrobial coatings
are acceptable, as are
disposables
Manual handling,
some Trust feel that
disposables are easier
to change. However
quick change systems
are available for fabric
curtains
Sustainability – there
is a large waste issue
associated with
disposable curtains
Designers don't like
them as they are
boring and bland, with
fabric you can add
interest and enhance
interior design
Any choice requires
careful consideration,
including risks,
benefits, life cycle and
financial costs
- 57 -
Themes Outcome of research Infection control
considerations
Other positive
considerations
Negative
considerations
General observations
5 Flooring Clear fronted storage is
helpful for staff to
locate items,
cupboards need
shelving that can be cleaned
Clinical areas require
floors with smooth
impervious finish that
is easy to clean and
maintain, with minimal corners. Edge finishing
needs to be durable
and cleanable
„Smart‟ flooring
developments are
including messages
and instructions inset
into the flooring. Future technological
developments might
include for colour
indicators of
cleanliness.
Standard vinyl is
slippery when wet.
This need to be
managed locally
The life expectancy of
flooring needs to be
factored in
6 Clinical hand wash
basins at ward
entrances
Agreement that they
are a good idea to
promote hand hygiene. There is a feeling that
they need to be at the
ward exits too, to help
stop travel of infection out of the ward.
This is a general
requirement, needs to
be clearly visible but
not at risk of being
struck by passing beds
etc.
Building Control may
approve one basin at
part M height of
740mm.
Ward entrances can be
congested, there are
often no accessible
water and drainage
points making it
difficult to retrofit
clinical hand wash basins
If there were two
basins, then one would
be @740mm, the
second @860mm for
clinical use.
7 Sensor taps Infection control teams
keen to have as much
as possible on sensors;
doors, toilet flushed,
lights
Infection control
enhanced with this
style of tap
Can reduce water
consumption
Can be difficult to get
the temperature set
correctly on some
designs
8 Sluice rooms – clinical
hand wash basins and
macerators vs. bedpan
washers
HBN 04 needs to be
amended to reflect
this. Macerators are
the preferred option as
there is no risk of
residual contamination
There should be a
clinical hand wash
basin in the sluice
Space in existing
sluice rooms may
preclude the addition
of a clinical hand wash
basin
- 58 -
Themes Outcome of research Control of infection
considerations
Positive
considerations
Negative
considerations
General observations
9 Single
bedrooms/patient
isolation
Generally felt that
higher proportions of
single side bedrooms
are required.
Increased side single
rooms might be
created to give an
element of
containment. If not room for side rooms
then doors to bays will
give element of
containment
There should be
adequate numbers of
single/isolation rooms
to provide segregation
of infected and non-
infected patients.
Consider doors on
bays with activated
sliding doors
Consider en-suites into
larger bays
Patients do not have to
leave bays to use the
bathroom, facilities for
staff to wash hands
close to bays.
Patients get more sleep
and rest, the issue of
privacy and dignity is
addressed
Sometimes doors to
isolation rooms left
open, use sensor
activated doors to side
rooms
10 Ward storage There needs to be
enough storage to put
everything away.
Nothing should be
stored on the floor.
There should be no
dust traps
Reduces clutter on the
ward
Can mean staff have to
travel further to get
what they need
Often poorly provided
- 59 -
Summary of recommendations
Through the discussion section there are seven recommendations from the research team
identified. These are:
1. To ensure CoI is embedded in the design the relevant CoI principles need to be
clearly stated at the commencement of each project.
2. Consideration must be given to how the CoI principles impact on each element
and area of the design. Once identified the CoI principles, areas of impact and
management issues should be documented to prevent them being lost in the
design process.
3. The tracking of any changes and rationale for any should be documented through
the iterative process of the design.
4. Infection rates should form part of the pre and post project evaluation as a value
for money measure.
5. Patients should be involved in the design process.
6. All stakeholders, in-house and external, are involved in the design process and
construction process from the beginning and at regular intervals throughout the
process.
7. The requirement for a clinical hand wash basin in the sluice room should be added
to HBN 04-01 ( DH, 2008b).
Summary of areas identified for future research
As this research study has progressed areas with potential for further research have been
identified. These are:
1. Investigation into the proportion of capital spending of hospitals in relation to
backlog maintenance, changes in thinking, technological innovation, behaviour
etc; as listed in table 7 (page 26).
2. Investigation of project management of capital projects in NHS Trusts to assess
level and efficacy of stakeholder management.
- 60 -
3. Investigation of the impact of ward design on infection rates with a view to
demonstrating whether there is an impact when different bed spacing and more
single bedrooms are available.
4. To evaluate the effectiveness of having infection rates as part of pre and post
project evaluation in hospital ward building/refurbishment projects.
5. To evaluate the cost of infection control design decisions in relation to
sustainability, personnel and whole life costing – including the savings through
reduced infection rates.
The undertaking of further research as detailed above would significantly strengthen the
evidence base and provide a strong basis for improvement in the control of infection in
ward design and management.
- 61 -
7 CONCLUSION
This section reviews the success of the research study, the limitations of the study and
contribution the research study makes to the literature.
This has been a successful research study. The methods of gathering data via the
freedom of information process and discussions with uni-disciplinary focus groups
worked well.
Valuable data were gathered from NHS Trusts, using the Freedom of Information route,
and analysed. There were 10 key issues identified and explored with uni-disciplinary
focus groups. This gleaned further insights into the issues, practices and rationales for
choices. This work has resulted in the creation of a Design and Management Decision
Making Tool. It is anticipated that the Design and Management Decision Making Tool
will assist anyone involved in the design and construction of hospital projects.
It is clear from the study that CoI is linked with design and can be successfully integrated
into the design process. However it is also closely linked with managerial practice and
individual behavioural issues. CoI knowledge is rapidly developing and emerging new
practice will need to be integrated into both operational and design frameworks. There is
also new technology developing in the facilities management arena which will influence
both design and operational practice. From the work with uni disciplinary groups a key
factor is getting a balance of stakeholder opinions to enable sensible local responses and
decision making.
- 62 -
APPENDIX 1: Freedom of Information Responses
- 63 -
Q1. copy of original bid Q2 How did you actually spend the money?Q3. who were the key steakholders in
the desisson making process?
Q4. would the Trust have done anything
different(ly) if more time had been
available?
Q5. Have you undertaken any capital work
since to improve the controle of infection?
Supplied Change existing carpet to a
washable floor covering, Isolation
facility, Toilet refurbishment,
Cleaning equipment, Light Cords:
Change to presence detection
switches, Laboratory Monitoring
and Surveillance system,
• Director of Infection Prevention and
Control
• Infection Control Doctor
• Infection Control Team
• Executive Team
• Clinical Departmental staff
• Heads of Nursing and Matrons
• General Managers
• Finance Department
• Estates and Facilities Management
• Supplies and Procurement
• Patient and Public Involvement
Group
The Trust responded within the stated
timeframes. The relevant discussion and
consultation took place with key
stakeholders to prepare the bid within the
time available.
The Director of Infection Prevention and
Control and the Infection Control Doctor
directed and approved the prioritisation
and decision making process throughout
to ensure that the funding was directed to
funding areas which would have the
greatest impact on reducing C difficille
infection as was relevant at the time the
bid was prepared and submitted..
Yes. £580,000 capital investment by the
Trust; this is work in progress.
Not available The review of accommodation high
lighted the need for the relocation of
Clinical Consultant Staff and Staff
changing rooms.
This move allowed the formation of the
following facilities:
9 off Single Rooms with en-suite
facilities (Aprox £100k)
5 off 4 Bed Bays with en-suite facilities
in 5 ward locations, 1 per ward (Aprox
200K)
In addition to the above investment
was also made in the relocation of the
Clinical Staff, Provision of Staff
Changing facilities adjacent to ward
areas and the introduction of
additional clinical hand wash facilities
at ward entrance points and Sluice
rooms.
Executive Lead and Chair
Medical Director/DIPC
Director of Nursing
Infection Control Doctor
Infection Control Lead Nurse
Hotel Services Manager
Head of Estates
Ass General Manager – Medicine
Consultant Medicine –
Consultant Surgeon –
The Trust was able to spend part of the
money within year, the balance and
further funding was provided from the
Trust Capital allocation in the following
year due to the time scale required to
undertake the identified works.
There have also been further investment
with the upgrades to patient bathrooms
and public and staff awareness promoted
by the use of signage and publicity
across the organisation. This whole
system approach has resulted in a total
investment to date of around £700k of
capital across a 2 year period including
the £300k made available via the
Department of Health central funds.The
Following are areas that the Trust is
continuing to invest to help reduce HAI.
Upgrade of Existing Hand Wash facilities
and provision of new.
Flooring upgrades
Patient washing facilities’
Signage awareness
In Patient Bathroom Upgrades
Ward Sluice Room Upgrades.
Did not bid - N/A - N/A - N/A - the Trust has a well-established system
whereby Clinical Directorates, the
Estates and Facilities Departments and
the Infection Control Team all have the
facility to submit bids relating to infection
prevention and control for inclusion in the
Trust’s Annual Capital Programme.
Schemes are prioritised according to risk
assessments, directives from the
Department of Health and other
agencies, etc. Examples of capital
projects relating to infection prevention &
control during the past two years include
purchase of new cleaning equipment,
upgrading of isolation facilities, general
environmental improvements (linked to
the deep clean programme) and
purchase of additional surgical
instruments to eliminate local
reprocessing of instruments.
Not supplied We spent on refurbishment of clinical
and common/public areas
Matrons and infection control team
including facilities and estates
No Yes we have an on going programme for
refurbishment of bathrooms.
- 64 -
Q1. copy of original bidQ2 How did you actually spend the money?Q3. who were the key
steakholders in the desisson
making process?
Q4. would the Trust have done
anything different(ly) if more time
had been available?
Q5. Have you undertaken any
capital work since to improve
the controle of infection?
No bid required The money was used to put
in extra non touch sinks and
extra commodes across the
Trust.
The key stakeholders were the
Infection Control Team, the
Director of Infection prevention
and Control, Senior Nurses,
the Medical Director and
Estates
The Trust had already identified a
gap analysis for capital for infection
control and were therefore in a
position to know what best use
could be made of the funding.
Yes
Not included £100k Equipment Washer
and Sanitiser £100k -
Modernising waste removal
£30k - PAS/ICNET Link
£30k - Provision of isolation
facilities and replacement
wooden floors
£20k - Storage of Dirty Linen
£12k - Maxmiser Audit Tool
£8k - Improving
environmental cleanliness
clinical staff, estates staff,
infection control,
management and members of
the executive team
No Replacement floors and
majority of wards
Development of new ward
block modernising ward
facilities and increasing the
number of single rooms
Refurbishment of Bathrooms,
Kitchens, Sluice facilities
Refurbished changing facilities
Investment in scope washers to
comply with national standards
Supplied Creation of cohort-nursing
bays for MRSA/C.difficile
patients on both sites
Creation of an additional 2
side rooms on Ward 3B
(cardiology) Wycombe
Hospital
Creation of a storage
facility on ITU, SMH
12 new hand-wash basins
on ITU, 10 on ITU , with
sensor taps + 2 on Day
Surgery Unit
26 new hand-wash basins
Improving ventilation of
toilets, l to allow use of
stronger cleaning
chemicals
Creation of separate
storage facilities for clinical
waste storage, and
creation of cleaners’
cupboards
Removal of carpets from
walls of wards
ICT, Infection Control
Directorate Leads, Trust
Board, PCT, Link
Practitioners.
No Yes
Supplied • Switch over of 2 wards
which enabled extension
of the Emergency
Admissions Unit and the
creation of additional
single rooms within the
acute medical ward.
• Provision of additional
single rooms in other
medical and surgical
wards
• Refurbishment of shower
rooms
• Additional floor and wall
hand hygiene signage
Please note that in the
letter referred to above it
states that the Trust would
seek to invest in cleaning
equipment, however,
following trial/s the
equipment proved to be
unjustifiable.
• Director of Infection
Prevention and Control
• Director of Nursing
• Infection Control Team
• Clinical Matrons
• Estates & Facilities
• Finance
No as other cleaning initiatives
were underway at the same time.
Yes. As part of the
annual Deep Clean
Programme the Trust has
used the opportunity to
upgrade toilets and
bathrooms to aid
maintenance and
cleaning. The Trust has
also replaced flooring
where necessary as part
of the Deep Clean
Programme.
- 65 -
Q1. copy of original
bid
Q2 How did you actually spend the
money?
Q3. who were the key
steakholders in the desisson
making process?
Q4. would the Trust have done
anything different(ly) if more
time had been available?
Q5. Have you undertaken
any capital work since to
improve the controle of
infection?supplied ICNet. Computerised information
system for infection control, Replace
and install new sinks in ward areas,
Refurbish Bathrooms/shower ,
Reprovide current teaching room as
an isolation room for Intensive care
patients, Clog Washer – theatre shoe
decontamination system , Provide
negative pressure ventilation for 2
isolations rooms in respiratory wards,
Refurbish treatment room, Provide
appropriate number of sinks in ward
and clinical areas.
Bids were received from all
departments in our hospitals and
prioritised by the infection control
service
No comment Since then we have spent an
additional £340k on various
schemes through the
national funding provided in
August 2007 which included
the following:
· Ward based bladder ultra-
sound scanners
· Additional bed curtains
· Additional commodes
· Teaching mannequins for
non-touch technique
· Replace floor on Ward 15,
Div Medicine
· Automated sensitivity
testing & bacterial
identification
· Teaching mannequins for
catheterisation
· Pictorial floor mats
· Trolleys for ANTT in
Theatres
· Replacement equipment in
gynaecology
· Portable suction units
We have also since
approved capital funds
annually for additional sinks
in clinical areas and
replacement of bathrooms
and toilets over a three year declined to provide
informationBid suplied was for
August 2007 - revenue
moneys
the hand hygiene sinks at lift
lobbies/ in bays
the continued ward upgrade
programme with infection control
features (wipe clean walls, en-suite
facilities, more single rooms etc)
- further changes to cleaning
methodology (eg use of sporicidal
wipes)
- development of a cohort area (able
to be put into operation as/ when
required)
- educational packs for all
patients/visitors coming into hospital
not answered Yes, we may have looked at
using it to support proposals we
already had planned (eg sinks
outside all ward bays) but we
would have been unable to
deliver them in the timescale
required.
No bid required Fund used a part of a ward upgrade The executive team No Yes relating to sanitary
facilities. The public toilets
throughout the Trust have
been fully refurbished and in
new facilities have been
installed on wards 2, 3 and 9
(theatre day case).
- 66 -
Q1. copy of original
bid
Q2 How did you actually spend
the money?
Q3. who were the key
steakholders in the desisson
making process?
Q4. would the Trust have done
anything different(ly) if more
time had been available?
Q5. Have you undertaken
any capital work since to
improve the controle of
infection?
As next column +
To upgrade clinical
treatment rooms on
the site COST
£30,000 - not
approved
Revenue:
Employment of Project
Nurses to implement a
Trust wide culture
change leading to
compliance of
infection control
principles with regard
to hand hygiene and
aseptic technique
COST £113,252 -
£60,000 approved
(funded for 6 months).
To set up C difficile
testing to enable
compliance with the
18 hour rule COST
£7,175 - approved. To
increase the number
of patients screened
for MRSA to include
patients admitted from
Nursing Homes COST
£43,339 - £22,000
approved (needs to be
funded locally in the
longer term).
proposal to provide a
centralised equipment
decontamination/equipment
loan library management
system on the
COST £250,000 - approved on
second submission of bid. To
provide a centralised shared
equipment (drip stand,
commode etc) decontamination
area of cleaning service at
Darlington Memorial Hospital
COST £70,000 - approved. To
provide mattress replacement
and commodes, as required and
identified by audit, within the
Trust COST £143.097 -
approved. Establish a dynamic
database of antibiotic
consumptions to permit
continuous reporting COST
£37,000 - approved. Extension
of the current intravenous team
COST £61,096 - approved. To
install laser printed floor signs
to the entrance of each ward to
remind all visitors about
expectations with regard to
Estates & Facilities
Ward staff/Matrons
Installation of cupboards in
sluice rooms at the older hospital
sites. This has now been done
Endoscopy washer business
case approved
Radiopharmacy (new clean
room) work ongoing
Installation of T Doc
scanning stations in theatre
for traceability of clinical
instruments Minor work
build in sterile services
department Extra shelving
within ward areas
New hospital - not
applicable
Steam cleaning
equipment for all ward
areas. Shared one
between 2 wards or
departments £26k
Purchase of Bioquell
Hydrogen peroxide
Systems for heavy
duty deep cleans of
infected rooms and
wards £113k
Refurbishment of the
ward shower areas
£45k Dani centres –
glove and apron
dispenser units £4k
Introduction of Micro
fibre cleaning system
– this money for
purchase of the
machines to
effectively launder the
mops and cloths £70k
Use of floortography
messaging £40k
Steam cleaners £63k Shower
refurbishment £6k Sign
Holders £400 Bump
Protection £6.5k Flooring
Replacement £5.3k Cleaning
Standards Information Boards
£1.5k Washer Disinfectors
(Ward 16 and ENT) £40k
Hydrogen Peroxide Systems
£60k Talking message in Lifts
£5.3k Floortography £26.5k
Ultraviolet Cleaning Machine
£18k MRSA Screening Lab
Equipment £4k £63k left
Although the spending has not
completely followed the bid, it
has encompassed all of the
targets raised in the initial bid.
This change in direction was
taken after careful
consideration from the key
stakeholders listed.
The decision and any future
decisions have been taken or will
be taken after consultation with
the Trust’s Nursing and Quality
team, Infection Control, Facilities
Management, Consultant
Microbiologist, The Trusts Patient
Experience Group and Medical
Engineering.
Due to the fact that we
Foundation Trust status we are
not under the same amount of
pressure with our capital
expenditure and end of year
targets as other non Foundation
NHS Trusts. This has meant that
we have been able to consider
how this money is spent and
how any remaining monies are
spent in the future. Although we
have not yet spent the full
allocation because of some
changes of thinking in the
infection control arena, we do
however have a clear plan as to
what will be required and when.
This Trust is currently
undergoing a major re build with
the merging of two sites in June
2009. Any funding left available
at this time will be used for one
of the future schemes listed.
This NHS Foundation Trust is
committed to the fight against
HCAI and everything possible,
given our current knowledge of
HCAI, has been considered in
the build of our new facility which
we believe will become a
valuable tool in our goal of
reducing HCAI.
As mentioned above, the
Trust is undergoing a major
redevelopment of all our
facilities from theatres to
boiler houses so continual
capital investment has been
made in many areas
including infection control.
Not supplied - due to
commercial
confidence under
Section 43 of the FOI
Act.
Hydrogen peroxide cleaners
New equipment
Pilot project for specialist
cleaning posts
Matrons,
Infection control team
Housekeeping team
Ward sisters
Estates department
Trust Boards
Yes, there would have been a
longer lead in time and more
robust systems established.
Yes, re-furbishment
programme of all our clinical
areas has been running for
18 months, not funded out
of national money.
- 67 -
Q1. copy of original
bid
Q2 How did you actually spend
the money?
Q3. who were the key
steakholders in the desisson
making process?
Q4. would the Trust have done
anything different(ly) if more
time had been available?
Q5. Have you undertaken
any capital work since to
improve the controle of
infection?
Supplied Multiple sink replacements and
installation of sensor taps. Sinks
with sensor taps installed at
ward entrances. Creation of en-
suits to single rooms, including
shower facilities, upgrading of
sluice ares to include handwash
basins, replacement of ped pan
washers, upgrade of ward
kitchens and replacment dish
washers, tiles in laundry and
other areas replaced or
covered with washable clading.
Contribution to infection
control software.
Director of Infection Prevention &
Control, Senior Nurse for Medicine,
Lead Nurse Infection Control,
Infection Control Doctor, Head of
Facilities Management
N/A Yes, further refurbishment
during deep clean process.
wheelchair washer/disinfector,
construct an isolation room in
the Intensive Care Unit (ICU)
and install sinks for hand
washing at the entrance to
each ward.
N/A N/A A project is also underway
to install a new IT solution
which will enable
appropriate and timely
management of infection
control organisms by
facilitating data collection in
support of the public,
service users and other
organisations locally,
regionally and nationally.
supplied (separate
email)Two isolation rooms were built
on each of two main hospital
sites (total 4 extra isolation
rooms).
Infection Control Team
Director of Infection Prevention
and Control Trust Executive lead
for Infection Control
Director of Estates
Director of Finance
Isolation rooms had already been
identified as a priority.
Two further isolation
rooms with negative
pressure ventilation have
since been built with
further funding. ( The
original lead bid time was
insufficient to allow
planning and purchase of
the more technically
demanding negative
pressure ventilation
suites.)Supplied - excerpt: In
recognition of the
importance of isolation,
we would like to make
a bid for £300,000 to
increase the number of
rooms in the trust
hospitals. Two single
rooms with ensuite
shower rooms can be
created from a 4 or 6
bedded bay at a cost of
£75,000. This figure
has been obtained
from the trust's capital
development
department which has
undertaken similar
work in another project.
Therefore, £300000
would be used to
create an extra 8 single
rooms. This would
make a real
improvement to our
isolation facilities. Any
reduction in overall bed
capacity has already
been taken into
account in our reduced
length of stay project
calculations.
The capital challenge funds
were allocated to providing 11
single rooms , 1 single en-suite
room, 2 en-suites added to
existing single rooms. Please
be are aware the Trust funded
the shortfall on these projects.
Director responsible for Infection
Control,
Medical Director
Director of Nursing
Head of Infection control
Head of Capital and Estate
Development
General Manager for Acute
Medicine.
If more time had been available
this could have been spent on the
decision making process ensuring
more feasibility work was carried
out to capture all the needs of the
Trust.
Yes. This is a consistent
feature of the Trust's
Capital Planning set
against its annual
Operational Capital. Works
incorporate improvements
to bed/trolley spacing,
additional single rooms
wherever possible,
improved washing/toilet
facilities.
As next column +
£40K - 2 replacement
mattress covers each
bed
£30K - mocrofibre
cleaning system
£3k - 3 steam cleaners
The Trust over bid and
these items were not
funded.
· £98k – Provision of ICT
systems in the routine
management and surveillance
of HAIs.
· £100k - Provision of a
decontamination area for the
Central Equipment Library for
Beds, Mattresses, mattress
covers, Hoist Slings and other
patient equipment
· £62k - Trust wide
Replacement of Macerators (19
in total).
· £20k - Replacement of
condemned commodes and/or
replacement parts
· £16k - Provision of an
additional clinical hand sink at
the entrance of wards.
· £5k - Improve Trustwide
signage in relation to hand
hygiene and cleaning posters.
Plus improve Patient
information i.e. leaflets, talking
posters and intranet access.
There was a wide consultation
involved in the decision making
process. The key stakeholders
involved in this process were the
Trust Board, the Hospital
Management Board, the Medical
Director at the time, the Head of
Infection Control at the time,
Finance, the Estates Department,
Hotel Services, the Head of IT at
the time, the Consultant
Microbiologist at the time and
Warwickshire Primary Care Trust.
N/A The Trust has undertaken
numerous other capital
work projects to improve
infection control.
- 68 -
Q1. copy of original bid Q2 How did you actually spend
the money?
Q3. who were the key
steakholders in the
desisson making process?
Q4. would the Trust
have done anything
different(ly) if more
time had been
available?
Q5. Have you undertaken
any capital work since to
improve the controle of
infection?
Supplied Interface from PAS to ICE
surveillance software £30k To
install a dual water supply unit
within the HSDU £90k
Endoscopy refurbishment -
including 'pass through' system
£120k
Hand hygiene awareness £2k
Web based Incident
management/monitoring
system £15k Purchase of
surgical clippers for pre-op hair
removal £2k
Hand wash basin – theatre staff
room £1k Keyboards and Mice
£10 - £40k
Expenditure was agreed by
the Trust and monitored
through the Capital
Planning Group.
The key stakeholders were
the Trust’s infection control
team, the Infection Control
Committee which included
local PCTs.
The Trust would not
have done anything
differently if more
time had been
available.
No further capital work has
been undertaken since to
improve infection control.
1. Cleaning Equipment (Ultra-
high speed battery burnishers
x2; caddy cleans (incl battery
packs and chargers) x18;
replacement vacuum cleaners x
20; buffing machines x 5; wet
pickup x 3)
£34,400 2. Endoscope UV
dryer/storage cabinet£21,000
3. Replacement
mattresses/covers £43,000
4. Replacement damaged
patient chairs £24 700 5.
Patient + public information
system (42” screen, PC, cabling
+ installation, professional
templating software)
£6,350 6. Endoscope
washer/disinfector (including
installation costs) £60,000 7a.
Building work Creation of en-
suite bathroom facilities in 3
wards 7b. Refurbishment of
bathrooms on wards 7c. Infra-
red taps (ICU) £104,000 8. IT
equipment: Panasonic CF-18
Ruggedised tablet PC; PC x 2
SPSS software (Base and Trends
As stated with the following
exceptions: Patient and public
info system bid not
implemented as was that for
infrared taps. IT equipment
budget was also scaled back.
This allowed the purchase of
instrument tracking system for
CSSD (29K).
Infection Control
Department /DIPC/Trust
CEO / Lead Director for
IPC / Other Trust Directors
/CSSD/Estates and
Facilities/IT
Dept/Endoscopy.
Possibly. Yes
The Trust having gone through
an option appraisal for use of
these monies, propose to
develop further isolation
facilities within our ward stock
including improved sanitary
facilities i.e. hands free
operating wash basins and
toilets. These facilities will
provide optimum support for
those patients with infection
control alert.
The money was spent on
Isolation facilities, a Stenis
machine, replacement
macerators, and medical
equipment.
The key stakeholders
involved in the decision
making process were the
Chief Executive Officer,
Director of Infection
Prevention Control,
Infection Control Manager,
Infection Prevention
Control Team and Finance
and Directorate Managers.
The Trust would not
have done anything
differently; the
availability of options
to spend capital on
IPC issues is limited.
The Trust has continued to
spend capital. We have
plans to spend further on
development of further and
improved substantive
isolation facilities.
Supplied • Upgrade of Bathrooms &
Toilet facilities, assisting
cleaning and decontamination
• Creation of Cohort bay on
every Medical and Surgical
Ward, to allow each Ward to
manage infection control
effectively
• Purchase equipment for the
training and education of staff
and patients.
Consultant Physician &
Clinical Director Infectous
Diseases DIPC and
support team
No automatic antibiotic
resistance pattern testing,
Informatics (pending) and
estates installed more
sliding doors to ensure
cohort care.
Supplied Replacing old bed pan
macerators with new ones.
Refurbishing the original
ward so that we reduce the
bay occupancy from 6 to 5
and included en-suite
facilities in each bay,
refurbished the single
rooms in this ward to
include a full en-suite
facility in one single room
and lavatory and hand wash
basin for the remaining four
rooms.
Infection Control
Team highlighted the
problem areas and issues
to be addressed with the
money. A bid was put
together by the Infection
Control Team in
conjunction with the
Facilities director and
capital bids director. The
bid went to Trust Board
for approval.
It would have been
useful to spend more
time planning the
work to ensure that
everything was
covered. However, I
believe the money
was spent wisely on
areas of concern
(with regard to C.
diff). Since then, the
remaining wards
have been given the
same refurbishment.
See previous answer
Did not receive any of the fund
- 69 -
Q1. copy of original bid Q2 How did you actually spend
the money?
Q3. who were the key
steakholders in the
desisson making process?
Q4. would the Trust have
done anything different(ly)
if more time had been
available?
Q5. Have you undertaken
any capital work since to
improve the controle of
infection?Suplied The £300k was put towards the
purchase of 2 temporary wards
(the Trust committed to
finding the balance of £663,000
from its capital resources) already
on site, whose lease was expiring
in March 2007. This allowed
them to improve bed spacings in
existing wards - by reducing bed
numbers, and improve numbers
of single rooms as the new wards
had more.
The Executive Team and
the Infection Control
Team.
No Yes
change of FoI officer -
lost questions - now
reviewing
Supplied £70k upgrade bathrooms with
accessible baths. £35k to
upgrade ICNet to link with PAS.
£18k new commodes. £129k
upgrade sluices to include hand
wash basins, new macerators,
flooring and décor. £47k to roll
out micro fibre cleaning system
across the whole trust.
The team for decision
making was
multidisciplinary:
· Head of Quality
· Consultants x 2
· Head of IC
· DON/DIPC
· Deputy Director of
Finance
· Director of Estates
No Yes, the outcome was very
comprehensive & all has been
implemented.
Supplied medical equipment library and
decontamination facility (£250k),
microfibre mop system for the
Trust (50K)
Director of
Infection
Prevention and
Control
Infection
Control Nurse
Specialist
Medical
devices
manager
Cleanliness
Services
Manager
Modern
Matrons
Director of
Finance
Yes - the approach would
have been to consider wider
organisational schemes to
improve infection control.
The focus was very much on
the acute sector but as a
fully integrated healthcare
system, spending some of
the money on other sectors
would have been of value in
a whole system approach to
managing healthcare
associated infections and
Clostridium Difficile.
Investment in Endoscopy Unit
Investment in HSDU
Investment in improvements
to hospital main reception
including hand gel stations
Additional investment over
and above that secured as
part of bid to replace all
commodes in hospital
Improvements to ward layout
in some areas to reduce
infection risks, including on
clean orthopaedic surgery
ward
Not required We had a very significant
equipment replacement
programme funded from this
money.
Infection Prevention
Team, Director of
Nursing & Patient
Services and Matrons.
No We are due to commission a
brand new 22 bedded
infection control isolation
ward with high specification
side rooms.Not supplied £222K on main C Diff schemes
– for examples sinks outside
each ward £11K infection
control system £16K cleaning
standards £20K legionella
plant Balance on other minor
schemes
Director of Nursing &
Estates Director
Balance of the capital
funds not spent in March
was carried forward as
per capital rules,
therefore not an issue for
the Trust.
Refurbishment of the main
ward block over 5 years at
£18million.
Not supplied
Enclosing open bed bays - £100k
Replacing carpets in clinical areas -
£70k
Upgrading work in connection
with infection control issue on
Hazelwood Ward - £100k
Replacement equipment - £30k
Not answered Not answered Not answered
- 70 -
Q1. copy of original bid Q2 How did you actually
spend the money?
Q3. who were the key
steakholders in the
desisson making
process?
Q4. would the Trust have
done anything different(ly)
if more time had been
available?
Q5. Have you undertaken
any capital work since to
improve the controle of
infection?
1. Healthcare Acquired Infection Case
Management & Surveillance Managed
Computer Software System (ICNet).
Cost (incl. VAT) £74K.
2. High visual impact floor signage
warning of need to clean hands before
entering clinical area (Johnson
Diversey).
Cost (incl. VAT) ~£40K.
3. High throughput molecular
fingerprinting / sequence based typing
/ pathogen identification system (ABI
Prism).
Cost (incl. VAT) £170K.
4. Molecular fingerprinting analysis
software packages (Bionumerics).
Cost (incl. VAT) ~£10K.
5. Mobile ward closure notice panels.
Cost (incl. VAT) ~£5K.
Lots of information on the bid
ICNet £74k
ABI Prism £122k
Bionumerics £10k
IT server £6k
Ward closure notice pannels
£5.5k
Still showing £80k left - can't
see that floor signage has been
completed
The main stakeholders
from the Trust’s
perspective were Clinical
Director of Microbiology /
Pathology and Director of
Infection Prevention and
Control and Director of
Finance. Our Medical
Director was also kept
informed and the planned
expenditure was approved
by the Trust Management
Board in January 2007.
The Trust received £300K
towards the end of 2006/07.
Due to the tight timescales
you refer to, this funding
was carried across the
financial year-end and
utilised in 2007/08.
Yes. In addition to the details
provided in response to
question 2 we have also
undertaken necessary
refurbishments to establish
an isolation ward at the
Leeds General Infirmary and
a cohort ward on our St
James’s Hospital site.
Supplied
increasing side rooms with ensuites.
DIPC, ICT, Chief
Executive, Director of
Nursing, Patient Safety
leads, Estates Manager.
No Yes
Supplied Money was used to refurbish
F2 ward and create the six
bedded isolation pod and
associated changes in that
area to achieve this.
CEO, DNS, Director of
Finance, IC Doctor/ICN
The Trust would have had
more time to consider
options more carefully and
not rush the application
The isolation pod created by
the above bid is now up and
running. Infection control
software (IC Net) was
excluded from the above bid
but funded by the Trust
subsequently
Supplied Patient chairs, bed tables,
commodes, curtains,
replacment macerators, micro
fibre mop system, new sinks
and tile replacment for 5
wards, dishwashers, dressing
trolleys, dry steam cleaner for
bed deocon, HEPA filter
radiator vacuum cleaner,
replacemetn Arjo baths,
cleaners cupboard.
Infection control team,
estates, matrons, finance,
housekeeping dept,
supplies dept.
Yes - the Trust would have
been able to upgrade some
areas, but due to timescale
this was not an option with
this funding stream.
5 ward areas have been
upgrades and additional
wash basins fitted in a
number of areas
not supplied We spent our allocation of
£300,000 on new bedpans,
bedpan washers and backlog
maintenance relating directly
or indirectly to infection
prevention
No records/existing staff
from the time able to
provide this inforation
No comment However we have continued
to invest since 2007 on
Infection Prevention. We have
continued the programme of
bed pan washer replacement,
implemented Project Refresh
and purchased ICNet, new
microbiology equipment and
cleaning equipment.
Provision of 7 side rooms @ £30,000
each 20 sinks to be
installed @ £950 each
3 clean steam generators and R.O
plant @ £28,000 each Two washer
disinfectors @ £25,000 each
Curtains £30,000
Steam generators, washer
disinfectors and RO £204,450
Curtains £30,000
Comodes £35,000
V Teck Rapid MRSA testing
£45,000
Executive team, Infection
Control, Facilities Teams
and the Matrons.
Possibly - The timing of
allocation made it difficult
to carry out any structural
capital work. However, the
money was used for other
infection prevention and
control capital.
Not specifically although any
capital work undertaken
always bears in mind the
responsibilities of the Trust
as far as COI is concerned
Declined to anwer questions
Bid for £300,000 only got £20,000
used it for training
No bid, no money
Say that they did not receive the
funding.
- 71 -
APPENDIX 2: Design Dilemmas of Guidance and
Regulatory Compliance
- 72 -
Design Dilemmas of Guidance and Regulatory Compliance: Optimising Design for the Fixing Heights of Handwash Basins Inpatient Wards A case study report on the agreement of design standards for entrance to wards, single patient room and en-suite bathrooms 1 June 2009 Balfour Beatty Site Offices, Salford Royal Hospital for Salford Royal NHS Foundation Trust, Balfour Beatty Construction, HKS Architects and MARU (Medical Architecture Research Unit) Background The presentation ‘Design Dilemmas’ by Anne Symons, Design Director Balfour Beatty was made to the MARU/HaCIRIC Infection Control Research Study Steering Group. This presentation, an evaluation on the completion of Phase 1 of the Salford Royal Hospital early 2009, critiqued the conflicting hand wash basin design guidance for inpatient wards against regulatory standards compliance. 3 case study examples were presented to illustrate the impact of potential design dilemmas and the implications upon programme delay and disruption without local agreement at the outset of design development between statutory and non-statutory compliance for infection Control and DDA of the position and fixing heights of wash hand basins: Wash Hand basins at ward entrances 1: Request for wash hand basin at Ward Entrance Not included in Brief Schedule of Accommodation 1:200 Layouts approved No space for WHB! Corridor width requires to be kept clear Area Schedule has to be updated before Financial Close Post FC New request for shelf to be located next to WHB to accommodate handbag/papers 1. Can it be accommodated? 2. Cost implications?
- 73 -
Wash hand basins at ward entrances 2: Request for wash hand basin at Ward Entrance Not included in Brief Schedule of Accommodation 1:200 Layouts approved Due to layout space is available near to the entrance Area Schedule has to be updated before Financial Close Post FC New request for shelf to be located next to WHB to accommodate handbag/papers 1. Can it be accommodated? 2. Cost implications?
Single Patient Bed Room
Position of Wash hand basin – relocated from corner wall opposite bed, just before FC at the insistence if Infection Control, despite having agreed position following attendance all previous User Group Meetings.
Serious consequences due to maintaining clear access for beds. Major difficulties in connecting drainage to WHBs
A workshop was agreed to be held in June 2009 with the Phase 2 project team to be facilitated by MARU to discuss future design guidance and agree a way forward. Aim The aim of the workshop was circulated to project team members: to agree a set of design principles relating to the setting out of fixtures and fittings to suit a range of differing requirements to establish a process for the design team to achieve solutions acceptable to all parties – client and the regulatory authorities before the start of site activities. Approach Two presentations outlining the potential problems were given by Franko Covington , HKS and Anne Symons, BB NBHJV (copies attached) before the subject was opened up for general discussion. The proceedings were then facilitated and summarised by Phil Astley from MARU Main Issues of potential design conflict The issues relate to Infection Control and the lack of prescriptive guidance and Building Control Part M where it is the interpretation of the legislation. The main documents for consideration being: Design of Buildings and their Approaches to meet the needs of Disabled People - Code of Practice, Access to and Use of Buildings – Part M, Health Buildings Note 00-02 Sanitary Spaces
- 74 -
The 3 stages for achieving compliance are:
• Verification (proposed performance standards and their solutions) • Validation (agreement of performance standards including any derogation form the
published design guidance, or interpretation of guidance for local benchmarking) and • Certification (layouts and specification sign off)
In particular the Trust concerns were over the fixing heights of wash hand basin. The requirement to cater for DDA means that for the majority of staff the basins could be too low and this in turn might lead to complaints relating to back pain. The full list for the team to address includeded items for wards such as :
• Wash hand basins and soap dispensers – entrance to wards, patient single bedrooms, bathrooms – clinical and DDA compliance
• Shower head positions – H&S and clinical for DDA compliance • Position of Toilet Roll Holders – Infection Control and DDA compliance
• Vision Panels to doors – Privacy and dignity issues • Coat hooks, grab rails, mirrors – Mounting heights for DDA compliance
• Staff Beverage Bays – layout for DDA • Reception Desks
• Switches and socket outlets • Thumb turns to doors
The conflict between guidance and regulatory compliance issues were presented between: Statutory
- Building Regulations - Health & Safety - Fire - DDA
Non –Statutory
Infection Control
Security
Performance Criteria
Legislation : HTM
Operational
Evidence / Education
Design Response
Optimisation..with Standardisation
Monitoring
Prioritisation of this information had proved problematic for the project team. Agreeing the legislative instruction against operational and design response required a reliance on the design team to interpret user group views to enable clear and concise instructions. In addition, programme instructions in the design development stages caused potential delays. The performance specification of each element required design coordination and agreed prioritisation of the guidance. Statutory Compliance v Design Guidance The designers posed the following questions: Which documents do designers follow? Which is mandatory and which is guidance? Health and Safety was considered the number one priority for compliance and interpretation required between:
- 75 -
DDA v Infection Control
Health & Safety v Sustainability
Operational Issues v Design Guidance The table below summarises the key documents for compliance and guidance: UK law requires all buildings to be accessible
• The Disability Discrimination Act 1995 (DDA) • The Disability Discrimination Act (Employment) Regulations 1996
BS8300:2001 – British Standards • Best practice guidance on how you can improve the accessibility of the design
of your buildings.
The Building Regulations Approved Document M - Government
Approved documents are intended to provide guidance for some of the more common situations. However, may be alternative ways of achieving compliance.
These is no obligation to adopt any particular solution contained in an Approved Document, if you prefer to meet the relevant requirement in some other way.
HBN / HTM - Department of Health
Health Building Notes give “best practice” guidance on the design and planning of new healthcare buildings.
Health Technical Memoranda give comprehensive advice and guidance on the design, installation and operation of specialised building and engineering technology used in the delivery of healthcare.
A case study focussed upon hand wash basins to illustrate the difficulties of interpretation between documents: Basins – Mounting Heights HBN 40 Part 2 suggests - 860mm – Handrinse for fully ambulant staff, visitors and patients 750 – 800mm – Handrinse for assisted / wheelchair users 765mm – Personal washing for assisted/ wheelchair users
- 76 -
Basin – Mounting Heights HBN 00-02 suggests - A. 680 – 700mm – for wheelchair users only B. 780 – 800mm – for ambulant disabled people only
Basins – Mounting Heights Approved Doc Part M dictates - A. 780 – 800mm – for people standing B. 720 – 740mm – for use from WC
Basin – Mounting Heights BS8300:2001 suggests - A. 680 – 700mm – for wheelchair users only B. 780 – 800mm – for ambulant disabled people only C. 720 – 740mm – for both A & B users
- 77 -
The interpretation of the guidance was developed further by the team into 2 distinct uses: Clinical and Non-Clinical:
Clinical 11. Departmental Entries 12. Patient Bedrooms 13. Patient Treatment Areas, 14. Clean/Dirty Utilities
(Requires use of elbow-action taps for Clinical Staff)
Non-clinical
Ensuites
Public Toilets
Ambulant WCs
Independent WCs
Staff Rest Rooms
Cleaners
Disposal Holds
Workshop Questions The architects presented a summary table of the design dilemmas; location of hand wash basins and the documented position on the fixing standards. This led to a discussion at the workshop on the hierarchy of approval between the statutory approvals and the project team users:
Location
Standing height
Seated height
Approved by
- 78 -
Department Entry (clinical HWB)
Y
Y
?
Patient bedroom (clinical HWB)
Y ?
Ensuite (personal grooming)
?
Y
?
Staff Rest Rooms (non-clin. rinsing)
?
Y
?
Cleaners / Disposals (non-clin. rinsing)
Y
?
Clean/Dirty Utilities (clinical HWB)
Y
?
The design team proposed 3 questions for the workshop to discuss:
Where adherence to statutory requirements compromises clinical functionality, should HTM’s be allowed to rule?
Should benefit of minority come at a cost of the majority use (e.g. Staff Rest Room basins)?
Where do we draw the line and who makes the decision? Outcomes There were no immediate solutions to the conflict at the workshop, but a way forward for design team user group meetings was established. This workshop was the forum for discussing the potential differences before they became fully developed. Key issues for facilitation that were raised at the workshop included: Adherence to, and derogation form, statutory compliance
6. Acknowledgement that the involvement of Facilities Management at early design meetings would ensure communication of design coordination implications, operational and cleanability issues of equipment and finishes.
7. Submission to the local Building Control Officer of any matters for derogation where HTM
clinical compliance may be in conflict with DDA regulations. This would ensure proper communication and understanding of the issues between the teams. At the workshop the Building Control Officer confirmed the willingness and procedure for receiving written requests.
Project benefits, prioritisation of guidance
8. There was a general discussion on the benefits of the outcome (and cost implications) for the ‘majority use’. It was agreed that there was likely to be the result of transparent and sensible decision taking with regard to:
• Clinical areas, where clinical priorities influence compliance eg was hand basin height to patient rooms utilising elbow or sensor taps.
- 79 -
• Bathrooms, DDA compliance where patient use and optimised flexible for the widest patient group was acknowledged specifically in patient en-suite bathroom hand was basins, but in
• Public areas, the majority use would cause no real conflict with DDA usage
and to prevent expensive duplication of fittings eg wash hand basins at ward entrances or coat hooks heights preventing clothes dropping onto the floor - an optimised fixing height between DDA levels and clinical levels would be agreed.
Information management and submission for locally agreed standards
9. Understanding by the Infection Control team to resolve potential conflict between DDA design requirements and clinical priorities was required at early design team meetings.
10. It was noted by all the project team that project sheets could be distributed for local agreement of design standards for key items listed in Table 1: Performance Criteria
Findings
• A better understanding of each others point of view was achieved. • Forums for discussing potential differences before they became fully developed will take
place – joint discussions with building control, designer and clinicians Lessons Learnt
• Discuss differences at the earliest possible stage • Good communications is essential for successful outcomes
Post meeting Guidance Summary: The team have agreed with local derogation by Building Control to offer different heights in the three main zones for was hand basins:
Clinical
Public (including staff areas)
Patient areas This has been a successful ‘optimisation’ of the design standards appropriate to the localised area of the fitting, has rationalised the range of options suggested by the plethora of design guidance to a sensible collection and have agreed policy across the Trust that looks to avoid duplication of expensive fittings and resources in significant areas at ward entrances.
Height Comment
Wash hand basin at entrance 740mm Building Control confirmed that here, they would approve basins at part M height of 740mm. If there were two basins, then one was @740mm, the second @860mm for clinical use.
Wash hand basin to single bedroom and 4 bed room
860mm This was agreed with the Building Control that 860mm was acceptable if the Trust wrote a statement to confirm that clinical functionality took precedent and that basins would meet HBN40.
Wash hand basin to Assisted Clinical Basin = 860mm This was agreed with the
- 80 -
Bathroom Patient personal washing = 740mm
Building Control that 860mm was acceptable if the Trust wrote a statement to confirm that clinical functionality took precedent and that basins would meet HBN40.
Wash hand basin to Patient En-suite
Patient personal washing = 740mm
As per Part M
Wash hand basin to Treatment Rooms and clinical rooms
Clinical Basin = 860mm
This was agreed with the Building Control that 860mm was acceptable if the Trust wrote a statement to confirm that clinical functionality took precedent and that basins would meet HBN40.
Wash hand basin to Staff Rest Rooms
Hand Rinse Basin = 790mm Following further discussion with BC & Access Consultant
Wash hand basin to Staff FM spaces e.g. Disposal/ Cleaners
Hand Rinse Basin = 790mm As Per Part M
Wash Hand Basins to Public WCs
Hand Rinse Basin = 790mm with 1 dropped to 740mm
As Per Part M
Wash Hand Basins to Independent WCs
Hand Rinse Basin = 740mm As per Part M
- 81 -
APPENDIX 3: Discussion sheets for focus groups
- 82 -
Curtains
Background:
The evidence shows that curtains do get contaminated and hold a raised microbial load
(the bug stay on the fabric with the potential to transfer to the next person who touches
them). There is a lack of clear guidance regarding the frequency of cleaning/changing of
curtains except following the care of a known infected patient.
The freedom of information results showed a divergence of practice:
New curtains purchased with a BioCote® finish (resistant to the bugs)
New curtains purchased with silver in the weave (proven to have anti microbial
properties)
Fabric curtains replaced with disposable curtains
One Trust removed the curtains from 30 wards and replaced then with screens
Questions for the group:
1. What is in use in the Trusts represented?
2. Have there been changes in practice and has this required new curtain track or
other changes to the fabric of the building?
3. If they were starting from scratch – i.e. new ward area what would their
preference be regarding curtains?
4. Are they aware of any other evidence relating to curtain selection?
5. Are you aware of any article(s) relating to this topic?
Curtains
Evidence Reference Gap
Curtains are a vector
for microbes
Hospital
cleaning
standards
There is no evidence other than promotional
documents from companies regarding the most
suitable curtain fabric/disposable curtain to
select. Curtains should be
changed following care
of an infectious patient
Hospital
cleaning
standards
Removal of curtains in
favour of screening
FoI
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Flooring
Background:
The freedom of information responses showed Trusts removing carpets and wooden
floors and replacing them with vinyl. Some were also removing skirting and replacing it
with coved vinyl skirting.
The guidance says that the cleaning of skirting and carpets should be compatible with the
existing cleaning regime.
Question for the group:
1. What are the group‟s views on the use of carpets and coved skirting?
2. Are you aware of any article(s) relating to this topic?
Flooring
Evidence Reference Gap
The cleaning of skirting and carpets should
be compatible with the existing cleaning
regime.
HBN‟s Common practice is to remove
carpet from all clinical areas.
Common practice is to fit
coved skirting Vinyl appears to be the flooring of choice in
clinical areas
FoI
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Clinical hand wash basins at ward entrances
Background:
The freedom of information requests revealed a number of trusts putting hand wash
basins at ward entrances. There is no design guidance or evidence to validate this action.
The rationale from the Trusts is that it is to encourage staff and visitors to wash their
hands before entering the ward area.
Feedback from our steering group has raised the issue of helves or hooks being available
beside hand wash basins at ward entrances. These are to provide a place to set down
papers /files /bags etc. to ensure full hand washing. The argument has been raised that
shelves become a dust trap and handbag are put down on toilet floors, pavements etc and
could be a source of contamination. Hooks negate this risk but are not good for papers.
One trust is looking into lightweight pack-away bags able to hold A4 files. These could
be colour coded by department and have a hand hygiene logo printed on.
Question for the group:
1. What are your views on the provision of hand wash basins at ward entrances?
2. What are your views on shelves or hooks beside basins?
3. Are you aware of any article(s) relating to this topic?
Hand wash basins at ward entrances
Evidence Reference Gap
There is evidence that shows that the
position of a sink can encourage use.
Akoyl AD 2007
Journal of clinical
nursing
No direct evidence that
there should be hand wash
basins at ward entrances
There is evidence that having soap
and paper towel dispensers filled
impacts on hand hygiene being
performed
Akoyl AD 2007
Journal of clinical
nursing
Sinks are being placed at ward
entrances
FoI
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Clinical hand wash basins in Sluice rooms
Background:
There is no reference to hand wash basins in the design guidance relating sluice rooms.
The replies from the freedom of information requests show a number of Trusts putting
hand wash basins in sluice rooms.
A parallel study to this one has demonstrated increased microbial load on the door
handles between sluice rooms and the first available hand wash basin.
Question for the group:
1. What are your thoughts on clinical hand wash basins in sluice rooms?
2. In you view where is the optimum position of a hand wash basin in relation to the
sluice?
3. Are you aware of any article(s) relating to this topic?
Hand wash basins in sluice rooms
Evidence Reference Gap
Some Trusts have put hand
wash basins in sluice rooms
FoI No evidence for putting in hand
wash basins in sluice rooms but this
is happening. Evidence of increased microbial
load on door handles from
sluice rooms
HaCIRIC
project
evidence
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Sensor taps
Background:
There is no clear design guidance relating to choice of taps in clinical areas other than
avoiding hand operated taps.
There has been a mixed range of actions relating to taps from the freedom of information
requests. A number of Trusts have replaced hand operated taps with wrist or elbow taps
whilst others have replaced elbow taps with sensor taps.
Question for the group:
1. What are your views on sensor taps?
2. Are sensor taps any better than traditional elbow operated taps?
3. Are you aware of any article(s) relating to this topic?
Sensor taps
Evidence Reference Gap
Avoid hand operated taps in
clinical areas
HBN No guidance on the choice of traditional
vs. sensor taps
Some Trusts installing sensor
taps
FoI
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Staff changing facilities for ward staff
Background:
Changes in practice have led to staff being responsible for the laundering of their
uniforms and a resulting reduction of staff changing areas.
There is little design guidance on the provision of staff changing areas, whether these
should be centralised or local to the work area (with the exception of theatres).
The freedom of information responses showed a few Trusts making space for local staff
changing areas.
Question for the group:
1. What are your views on staff changing areas?
2. Should they be close to the work place?
3. Should they be centralised?
4. Should the laundering of uniforms be the responsibility of the Trust?
5. Are you aware of any article(s) relating to this topic?
Staff changing facilities for ward staff
Evidence Reference Gap
Local staff change facilities are
being provided by some Trusts
FoI No guidance of whether there should be
staff changing facilities.
If they are provided no evidence to say if
they should be local or centralised.
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Centralised ward equipment decontamination area
Background:
In the 1970‟s the „Best buy‟ design hospitals were built with a bed wash area. Over time
these have been changed in to other facilities and the centralised washing area lost.
There is no design guidance relating to centralised decontamination areas. The Freedom
of information requests showed a number of Trusts making space for and equipping
centralised areas and a few enlarging sluice rooms to provide localised decontamination
areas.
Question for the group:
1. Does your Trust have centralised / local decontamination areas (steam
cleaning/wash areas)?
2. What are your views on centralised decontamination areas?
3. Are you aware of any article(s) relating to this topic?
Centralised ward equipment decontamination areas
Evidence Reference Gap
Several Trusts have invested in centralised
ward equipment decontamination areas.
FoI Currently there is no design
guidance to support this
action Some Trusts have increased sluice sizes to
enable localised decontamination of
equipment
FoI
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Single side rooms / patient isolation
Background:
There is a lot of published research up to 2006 supporting the case that single side rooms for isolation purposes have proved significant in the prevention of healthcare associated infection and
reduction of numbers of MRSA. However this research has been more recently challenged by a
researcher looking at the proportion of single rooms in English hospitals compared with their
infection rates.
The freedom of information results showed common practice: Creation of additional side rooms
with ensuites
Questions for the group:
6. What is the general specification for the additional side rooms related to infection
control?
7. Have there been changes in practice eg or specific requests for positive/negative pressure , new pressure ventilation?
8. On new builds are you being asked for anything specific in relation to the provision for single side rooms?
9. Are you aware of any other evidence relating to side room specification and infection control?
10. Are you aware of any article(s) relating to this topic?
Side rooms
Evidence Reference Gap
Increased single room
accommodation reduced
levels of HAI between 50-
100% provision
Ulrich et al
2004,
Chaudhury et al
2006,
Dowdeswell
2004
Argument that increased isolation
reduces probability of cross infection.
Little scientific evidence on the
reduction of the occurrence of infection
with increased single room provision.
Increased single room provision on its
own is not significant in reducing
infection rates, guidance supports the
benefits for improved patient safety.
Patients are at increased risk to infection
form MRSA and nosocomial diarrhoea
when patients located in close proximity
of exposure with common nursing staff
Increased single room
provision permits increased
bed occupancy level
HAI
surveillance data
(2004)
Single rooms with good air
quality reduces incidences
of nonsocomial infection,
reduces patients length of
stay, offers maximum
flexibility
Jernigan (1996),
HBN 4, HBN 23
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Ward storage
Background:
The HBN‟s (Health building notes) advise that there should be storage for hoist and
associated equipment. There should be adequate storage for ward stores and supplies.
How, where and in what quantity storage should be provided is not detailed.
The freedom of information request showed a number of Trusts increasing storage space
to clear „clutter‟ from the ward. There also is a move away from open shelf storage to
cupboards. Local experience has also shown that infection control teams are against
roller shutters for cupboards.
Question for the group:
1. In your opinion where is storage best located in the ward?
2. What is your ideal storage solution for ward stores and supplies?
3. What are your views on roller shutter doors on cupboards?
4. Are you aware of any article(s) relating to this topic?
Ward storage
Evidence Reference Gap
More storage required at ward
level
FoI There is little guidance on the quantity
of ward storage to be provided.
There is no guidance on where storage
is best placed on wards.
There is no guidance on open and
closed storage solutions.
Closed cupboards are preferable
to open storage
FoI
Traditional cupboard doors are
preferable to roller shutter
Steering
group
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Choice of cleaning method
Background:
The freedom of information request showed Trust investing in equipment to support a
range of cleaning methods i.e:
Micro fibre
Steam cleaning
Hydrogen peroxide bombing
Ultraviolet
Vacuum cleaners
There are recommended cleaning frequencies for ward areas. There are recommended
regimes following the care of infectious patients. There appears to be little guidance on
the method of routine cleaning, with the choice sitting with individual Trusts.
Question for the group:
1. How much does ward design influence the cleaning method chosen?
2. What would be your preferred cleaning method?
3. What design would best support this cleaning method?
4. Are you aware of any article(s) relating to this topic?
Choice of cleaning method
Evidence Reference Gap
Frequency of cleaning and
cleaning following infectious
patients
Towards cleaner hospitals,
National standards of
cleanliness
Little guidance on the
cleaning method for
routine cleaning.
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Group:
Date:
Page Subject Order for
discussion
1 Curtains
2 Flooring
3 Hand wash basins at ward entrances
4 Hand wash basins in sluice rooms
5 Sensor taps
6 Staff changing facilities for ward staff
7 Centralised ward equipment decontamination areas
8 Single side rooms / patient isolation
9 Ward storage
10 Choice of cleaning method
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APPENDIX 4: Transcript sample (part 1 of Microbiologists
focus group)
- 94 -
Focus Group Meeting – File (6)
Infection Control
So you‟ve got a little pack there which has got a list in it of the range of subjects that
we‟ve picked out that are we feel are fairly key. So we‟ve got Curtains, Flooring, Hand
washbasins at Ward entrances, Hand washbasins in sluice rooms, Sensor taps, Staff
changing facilities - Ward Staff, Centralised ward equipment and decontamination areas,
Single side rooms/Patient isolation, Ward storage and Choice of cleaning method. So
we‟d like to – if you‟re happy – go through those and we‟re not fussed about what order
we attack them in, so if you‟ve got anything that‟s a burning issue?
M: Antimicrobial coating of surfaces – you haven‟t put that in your notes on…
I haven‟t, but we‟ve got a free talk section after we‟ve been through those…
M: There‟s nothing specifically here about en suite facilities of toilets….
No, there isn‟t.
M: Except single side rooms, I guess, but toilets as facilities for whole bays….
So en suite facilities plus toilets….?
M: Well, toilets will be bathroom facilities generally, I guess, that would include en
suites and also for bays. And there‟s nothing about single sex accommodation, it
seems to be an issue of the moment.
M: But that‟s really a sort of managerial thing, isn‟t it?
M: Well it impacts on infection control because we‟re now looking at putting patients
in single rooms because the only bay that‟s left is male, for example, and….
F: You need a female…
M: I would suggest we say you should have single sex floors, full stop.
F: But even that leaves you an issue if you‟ve got four empty beds in the female
ward and you‟ve got four men sitting in A & E.
M: Sorry, I have a very strong feeling about this, actually..
F: The designs that are coming in, a number of them are one hundred per cent single
room, which negates that issue.
M: Yes, that‟s what the problem is, providing them with en suite facilities.
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F: Yes, it‟s an awful lot of bathrooms to clean, though.
F: Well we‟ve only got one hospital built like that, Hexham, so far.
M: Yes, and that‟s a very small hospital.
F: It is a small hospital. Pembury‟s in progress, that‟s the other single bedroom
hospital.
M: The staff changing facilities, there‟s nothing about staff office space or desk
space.
Is that an infection issue?
M: Well, I suppose the issues are we want to isolate patients and sometimes they
can‟t be isolated because they‟re too sick, they need to be observed. So we‟d
need some way of monitoring patients if they‟ll be isolated, as part of that
process. I mean maybe we‟ve just got situations peculiar to us in that our single
rooms are often shoved way down the corridor away from the nurses‟ station, and
often this is brought up as an excuse as to why they can‟t be put into a single
room, because they need to be monitored. Doesn‟t sound very convincing, does
it?
No, it doesn‟t.
M: But we get faced with this a lot.
M: I know the argument you mean, but I think we can discuss that under….
It‟s your staffing levels really, isn‟t it, that guide that?
M: It is, yes, and visibiltiy.
Which is also managerial.
M: I‟ve heard some people saying that they don‟t want any nurses‟ stations at all,
they just want the nurses moving around stationless, as it were.
M: I think we can discuss it under single room patient isolation, it‟s an aspect of that
which is very important, I agree.
M: If we think of anything else we can just add it?
Yes, absolutely. So would you like to start with single rooms, then, which is Sheet 8 –
page 8, at the bottom?
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M: Which researcher is the one…which one do you mean here?
It‟s somebody in the Midlands, somebody that…..
M: Is this the report by…I‟ve forgotten his name now, works at HPA in the
modelling area – Ben Cooper?
M: Yes, I thought you might have quoted that, it‟s a very famous paper looking at
MRSA ..in The Lancet, wasn‟t it?
M: BMJ, I think it was – a few years ago.
M: Doing modelling of the provision of isolation for reducing MRSA infections. But
I have to say, sadly, they I think included twenty years for the impact of increased
single rooms…to have any impact upon MRSA and during the last two years the
MRSA rates have gone down by sixty per cent without much increase in single
rooms. So I would have to say that the data in that paper is now suspect as it was
a model suggesting that actually, it would take years and years for single rooms to
have much impact on infection rates, or at least in order to build them and then
have an effect, I think it should be quoted in your analysis. My own view now, I
must say, is that the evidence doesn‟t really support that model.
M: No, and there was a lot of debate at the time about the assumptions that were
made and whether they‟re valid. As you point out, history‟s proven that most of
them were not valid.
M: I think that was my criticism – we‟ve often discussed this at the time – that when
they looked at…it was also based on a judiciary review as well, and the judiciary
review I‟d say didn‟t make much difference. I have to say, some people say that‟s
because the patients weren‟t actually isolated. They had the room but we all
know that nurses like to keep the doors open and doctors go in without washing
their hands, so actually, whether or not isolation made any difference because it
wasn‟t being isolated…and there‟s another paper from UCL on isolation of
patients in intensive care units which demonstrated, I think, that that isolation
made no difference to transmission of MRSA in intensive care units. And again,
people like me would say, well in our intensive care unit, the isolation room is
really only a nominal isolation room in a busy ITU where people are moving
around it, and so on and so forth. So I think the literature evidence is extremely
doubtful because people haven‟t isolated properly. I would tend to go with Brian
(inaudible) quite reasonably said that quarantining of patients is something that
has been going on for four hundred years, and we think it‟s a reasonable thing to
do. And it‟s interesting to me with this flu outbreak, it's what we‟re trying to do at
the moment. I personally think it‟s reasonable to isolate patients if you can, but I
think the essence is how you isolate. I don‟t think it‟s necessary to have a single
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room to isolate, much easier if you do – I think there are reasons for having a
single room….
F: I think there are other reasons for having a single room which is what we touched
on before, about there being diversity in the single sex.
M: To my mind, a single room has two major purposes – one is as a physical barrier
to…limits contamination of the environment from a patient who‟s shedding
micro-organisms in one way or another. That gives you obviously a very targeted
area for cleaning, so someone with diarrhoea, for example, isn‟t going to have
diarrhoea outside those walls, which makes it a lot easier for the cleaners. But it
also has..or could have at least, this is probably why it‟s fallen down a lot, it could
act as a psychological barrier as well as a physical barrier to the spread of
infection. It should give the idea that you‟re moving from an area of low risk to
high risk in terms of contamination of the person who‟s going in and the risk to
them if they‟re going in there, if they need to wear personal protective equipment.
I suspect that hasn‟t really emphasised enough, that aspect of isolation. People
might not appreciate that they‟re moving into a special area. And ways of trying
to improve that may improve the function of single rooms as isolation areas.
Because single rooms aren‟t only used for patient isolation, there‟s lots of other
reasons as well.
M: I agree with all of those, and I think having en suite facilities is very important for
control of things like diarrhoea. And the other thing, I don‟t know whether you
know more about this than we do probably, whether the NHS is really going to
move towards one hundred per cent single rooms. If we could, that‟d be fantastic
but I would have thought it was unlikely.
F: I think because of the other drivers, I don‟t think it‟s purely infection control
that‟s driving it. I think because of the flexibility you gain within ward area in
terms of single sex accommodation, those issues are higher. At our particular
Trust, we have consultants in one particular area where they think they have two
four-bedded bays and they are really quite insistent that even in a new hospital,
they have those replicated because of the socialisation aspect of those patients –
and they are often repeat returners, long term….but you just wonder whether
more of their rehabilitation would be achieved by actually having or going back to
a day room or dining room type area where you could go if you didn‟t have an
infection, and were free to actually manoeuvre yourself into that area, or be
assisted to that.
M: Yes, those areas have completely disappeared, haven‟t they? Or at least in our
Trust.
F: Most of them have been turned into bays or side rooms to increase capacity. On a
lot of the places where you‟re constrained and it was a lot easier to do that, and
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again, that‟s where the managerial essence of the building and the way it was
designed gets lost.
M: There‟s a fantastic paper by – in fact, one of the few papers by a chap called
Stelfox a few years back, looking at the impact of single rooms on (inaudible)
patients. It‟s one of the few proper papers looking at this aspect, so he looked at
patients who had cardiac failure and some of them had MRSA and some of them
didn‟t, and the ones with MRSA were put into single rooms and he looked at
various aspects of their care. And also their experience, and virtually on all
counts, they did worse or had a poorer outcome. So they looked at visits from
doctors and nurses, and they were reduced. They looked at changes in medication
to what…looking at what they thought was better medication, and you‟re much
more likely to go out on more appropriate medication if you didn‟t have MRSA
than if you did. And they also impacted on future care because during the in-
patients‟ day, a lot of the patients would go to education classes on how to deal
with heart failure and that sort of thing, except the ones in isolation, who didn‟t.
And so there‟s that aspect, and the complaint rate was much higher from the
isolated patients than the ones who weren‟t isolated. Surprising that that paper
stands alone, almost, on the literature on this.
F: There was a paper – I can‟t remember who wrote it – and it was about the social
isolation of isolation and enforced isolation, and how depressing it is hour after
hour, just being on your own.
M: There‟s a number of subjective papers like that but in terms of objective evidence,
there‟s very little apart from this particular paper.
F: I think if we‟re going to go to having single rooms, I think there‟s got to be an
awful lot of work done on the nursing and care side that negates those things, and
that everybody – doesn‟t matter whether they‟re just in a single room or whether
they are isolated within a single room – that they still get the same standard of
care and input.
M: And then one of the problems is looking at a patient – if you‟re not going to go in,
does that mean the patient doesn‟t get observed, or are there other ways of
observing the patient remotely which haven‟t really been addressed? I mean
there‟s potential technologies, with those kind of walls that changed from clear to
opaque glass.
F: Yes, I‟ve seen that in Sheffield.
M: And there‟s cameras…people are very reluctant to put closed circuit cameras in.
F: But actually, nurses will often pick up changes within a patient and it‟s about
visualising the patient, it‟s not about what the monitor says. The monitor won‟t
have changed yet, their vital signs won‟t have changed yet, you‟ll have picked up
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before that happens, you know, it may only be minutes before but you‟re there
and you‟re ready and you‟ve already called in for assistance because you know
something‟s about to happen. So yes, visualising a patient is a very key issue.
M: What you raised earlier, I‟ve seen an intensive care unit designed so that there are
several walls of single rooms. They‟re all visible by glass from where the nurses
are sitting or people are standing where most of the action is, so I think being able
to see the patients inside is very important. I personally think that if we think
isolation helps infection control, then we should do that for infection control
purposes, which we‟ve already discussed. Other issues of isolation having to be
dealt with by a quorum, in a way.
F: Yes, I think that‟s right.
M: And I think if you‟re going to isolate someone, you should isolate them properly
and that does mean the patient is going to be isolated in other ways as well. I
think therefore it‟s important to manage them appropriately to reduce those risks.
And the only other things they do, in private hospitals everyone has a single room
and generally, patients are happier in single rooms. I know that doesn‟t apply to
everybody and it doesn‟t apply to perhaps the sickest patients, but I don‟t see that
single rooms should be an issue. If people are not going in to see the patient, then
therefore they‟re not doing their job.
M: No, it‟s interesting that lots of us would prefer, I guess, a single room than an
open bay, certainly not a Nightingale ward, but a lot of patients reportedly
currently prefer those.
F: Again, I think a lot of it is about what they‟ve experienced and what they perceive
as a hospital. I‟ve nursed on Nightingale wards and they‟re fantastic on a night
shift, to be able to tune in to all your patients up and down the wards and if
anyone starts to get a bit fidgety, you can go across straight away and you‟re
there. I should imagine the falls rate on Nightingale wards is a lot lower than the
falls rate in other areas, but there‟s now technologies that can negate that - you
can have sensors under mattresses that let you know if the patients are on the
move, and things like that. So it‟s building in the technology to give you
knowledge of what the walls stop you seeing, really.
So in terms of single rooms, in general, would you feel there is a requirement for a larger
percentage of single rooms than are currently available in the majority of Trusts?
M: The majority are less than twenty per cent. We certainly looked to increase the
when we were planning our PFI project, which is stillborn now, we were looking
at thirty per cent as a minimum, fifty per cent in what were proposed to be
surgical areas. Whether we would have ever achieved that is impossible to know.
That was one of the costs being looked at when we were revising the plans and
they were disappearing before our eyes, so they are seen as expensive options.
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But then I guess from a health economic point of view, you‟d look at the cost of a
single room in terms of building it, costs of manning it, and set that against the
costs of infections.
M: And ward closures because of infection – Norovirus is a classic example, every
week there were more closed wards, and having more single rooms makes it
easier to contain the situation. I mean, I think we would support single rooms but
I‟m not sure what the percentage should be.
F: No. It‟ll be interesting, I think, to see how places like Penbury go on, once
they‟re open.
F: When they did the alterations at Poole Hospital where they did fifty per cent
single rooms, the problems still emerged that the occupancy rate was such that
when the patient came in, they had no choice – they went into the next bed, so
they couldn‟t choose whether they went into a single room or a bay, which has
been one of the guiding ideas. Not about infection control, but that didn‟t work
either with high levels of occupancy.
M: There are some large PFIs dealt with very high percentages in single rooms, and I
think the one in Reading‟s Great Western – or it might be Swindon – I think fifty
per cent.
F: The new Leeds Oncology Unit‟s forty two per cent.
M: Our oncology unit here has got about fifty per cent and another ward – interesting,
because it‟s the first time it‟s happened in my lifetime – is when we said no,
you‟ve got to have more side rooms and they said ok, then reduced the total
number of beds in order to have more side rooms and I have to say at the moment,
in this Trust we‟re managing to keep patients in single rooms, or in some form of
isolation because we have recently had sufficient numbers of side rooms.
Do you know roughly what percentage?
M: No, I don‟t, now this has come up, I realise I don‟t know because it varies from
ward to ward, so there has been a tendency to move patients into certain areas
where there are more singles available.
M: One of the trends in our Trust that we reversed recently was conversion of single
rooms into offices…we went round and managed to boot out a number of
consultants who weren‟t very pleased with that, but the rooms still had oxygen
and gas fittings/wall fittings and it was easy to put the rooms back in to use.
F: They certainly lend themselves to offices better than most multi bed bays.
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M: And the other thing is to have sufficient space in the single rooms because
sometimes you will need to bring other equipment in and time after time, you
can‟t do it and then you have a real problem. Or you need to accommodate a
wider or longer bed.
M: Keeping the door closed is an issue too.
F: Yes!
M: And there must some very easy way of making sure the door is kept closed these
days with alarms and so forth.
F: If the room‟s just being used as a room, then the door being closed isn‟t an issue
but if a patient comes and needs to be isolated, then there should be something
you can do that if the door‟s left open, like it will alarm.
M: But then you have to ask why the door‟s being kept ajar then, because is it for the
patient, is it for the nursing staff? There must be some reason for it when it‟s such
a common observation that there must be a frequently occurring reason for it.
F: I guess it depends on the vision panel in the door, doesn‟t it?
M: There‟s also..there‟s no doubt, really, it‟s to do with the patient and the nurse
involved who would be the connection with the outside world, and I have no
problems with that but I just think, if it‟s a managerial issue – it‟s not actually, to
my mind, a mechanistic issue although that might help alarm. I think we have to
say, if a patient‟s infectious, they must be isolated full stop. Just a few years ago,
three or four maybe, it was quite difficult to get that across. That was much less
of a priority than making sure you could see the patient and that you could talk to
them and the patient didn‟t feel isolated. And I have to say, if you‟re going to
isolate a patient, you isolate the patient, full stop. Then you sort out the additional
problems that may follow. So I think an alarm – or some very visual alarm, for
example – would be useful but I do think that‟s a managerial issue, not just
physical so…but I agree, if you‟re going to isolate a patient, they must be isolated
and there must be appropriate facilities there. This is why en suite facilities are so
important because if you‟re trying to isolate a patient if they don't have their own
facilities they‟re going to wander away.
F: Yes absolutely, or use a commode and that is then wheeled along the ward to the
sluice.
Ok, we‟d better move on.
M: Air flows, then. I think it‟s very important to get the air flows right and it‟s very
difficult to engineer these retrospectively, so if you‟re building more single
bedrooms, then they should have in general air flows into them. There is a
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problem around monitoring airflows because I‟m not quite sure if we‟d get it
right, but I‟m sure in the modern world, you could have a system which can tell
us…..
F: I think what we‟re leaning to all is positive air pressure in the lobby, to form a
barrier.
M: Well, that‟s the question, if you have a lobby or not.
F: I think you have to have a lobby if you‟re having air flow control. You can‟t
really have air flow control without a lobby.
M: But that‟s extra cost, then, isn‟t it?
F: Well, it‟s a different level of provision, isn‟t it? I think they‟ve mastered that
remotely to stop staff from switching them locally and making a mistake.
M: I‟m sure you‟ve gone over this much more than we have already, so I‟m sure none
of these things are new, I just think you should write it down to say – the issue of
air flow needs to be addressed, and a way of getting the air flow right, as to
whether or not it should be in or out, but generally, it‟s going to be in. And how
that‟s done is another engineering question.
F: Yes, it is.
Ok, shall we move on to Curtains? Somebody raised a few bits and pieces there about
disposable choices and fabric. In the Trust that you‟re in, is there a combination being
used or is it all fabric, or…?
M: We‟ve moved towards disposable curtains actually and it‟s quite interesting
because we actually did some studies on the fabric curtains as to whether they got
contaminated, and the answer was yes they did, but no they didn‟t because the majority of
the curtain didn‟t get contaminated but there were some areas perhaps that did. I don‟t
think there‟s any evidence that curtains distribute organisms but I think they probably do,
but I don‟t think there‟s any evidence to that effect. One of the interesting things we
found is that the biggest issue is on delivering a mountain of fabric curtains – you know
about this, I know, where they sit on the floor because they‟re heavy, generally girls are
not all that strong, and it‟s difficult isn‟t it?
F: It is.
M: And one of the major things that we found is that it‟s slightly easier, these
disposable curtains are light…
F: The disposables, yes.
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M: Easy to put up, easy to take down, can be done very quickly but no-one knows
how often they should be changed. We‟ve gradually been lengthening the period
between changes and I can‟t tell you actually how far they‟ve got, but it‟s
probably about six months and after any infectious patient, or if they get
physically damaged. They look very attractive, given the fact that I don‟t think
there‟s much evidence that we know what curtains can do, so around issues of
appearance, hygiene, cleanliness, probably a reduction in transmission of
infection, easy use, not getting contaminated on the floor, easy to replace – they
win, in my view, on all of these issues. I don‟t know whether they win on cost,
although I think there may be a business plan which says they‟re not that much
different.
F: Yes, interesting.
M: I dread people asking me about curtains because I already don't know what the
infection control importance of curtains is. I suspect that they are a risk, in terms
of infection control, presumably it‟s only when you touch them or if you give
them a good shaking and dust falls off them. But the trouble is, I‟m not really
aware that there‟s any linkage between curtains and the types of curtains,
frequency of change and infection control risk.
F: I think it‟s really difficult to measure anything, it isn't audit-able and any changes
you put in because there are so many other changes going on in terms of the
clinical practice so all of the antibiotic reductions and the enhanced catheter care,
all of those sorts of issues, all of the rates are being driven down, so whatever else
you change, you can‟t say „Yes, that made an impact‟.
M: Well I wouldn‟t want to spend more money than I‟d have to on curtains, I suppose
would be my comment. And clearly, of course, if you‟ve got…the more single
rooms you have, the less curtains you‟re going to need as long as there‟s privacy
within the single rooms and then, of course, observation, so it all depends on
whether or not you can think of alternatives to curtains.
M: I agree, I don‟t think there‟s any evidence that curtains make a major contribution
to transmission of infection.
F It seems to have become an issue and people sort of view it as a risk.
M: Yes certainly facilities managers think of it as a risk, and they are often very keen
on getting the silver coated ones, for example….
F: They smell diabolical when you get them out of the packets, though….they‟re vile
when they‟re brand new.
M: I think we should come back to coating – I mean I can just make one other point
about our own use of curtains, and that is that the wards have had a big push to
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change them but this is not because of infection control purposes, it‟s because
they‟re so much nicer to use, easier to use.
So they prefer them. Have you got a design on your disposables, or just a plain block
colour?
M: They‟re a plain block colour but they‟re quite attractive, they‟re very modern,
they‟re sort of textured and they‟re concertinaed. They just look very nice. I
must say, it raises the appearance of the ward and I‟m convinced that having a
bright, clean modern looking ward contributes towards hygienic behaviour. It‟s
like walking down a dirty street or a clean street, and I‟m sure that has an impact
on people‟s behaviour on the wards. So I like them but I really have no idea what
the final outcome of costs is, because you‟re always given a business plan which
says there‟s no difference and you come back a year later, or five years later, and
financially it‟s changed. But I think the fact that we don‟t change them all that
often obviously reduces the cost.
You said you‟d heard of one place that was taking it out to a year now?
F: Yes, somebody reported in another meeting that they were changing them over a
year, which is quite long because washable curtains are changed more often than
that, aren‟t they?
M: Maybe! The other thing to think about with the curtains is what they‟re attached
to and if there‟s any issues there in terms of deflection of dust, all those sort of
things, whether you can do anything about that. Whether or not there‟s any more
advantage you could get from curtains, you know, if you‟re doing disposables,
you could have printed messages on them perhaps, or hygiene „Wash Your
Hands‟ or psychological drive to improve hygiene one way or another, I don‟t
know!
Ok. Any other comments on curtains? No, ok moving onto Flooring - taking out wooden
flooring and replacing it with vinyl, and the general move to taking out carpets in clinical
areas or adjacent to clinical areas, and some issues with skirting. Obviously, I think
people are trying to provide floorings with no gaps or little creases where you can get the
dust gathering, and so there‟s a nice clean and smooth impermeable surface.
M: Well, there shouldn‟t be any carpets in any clinical area.
M: I agree.
F: I think they‟ve got carpets at Hexham, in their single rooms!
M: That‟s a far outpost in the Empire, isn‟t it?! Almost like Hadrian‟s Wall! They
did that in our Oncology Unit when it was built about ten years ago because one
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of the previous directors of nurses thought it looked more homely to have carpets
in the clinical area, then she went and so did the carpets.
Clearly, the flooring must be cleanable and must stand up to cleaning and so you
need to look at chemicals you‟re going to use and whether they‟re going to be
harmful. Then you‟ve got the other aspects to flooring in terms of noise, push
ability and appearance.
F: And being able to get your feet over it as well, shuffle-ability – with a frame.
M: Stilettos, the impact of stilettos on them, when the SHA Chief Executive comes
round to have a look!
F: The coving that tends to go in at the moment is sort of a curved edge that runs up
the wall to 150mm, so kind of mop head height so that you‟re not destroying
anything along the wall. We‟ve seen some areas that aren‟t going down that
model at all. That seems to be the predominant model though.
M: I think as long as you‟ve got a barrier, for where a cleaning machine would be,
and I think there are machines that can clean the coving too, I don‟t know very
much about it. I think the idea of curved skirting is a very good one.
F: You certainly don‟t see people on their knees any more scrubbing right into the
corners, do you?
F: Do you have concerns about bugs on the floor, or contamination?
M: Well, from my perspective, if you‟re providing dust traps, then potentially the
organisms like MRSA or C.diff. that could otherwise be cleaned away will persist
and potentially could then contaminate and infect other patients if they come in
contact with them.
F: That‟s one of the arguments that comes in the American literature for carpet, that
actually it contains the dust and it doesn‟t gather up, then you vacuum it up.
M: You can‟t vacuum it up you can try steam cleaning, but then that becomes more
difficult. I personally think that a floor should be wipeable. I don‟t think we‟ve
solved this yet but we know with the decontamination of surgical instruments –
the first thing is cleaning them and I‟m sure that applies to surfaces too, and if you
clean it, you‟re going to get an awful lot of stuff off. What we don‟t know –
because there‟s plenty of work showing that organisms have been recovered from
the environment – we don‟t know how significant they are, and we also don‟t
know whether they‟re there because they‟ve been cleaned properly or improperly.
F: That‟s right, a natural microbial loading and whether that‟s….
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M: I mean, there‟s some evidence to suggest that the standard of cleaning procedures
don‟t clean the floors properly. That may be, in a sub section we‟ll be talking
about today, we have different cleaning procedures but the first thing, in my
opinion, is it should be clean and smooth so it can be cleaned very easily. On
antimicrobial coatings – I don‟t think there‟s any evidence at all that antimicrobial
coatings have any effect whatsoever on the environment and it‟s interesting that in
the American literature, a lot of these antimicrobial coatings have been around for
a long time and are only now being introduced, or being proposed for use on ward
furniture and usually they‟ve been used for decades in various other settings like
kitchens and mainly, when you look at the package insert, they say that they
reduce spoilage and fungal/damp areas in buildings, or in clean areas where food
is being produced. But they specifically say, some of these companies, the
American inserts – in America, this is not evidence, or should not be used or
should not be taken to indicate this has any impact on health care. But it‟s in
Europe we‟re having it constantly proposed to people that they should put that
antimicrobial coating on everything. And they‟ve shown that if you put
organisms on this stuff, they don‟t survive, or they survive less well than on plain
things. But if you clean them off, there‟s no need for it and further, there‟s always
going to be some way you can‟t get to clean and they‟re going to grow. So I‟ve
always taken the view that if it‟s exactly the same price to have your walls or your
surfaces or your floors or your paints antimicrobial, then I would have no
objection to getting the antimicrobial product. But if it‟s any more expensive, I
don‟t think there‟s any evidence that it works.
F: What about doorknobs?
M: Similarly, because I think that – I just don‟t think there‟s any evidence that it
works properly, that the transmission on hand contact sites are going to be there
all over the place, on dials and knobs and things which are not necessarily
antimicrobial, and I just don‟t think there‟s any evidence and furthermore, it‟d be
very difficult to get any evidence actually.
F: A number of Trusts reported in the freedom information that they got covers, or
different sorts of keyboards for their computers.
M: Those are very expensive. They were trying to sell me these at University
College Hospital and they‟re about £120 a keyboard. Actually, I was on a visit
down there, I went to see something else in UCH and a lot of them, the lights that
have been flashing indicating they need to be cleaned, people have just taped over
them all!
M: I agree with you, it‟s a bit of a shame really because Peter Wilson actually did the
work and I think his publications were very convincing, and I believe his results
in which he did demonstrate that keyboards were being contaminated and that
there was transmission from hands in both directions, and I think the idea of
having a keyboard you can clean in critical areas like, for example, in operating
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theatres where there are often used – amazing to me – keyboards. I think it‟s a
very good idea in principle.
F: Well, you can get the flat pads now with the smooth surface so you just tap on to
them and just wipe it over.
M: Yes, I think that‟s a good idea. I think the cut outs that you put on keyboards
must be nonsense, how anyone could think that they would work…. But I think
wipable covers was a good idea but not essential. Hand washing would prevent
the need for these.
M: Just getting back to flooring, I just wonder whether or not we can get flooring to
work harder in the sense from an infection control perspective? Whether there‟s
any way we could integrate technology - whether there‟s any technologies that
would indicate if the floor hadn‟t been cleaned properly?
F: Sort of colour change vinyl, or something?
M: Or something like in CSI, where that kind of ultraviolet lights and things, you see
the stains where there are materials that would glow in the dark if they hadn‟t
been cleaned properly or they‟d over-react with the cleaning chemicals used. Or
whether or not….there was some glass, now, for example, that will apparently
clean itself with ultraviolet light. I remain unconvinced about how effective that
is, but whether or not that is something that‟s worth pursuing, as opposed to the
antimicrobial coating. I mean once they get incorporated to the matrix of the
thing, presumably they‟re not active at all?
M: Well they claim to be active indefinitely, I mean, I would take their word for it, I
think they are active for a very prolonged period, certainly for five or ten years.
But I just think, it concerns me that whatever you put on these surfaces that imply
they‟re going to be self-cleaning or self-sterilising, it reduces the tendency to
clean them at all.
F: Yes, I‟m a bit worried about that. It makes you worried with the antimicrobial
coatings, doesn‟t it, if your locker‟s covered in that, will the cleaner actually give
it a clean or will they think, „Oh, it‟s coated, it‟ll be fine‟?
M: That‟s like when you come into your single room and find somebody else‟s
underwear under the bed because they‟re self cleaning!
Shall we move on to Hand wash basins at ward entrances? I hear that quite a few Trusts
decided that this was important to them and have made capital investment into this. A
number of Trusts haven‟t, but I don‟t know whether that‟s because they couldn‟t –
because of the plumbing and design or if they already had them.
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M: We don‟t have this in general, we have gel dispensers outside ward doors, but
what we do have is a couple inthe intensive care and I think Paediatric areas, there
is a proper lobby that you go into with a hand wash trough in it and all the
appropriate soap and hand towels - everybody uses it, everybody, visitors,
doctors, nurses, they all do it and it‟s such a big thing that you can‟t avoid doing
it. I think it‟s a very good idea, actually. It does mean people think about their
hands going in and out. If that works, and we don‟t know that it does, I guess that
it does – so I think it‟s a very good idea but like a lot of these things we‟re talking
about, it requires space and investment, and often space is the thing which is not
available. I think just to have a hand washbasin and a door is going to be difficult
– no space, nowhere to hang your stuff as you mentioned, nowhere to put your
papers. It actually goes against the philosophy of using hand gel, which is quick
and easy and therefore people do it. Whereas one of the reasons people don‟t
wash their hands is there‟s never any sink, or it was a community sink or it was a
mess and all the rest of it. So I think in special situations, like Paediatrics and
intensive care units for example, it‟s a very good idea but otherwise, I think we
should encourage people to use hand gels and all those other things which have
been designed to try and encourage people to decontaminate their hands, rather
than have a sink.
M: I don‟t think I‟m generally in favour of sinks. We ended up putting a few sinks in
front of a few wards, partly as (inaudible) we‟re trying to promote hand washing
and one of our logos as we went through the door was this sink with a hand being
washed in it, and people would say, „Well, where can I wash my hands?‟ And
then what happened after that was, our patient group started looking to make sure
doctors were washing their hands before they went into a ward, and they would
generally not wash their hands – well, they may or may not have done, but they
would have gone in possibly for some non-clinical reason or they may have
argued they were going to wash their hands between patients rather than just the
once before going in. I think the other problem was they were kind of shoe-
horned into areas which weren‟t really suitable and there was also the issue of
water splashing all over the floor then, people slipping and that sort of thing.
Clearly, if they‟re going to be put in, they need to be put in with due thought. I
think you wouldn‟t start from here, is the attitude, they would‟ve been designed in
to begin with.
M: I think this was the point I was getting at too, about the trough that we have, an
operating theatre trough. Several people can wash their hands at once. You have
to have a pretty big sink and if you‟ve got a group of you or visitors, or people at
the sink and other people arriving, I just think in the end, people are not going to
bother. They can‟t get to the sink and they want to get on with their day. Having
said that, we do have a problem with C.diff. Only being effectively removed with
soap with water, but I think a C.diff. ward is going to be closed off for a certain
time anyway and will have their facilities inside, you‟re going to limit the whole
visitor thing…..an ordinary ward with….I just don‟t think sinks work.
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F: But as we move to more single rooms, it may be that you‟ve got parts of the ward
that maybe do have C.diff.
M: I think a single room should have a sink in it.
F: Yes, the single room itself should have a sink in it.
M: But if you‟ve got the lobby area for the positive pressure, then that would be the
place to have the sink as well, so that you wash your hands before going in and
leaving that particular area. The other issue with sinks is soap and how it runs
out. There must be an easy solution to that one.
M: Yes, things running out should be replaced, that‟s right! Can I just also raise at
this point, all these things which are being chanted round at the moment of sort of
controls to check who‟s washed their hands and how often they wash their hands
and so on, under these electronic systems. There‟s a whole bunch of them, hugely
expensive as far as I can see although everyone‟s very coy about the price, but I
think it‟s something you might want to look at in terms of taking a view on it, you
know, that if you wear a badge.
M: No I haven‟t seen those, but what are they, radio-frequency…
F: Yes, it‟s part of your ID badge and it knows when you‟ve been at the sink.
M: That‟s a good idea.
M: And it‟s all done centrally, well, it sounds a good idea and then you start to think
about it and, you know, it becomes rather less of a good idea, but then some of
them have got rather sophisticated now and suggest that you also check people
when they come within a certain range with a patient, so it‟s like the old tape
round a patient – when you step over that…..
M: Well that‟d be great, I‟ve been trying to get the hospital to be interested in that for
the patients as well so that when they wander off out of the ward and they‟re
supposed to be going down for X-ray, this alarm goes off to say, hang on a
minute…or alternatively going down for X-ray and they‟re actually just about to
get their antibiotics and they miss a dose out because they‟ve been away – you
know, there‟s some alarm saying…before you send him down, just give him his
Amoxycillin, or whatever. And then also with finding out where the patients have
been because we‟ve got very little idea at the moment, apart from the ward
they‟ve been sent to.
M: I think it‟s a good idea….
F: It can be part of the wristband.
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M: But if we go back to the hand washing thing, one of the…this sort of system has
been sold to management, you can have your central place to actually do your
surveillance of hand decontamination without human intervention, so to speak,
and you don‟t do it just on the half a dozen observations that we use at the
moment, you do it on everybody. But you have this situation where a person goes
in to see a patient, not everyone is going to necessarily need to wash their hands at
that point, and they‟re all going to be lumped in together and it‟s not clear how
many people belong….so I think it‟s very interesting technology. It ought to be
successful but I think there are some problems that you might want to have a look
at.
M: Marks & Spencer have been using this sort of stuff for years and so you just walk
down with a sensor and it shows you how many particular trousers or coats or
whatever are still on the rack, without having to count them all.
F: There‟s a lot of application for this for things like – we‟ve been looking at it, just
off the subject slightly, about within a hospital lobby and so your porters can have
a tracker that tells them how many wheelchairs are in the main reception and once
it gets to two, it‟ll flag an alarm. But it will also show them where inactive
wheelchairs have been for the last three hours so they can target and go round
toexactly where they are, and it‟s a much more efficient use of time and sit's ort of
customer service.
M: Good idea. If you‟re going to have hand washing, you‟ve got to talk about hand
drying. Dyson airblades - they‟re very efficient as hand dryers go but I think the
choice would be between them and paper towels really. And the problem with
paper towels is that they get overfilled and then you can‟t get any of them out at
all or you pull them and the whole lot comes out.
F: I think there‟s an issue around quality of paper towels as well, isn‟t there?
Sometimes you use a company and make a saving, and end up with a much
cheaper version which causes problems for the users – either they use more to
ensure their hands are dry or they developed chapped hands.
M: Yes, false economy.
F: The Dyson airblades are quite noisy.
M: They are, yes, and they really can‟t be where patients are going to be because they
would wake people up in the middle of the night. We‟ve got a few around in the
Trust and interestingly, one of them is next to a big trough next to the main
entrance to the hospital rather than by an individual ward. There‟s a big steel
trough, looks like a surgeon‟s trough, and then a Dyson airblade and of course the
novelty of those means that people – especially men – are more likely to use
them. They are quite..they give you very dry hands, it actually feels quite nice.
It‟s better than the usual hot air driers
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F: Well it‟s quick, is the other thing, the other dryers are too slow aren‟t they? You
don‟t want to stay and wait until your hands are totally dry
M: Then you leave with half wet hands, yes.
F: Where presumably, half wet hands are as bad as wet hands.
M: Yes, absolutely yes and the breakdown of the skin, you get chapped cracked
hands, skin infections and also encouraging the carriage of certain organisms and
then they‟re more easily spread as well.
Shall we move on to the hand wash basins and sluice rooms? A number of Trusts
reported they were putting hand wash basins into sluice rooms – again, it‟s really difficult
to judge this in terms of, you don‟t know the way out of the ward and how close the hand
wash basin is from the exit.
M: I‟d have thought they‟re compulsory.
F: Well they‟re not now, they were, I think, when I first started architectural practice
they were, and then they came out of the Guidance and you‟re finding particularly
dirty sluice rooms without hand wash basins.
M: I‟ve just assumed it was self-evident they were necessary.
F: It‟s one of those quirks that we found which we didn‟t expect.
M: Well we ended up with wards with bays without hand wash basins in our Trust.
F: Oh did you? That was difficult, then.
M: Yes, so you‟ve got a six bedded bay and there‟s no sink in it at all, you have to go
out of the bay into the corridor to wash your hands. Of course, you can guess,
that doesn‟t happen.
F: A similar thing where we had a refurbishment and hand wash basins were put into
six bedded bays, they were positioned in such a way that actually it compromised
the sixth bed. So you either had a five bed bay or what they ended up doing was
actually switching the plumbing onto the wall from the outside and moving the
sink to the outside wall.
M: Very difficult to do that retro fit though, and we‟re looking at that for these
particular wards and it‟s in a tower block and apparently the answer is, you have
to empty all the wards in the vertical themes to get that done because there‟s so
much knocking and plumbing and stuff going on, very difficult to do it all in one
go without emptying those particular bay areas. So, is there some debate about
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the types of sinks? It really annoys me when you can‟t get your hands under the
tap in the sink.
F: Hand wash basins are regulated it‟s called a clinical hand wash basin and I think
there are rules and regulations as to the height of the tap to the sink and the tap not
being over the drain, and no overflow.
M: I was in a hotel yesterday in Birmingham and you couldn‟t get your hands wet
without the water going on the side stuff….it didn‟t project over the bowl far
enough for you to get your hands really underneath it, and then there was water
everywhere.
F: No, I think there really are quite strict rules around the taps that are in use.
F: I think there is a height guideline, I can‟t remember what it is. It‟s also to do with
splash and the shape of the bowl, so I think hand washing is better designed by
manufacturers than many things.
F: It‟s obviously not transferred to hotel rooms!
F: Although I‟ve just seen a new hospice near where I live where the basins are
minute, only that big, with a little tap and I can‟t see how they‟re going to not
splash all over the floor or even wash their hands up to their wrists.
M: Well they never have plugs in, of course, these days and….they‟re not allowed to
have plugs in and what they do often have in are bits and pieces like jugs and
those little plastic pill containers, and people are always washing things and
leaving them in sinks.
F: Yes. But is this design or is it behaviour, is the problem, isn‟t it?
M: Related to this is the bins, if you‟re using hand towels, then you‟ve got to have
somewhere to throw your hand towels. They‟ve got some fantastic bins in now
which are silent closers, very good. I'm still kind of twitch every time I use a bin
because of the noise it makes! But the design defect of the news ones is that
they‟re flat tops and so they instantly attract people putting things on top of them.
F: This is why, with the other one here, we thought about having hooks or shelves
beside hand wash basins, because people are often carrying bits of paper into
ward areas – I suppose there‟s an argument to say perhaps you shouldn‟t be
carrying things into ward areas or you should have a lightweight bag of some
sort…
M: We‟re not encouraging that, though.
F: Well that‟s right, because then it gets put on the floor.
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M: Or people hang it over their shoulders and sort of swing round into a
patient…there used to be a sort of sensible compromise to all this, but…bins that
can‟t be used as shelves would be reasonably easy to do.
Shall we move on to sensor taps? There‟s a number of Trusts have put in sensor taps,
certainly I was working at the West Suffolk and we put sensor taps in, just happened to
coincide that the money came in at the point we were already thinking – we‟ve got a
problem, the taps are thirty two years old and actually, they‟re starting to fail and we need
to change them. They‟d all been elbow taps up to that point in the main corridors, so the
best thing was to put the electrics behind it and put in sensor taps. Quite a few areas we
put sensor taps in but there are other areas that have changed taps but not gone to the
sensor solution. Again, issues on funding, issues on access to electricity and issues on
maintainability.
M: There‟s a number of issues here..one is, do they work? You can either get ones
that are just on or off and use whatever water comes out and that tends to rely then
on the valve behind the façade, so you get a reasonable temperature of water.
Others are much more sophisticated and potentially more difficult to use without
some degree of explanation, and you have to kind of wave your hand over it and
you can alter the temperature that way. And we‟ve got a mixed economy in
Leicester of various taps, and we‟ve got the ones you just stand in front of them
and the water comes out, and others where you move your hand around and get
the right temperature. It all depends, I suppose, people always throw up a number
of concerns about things and whether or not they‟re real concerns is difficult to
elucidate sometimes. I‟d have thought these taps were relatively straightforward
to use but you probably ought to get some advice or some kind of consumer
opinion on this because some patients clearly are confused, if you‟re elderly or
poorly-sighted or blind, it might be quite difficult for them to use these things.
Are you finding that they‟re actually going to be put in to basins patients use?
M: Well, there are sinks in wards and we don‟t exclusively restrict their use to
clinical staff, so wash hand basins as opposed to toilet areas. Actually, they‟re in
the general toilet areas on the corridors for visitors‟ toilets, but I don‟t think…..I
can‟t recall if they‟re in individual rooms as en suite facilities.
F: There should be two – a basin for the patient with a plug, and a basin for clinical
hand washing without a plug, without an overflow, which is one of the critical
things and a continuous flow so you wash your hands under the flow. So really, I
think, do you actually expect patients and staff to use the same basins?
M: Well I think, given some of the wards, there‟s very few basins and I think that‟s
inevitable.
F: Is it desirable?
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M: Well, I‟ve never seen…our philosophy has been that we don‟t discourage people
from using sinks and so if anybody‟s using the sink, that‟s generally seen as a
good thing. Whether it‟s one that‟s regarded as a staff sink and patients use it, we
wouldn‟t criticise people for doing that. The other thing on these taps is that the
flow tends to be very poor and standing there trying to get your hands wet under
these things, you just give up in the end. Very closely related to this, have we got
sensor operated soap dispensers? I think we might have one or two but we‟ve
certainly got sensor operated towel dispensers which take a bit of getting to
because you put your hand in front and nothing comes out, and you wait a bit
more, sometimes it comes out, sometimes it doesn‟t. I think the performance of
these things, there needs to be a bottom line minimum standard which I suspect at
the moment isn‟t always reached. I don‟t know if there‟s a National or European
standard on these things or not.
F: It is about the usability, isn‟t it.
F: This is on the basis that by not touching the dispenser at all, there is less risk of
contamination at all, the towel just coming out and you wave your hands
underneath?
A lot of questions – first question is, do they work?
M: Or do you need some kind of written instructions to use them, some of the designs
are quite complicated.
M: I‟ve only ever used them in hotels or toilets and they seem to work quite well. I
thought they were quite a good idea actually, are there problems with them?
M: Well there‟s ones you just stand in front, and that‟s fine but if someone puts
something in front of the taps, it switches it on all the time and you get this on-off,
taps tend to switch themselves on in the middle of the night and you get water
dripping out. Just need to make sure they‟re designed properly in terms of the
focus of the sensor. But there are some that are really nice and attractive, but very
complicated. We‟ve had some, particularly elderly patients, who just couldn‟t
work out how to get the water out of the tap on this particular one.
M: I like the toilets that flush on sensors though.
F: And room sensors, where you open the door and the light goes on, I think that‟s
very sensible to have for patients. You can position the toilet sensor in the wrong
place though, so it acts almost like a bidet sometimes so you‟ve got to be careful!
M: The door issue is always a problem, you can have sensors on doors but then they
can be opening and closing at inappropriate times I‟m sure. I think that we‟re not
going to eliminate transmission of organisms, just as we‟re not going to eliminate
- 115 -
flu, by the way! I think we can reduce the risk – each time you put one of these
things in place, it does reduce the risk slightly and the accumulated risk reduction
may – we‟ll never know – be a sensible thing to do to add to the overall risk of
transmission.
M: It should do. The other thing is the performance of some of these taps give you a
very miserable stream and it‟s very difficult to wash your hands. And it all
depends if you get a fixed temperature water coming out of it. Hospital water is
either freezing cold or it‟s scalding hot, so you‟ve got to make sure the mixer
valves are working appropriately, otherwise you go „Oh God, that‟s hot‟ and
that‟s it, you‟re not going to wash your hands any more.
F: But then before, when we had the elbow taps, trying to get the temperature right
was always tricky, whereas at least if it‟s a set temperature, it might take you just
a fraction to get used to the temperature possibly, but you haven‟t got that
tinkering, which makes it quicker.
M: They should really be designed to be fail-safe so they‟re not too hot.
F: Yes, I think they have to be a set temperature and not above a specific
temperature.
M: But I would certainly support the idea of the toilet flush which is one more
reduction in contact.
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APPENDIX 5: Key points from the focus groups
- 117 -
Key points from the
focus groups
A. CoI nurses and specialists B. Designers C. Microbiologists D. Facilities and
housekeeping management
E. Estates managers F. Patients group
MARU staff
present
PA / RG PA / RG / RM RG / JM PA / RM / JM PA/JM/RM JM/KS
1 Curtains A1.1 Choice of disposable
curtains or biocote
B1.1 Research had been
done into location of
microbiological load. This
should reveal if cubicle
curtains are a problem.
C1.1 Trusts are/ have
changed to disposables
D1.1. Trust have changed to
disposables
E1.1. Biocote has limited
lifespan
F1.1. The issue of privacy
and dignity versus infection
control was discussed. Also
issues of design and
aesthetics.
A1.2 Disposable curtains
programme started at 6
months change + 3 months in
ITU, moved to 12 months
change programme + change
curtains after an infectious
patient
B1.2 Trust had replaced
with disposables-12 month
life.
C1.2 For: Lightweight:
easy to put up / manual
handling, Raises
appearance of ward
D1.2. Positives
:Lightweight: easy to put up
/ manual handling, Quick
change. Dated (therefore
auditable), Easier to comply
with infection control
measures because of above
E1.2. “Cliniweave” can be
washed at 60 degrees
F1.2. Disposable curtains can
be wiped or cleaned on site in
a way that fabric curtains
cannot. It is generally
necessary for fabric curtains
to be changed by a specialist
team which can cause a delay.
It was noted that this is an
issue of the hanging system
not the curtain, and that some
manufacturers are looking at
easily changed fabric
curtains.
A1.3 Curtain tracks had to
adapted or replaced
B1.3 PFI industry much
preferred laundered
curtains to disposables –
due to cost and quality.
Disposables are a limited
market due to v. few
manufactures, limited
colours /designs, and
paediatric patterns needed.
C1.3 Other Trusts have
not changed due to
finances – too expensive.
D1.3. Negatives: Cost
(purchase and increased
waste cost), Excessive
Waste – poor sustainability,
Transparency a Privacy &
Dignity issue – this results in
not much colour choice,
Design / colour not matching
Interior Design – choice of
colour has to be considered
in light of the patient group
– yellow can make patients
look jaundiced etc., Can
require track change,
Stocking holding and storing
issues – due to quantity,
Tracks can be dust traps –
needs to be considered as
part of selection process
E1.3. Standard curtains are
best
F1.3. Some Trusts were
using solid screens to separate
beds. There was a report of
fall hazard if the screens were
not fixed and they were leant
on.
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Curtains (cont.) A1.4 Changed to glass
screens in consulting rooms
B1.4 Choice relates to life
cycle costs of cleaning/
replacement and fitting.
C1.4 Anti-microbial
surfaces/coating – if no
more expensive would use.
D1.4. Trust not using
disposables – No evidence re
IC, Curtains changed after
patient in ITU, Otherwise
Curtains changed at 3
months
E1.4. The disposable
curtains are often sold on
the easy of manual handing
– but you can get quick fit
systems for linen curtains.
F1.4. In Austria a hospital
(Klagenfurt Regional
Hospital) was seen to use
metal wall screens between
the beds which were washed
down. Doors were also
opened with elbows.
A1.5 Silver impregnated
curtains – evidence not
strong, needed local evidence
of samples of bacteriological
contamination
B1.5 There was a track
height issue for refixing
C1.5 Material surfaces
generally don‟t harbour
microbes.
D1.5. Alternatives: Screens,
Switchable glass, Blinds
between glass
E1.5. One hospital has had
“ no entry” and “wash you
hands” sewn on to fabric
curtains.
F1.5. It was noted that
compliance (both staff and
visitors) was a key challenge
– Clean Your Hands
campaign had had a positive
impact on culture.
A1.6 Curtains changed in
Trust every 6 months or after
an outbreak
B1.6 WINDOW
CURTAINS - Similar
problems to cubicle
curtains.
C1.6 Neither convinced
that any system is better
than any other
D1.6. Disposables being
changed annually in general
areas, ICU/CCU every 6
months + between infectious
cases.
E1.6. Need to be careful
you can get a conflict with
curtain track and overhead
hoist track.
F1.6. It was agreed that it
was important that Trusts had
all the information they
needed in order to make a
decision about curtains on the
correct grounds.
A1.7 More storage needed or
identified for curtains
B1.7 Vertical and
horizontal blinds equally
unsuitable due to cleaning
problems
C1.7 No evidence that
curtains distribute
organisms
D1.7. One Trust had
curtains to match the
different themes on each of
the floors – every floor was
different. The curtains were
repeatedly not back from the
laundry in time for the next
use. All of the track has
been replaced and disposable
curtains now used
throughout – all are blue.
E1.7. To create more space
at one Trust, curtains have
replaced doors to enable en-
suites.
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Curtains (cont.) A1.9 No evidence on
sustainability – lots of
evidence on disposable gowns
B1.9 Switchable glass is a
new technology but too
expensive and short life.
D1.9. One Trust has no
curtains in side rooms
E1.9. DDA compliant
shower needs a shower
curtain.
A1.10 Not much difference
in contamination levels
between disposable and
traditional curtains
B1.10 One option for
single rooms is no curtains
at all
D1.10. There are examples
of PFI project companies who
have linen and laundry
companies as part of their
portfolio – so it is in their
interest to have fabric
curtains.
E1.10. An example given
of a liver ITU that has no
curtains, has frosted
screens that are washed
down daily.
B1.11 External blinds
were the answer – they
also deal with solar control
and can be maintained
from outside.
D1.11. One Trust changed to
disposables and is now in the
process of changing back as
they are too expensive when
there are multiple out breaks
of infection.
E1.11. Soft FM, M&E
and design team need work
together – need a strategic
consumerism agenda.
B1.12 Consensus was that
traditional properly
laundered curtains were the
best answer, if curtains are
needed at all.
E1.12. Has anyone
considered the patients
perspective in relation to
curtains/lack of curtains?
B1.13 COATINGS -
Generally coatings should
be avoided. Use will take
the initiative away form
other issues
E1.13. “Blink” glass
/screens how do they make
patients feel? Does it give
a “cold” environment? Do
patients feel exposed?
B1.14 All building
products have to have anti
microbiological properties
anyway – simply to enable
them to withstand building
site conditions.
E1.14 Disposable curtains
– waste issue.
B1.15 Cost and value
engineering has an impact
on liabilities for PFI
E1.15 Health and safety –
disposables are light to
change.
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Curtains (cont.) B1.16 Informed debate
needed
E1.16 Window curtains –
Trust proposing having
integral blinds. Trust
worked out 35 year cost of
laundering window
curtains vs blinds and the
blinds were found to be
most economical. This was
the Trusts idea in a PFI
scheme, PFI don't like this
solution as they are
difficult to maintain. They
are not blackout blinds and
some are in opening
windows, the blinds
chosen will tilt and turn
but will not run up and
down.
E1.17 Discussion about
the merits of external
blinds, these are good for
black out, for reducing
solar gain and can be
maintained externally.
They are however difficult
to clean.
1.18 Extensive use of
external blinds at one Trust
– they have found the need
for maintenance to be
intensive.
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A. CoI nurses and specialists B. Designers C. Microbiologists D. Facilities and
housekeeping management
E. Estates managers F. Patients group
2 Flooring A2.1 Choice driven by
maintenance issues
B2.1 Vinyls seem to be
standard throughout inc.
non slip. Liked by
microbiologists
C2.1 No carpets in any
clinical areas.
D2.1. We have no place for
carpet -vinyl or lino
E2.1 Refurbishment of
bathrooms to wet rooms
flooring changed to
dimpled or stippled to give
non slip properties but
these are shredding micro-
fibre mops.
F2.1 Shared bathrooms were
considered to be a hygiene
„hazard‟ as they were often
not cleaned between patients.
A2.2 Carpets not looking
clean
B2.2 Vinyl skirtings can
be a problem if coved –
due to cleaning machines
causing damage to
cappings
C2.2 Vinyl is easy to
clean, provides no dust
traps and a smooth
impervious surface.
D2.2. Trust require floor
finishes to be sealed
E2.2 Can refurbish with a
bathroom pod but is
expensive but these have
GRP moulded floor and
walls.
F2.2 Flooring should be
„germ resistant‟.
A2.3 Wood rejected by FM B2.3 Trust raised the issue
of non slip needed but
difficult to clean
C2.3 Vinyl is damaged by
stiletto heels.
D2.3. Safety problems with
non slip wet floors à cleaning
problems
E2.3 The “natural” choice
is Marmoleum or
Linoleum and traditional
skirting
F2.3 It was agreed that
flooring was a big issue for
hospitals – however
frequently a floor was
cleaned, it got dirty again
very quickly due to the heavy
traffic. Spot cleaning as soon
as a floor is soiled should be
possible – it was queried
whether this could be a
nursing duty. Some hospitals
had cleaning teams on wards
or quickly available (rapid
response team) who could
respond quickly to this.
A2.4 Leads to vinyl route B2.4 Most clients say no
to carpet.
C2.4 Can we make floors
work harder for us? –
colour change vinyl that
responds to cleaning, or
glow in the dark if
contaminated?
D2.4. Carpet gathers dust E2.4 this is problematic
with mopping as the
skirting gets wet and
damaged.
F2.4 The scope of work of
housekeepers was discussed –
some cover several wards and
this was thought not to be
ideal.
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Flooring (cont.) A2.5 Carpets used in Trust
private sector – evidence that
patients learn to walk again
quicker on carpets
2.5 Two Trusts extolled
the virtues of carpet with
timber skirting. Used
successful in one PFI
hospital 100% single
rooms. Carpet and skirting
easier to clean – can be
mopped due to backing.
Better acoustics. Carpet
not used in A&E or
theatres.
D2.5. Carpets don‟t cope
with the use of bleach – this is
required to deal with any
spillage of body fluids
E2.5 Some see end result
as poor workmanship but if
a side room is designed
with 17 facets it is difficult
to get a good job. Design
should be mindful of how
the finishes will be
completed.
F2.5 Light floors were
considered preferable as any
dirt can be seen, whereas dark
floors could hide dirt.
A2.6 Carpets in corridors and
dayrooms
B2.6 Slips trips and falls
are different on carpet to
vinyl.
D2.6. Floor inlays are often
difficult to seal
E2.6 Someone commented
on the ability to put
acoustic surfacing on
vinyl.
F2.6 The group consensus
was that carpet was not
necessary as a floor covering.
A2.7 Increased falls when
carpet replaced by vinyl
B2.7 Consensus: Issue is
cleaning – frequency and
good practice
D2.7. E.g multiple outbreaks
of norovirus on a ward –
carpet was found to be soiled
and so was removed. The
contractors who removed the
carpet contracted the virus.
E2.7 One solution can be
vinyl to floor from mid
height welded at 90º to the
floor.
F2.7 There was discussion
about the possible
contamination from shoes,
and the use of over shoes or
the need to disinfect shoes.
A2.8 How to manage skirting
with wood floors
B2.8 No evidence on
infection risk of carpets,
but issues of cleaning
regimes, slips, trips, falls
and acoustic
E2.8 Most used to vinyl
with coved skirting.
F2.8 Also hangers for
handbags so that these were
not placed on floors.
A2.9 Marmoleum is the only
sustainable material
B2.9 Coving does not
work with columns
A2.10 With a quick turn
around of patients, vinyl is
quicker to turn round
B2.10 Capping (required
by HTM) can harbour
growth
A2.11 When vinyl turned up
wall cleaning machinery does
not always cope with coving
A2.12 Design features cut
into floor have caused trouble
A2.13 Dilemma with hard
flooring of matching skirting
detail and cleaning gear
A2.14 Visual clues provided
in flooring for visitors and
staff – part of promotion of
mind set of infection control
- 123 -
A. CoI nurses and specialists B. Designers C. Microbiologists D. Facilities and
housekeeping management
E. Estates managers F. Patients group
3 Hand wash basins
at ward entrances
A3.1 Alcohol gel is stolen B3.1 It has been proposed
that hand wash basins be
located at entrances to
wards. RM proposed that
these be in a lobby
C3.1 PICU has lobby with
hand wash trough – this
works well as a number of
people can was their hands
at the same time – useful
for visiting teams of
doctors.
D3.1 Aim to build a culture
of hand hygiene – DoH
advises hand washing on the
way in and out of wards in
addition to the MPSA advise
of before and after patient
contact.
E3.1 Managing hand
washing of motivated team
– basins in line of sight
when ever possible.
F3.1 Comment that wash
hand basins needed at
entrances and exits to wards.
A3.2 Limited benefit at
entrance to ward - hand
hygiene required at point of
care
B3.2 PFI does not like
this – hand wash basins are
not used. – therefore
legionnella risk
C3.2 Due thought should
be given to design to avoid
water on to vinyl floors –
as this introduces a slip
hazard.
D3.2 Should be used to
reinforce the belief that hand
hygiene is good and
important, should be in key
areas including bays and side
rooms
E3.2 What height do you
put basins at? DDA level
is too low to stand at and
wash your hands – some
places putting 2 in – one at
standing height and one at
DDA height.
F3.2 Ward doors should be
locked and it was suggested
that people should not be
permitted to enter until they
had been seen to clean their
hands by video link.
A3.3 Need space at entrance
to recess basin
B3.3 Hand wash basins
should be there and
compulsory to use. Also
required at exit to ward.
C3.3 Design needs to
consider and provide for
volume of traffic
D3.3. Handbags – there
needs to be a place to rest
things you are carrying whilst
you wash your hands
E3.3 Part M – building
control – Trusts have to
write and access policy
which clearly defines users
of sinks/areas with the
right people round the
table.
A3.4 Why distinguish
between wards and ITU etc
B3.4 Use could be
monitored by CCTV.
C3.4 Soap and hand towels
need to be replenished
frequently to prevent them
running out as this inhibits
hand washing.
D3.4 quality of hand towels
is important as staff wash
their hands many times a day
E3.4 Newham have put in
shallow square shaped
sinks – wheel chair users
can reach and get their
knees underneath.
A3.5 Need for shelf
associated with basins
B3.5 A shelf is needed
alongside hand wash
basins for bags and papers.
C3.5 Hand drying is key –
like Dyson air blades but
are too noisy for on wards,
a good quality paper towel
is required for ward area.
D3.5 PFI have to run trials of
soap and hand towels if they
want to change them – the
Trust only agrees if they are
suitable for the staff
E3.5 Rada sensor taps
have been found to have an
issue with high frequency
lights.
A3.6 GOSH has basins at
different heights
B3.6 Drying of hands –
needs good quality paper
towel. Dyson types are too
noisy, esp. in ward areas.
C3.6 Feel that ward
entrances should have a
hand wash trough and 2
Dyson air blades
D3.6 One Trust – all wards
have hand wash basins at
entrance.
E3.6 Shelf required (or
similar) for a resting place
of any thing being carried
whilst hands are washed.
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A3.7 Hand drying dilemma –
dryers or paper towels
C3.7 Think there should be
sinks in bays.
D3.7 Hand wash basins at
ward entrances reinforce the
culture of hand washing, but
actually this does not
necessarily relate to the
patient.
E3.7 Shouldn't
underestimate the power of
TV – the Holby campaign
had a high impact on
relatives and patients hand
washing behaviour.
Hand wash basins
at ward entrances
(cont.)
A3.8 Clinical areas need
paper towels
C3.8 Waste bins should be
designed so that they have
sloping tops to prevent
items (hand bags papers
etc) being place on them
whilst hand washing takes
place.
D3.8 Note: hand dryer
machines are not acceptable
in clinical areas due to noise
esp. Dyson blade type.
E3.8 Quantum of hand
wash basins – overkill!!!
A3.9 Issue of not drying
hands properly – wiping
hands on trousers
C3.9 Like the thought of
RFID – it can track if you
have been near a sink but
not if you washed your
hands – also would like to
track patients to know
where they have been in
the ward.
A3.10 Noise of hand dryers
A3.11 Trying Dyson type in
public areas – strong blast of
air, noisy but quick
A3.12 Paper towels can be
pinched
A3.13 Evidence – damage to
hands from dryers, quality of
paper towels
A3.14 Sluice room needs
hand washing
A3.15 Separate hand washing
from equipment washing
A3.16 Hand washing is a
must in most procedures
A3.17 Seeing the actual
equipment not the drawings is
essential
A3.18 Value engineering is a
danger
A3.19 Beware of small local
changes – Trust Guidance
issues
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Hand wash basins
at ward entrances
(cont.)
A3.20 Development and
estates and facilities need to
work closely together or be
amalgamated
A3.21 Sensor taps are more
vandal proof, engineers prefer
them, good quality are longer
lasting, would like them
everywhere
A3.22 Our Trust have
developed a design directory
with requirements and
product specification
A3.23 HTMs are out of date
A3.24 Not aware of any
evidence about choices
A. CoI nurses and specialists B. Designers C. Microbiologists D. Facilities and
housekeeping management
E. Estates managers F. Patients group
4 Sluice –
macerators vs.
bedpan washers
Hand wash basins
in sluice rooms
A4.1 Sluice room needs hand
washing
B4.1 All surprised that not
in guidance. Not
mentioned in HBN 04.
Reference is to core
accommodation HBN 40
which does not show a
whb in exemplar layout.
C4.1 Hand wash basin in
sluice should be mandatory
D4.1 In one London Trust -
hand wash basins in sluices
are a “must have”
E4.1 No reference in HBN
04 to hand wash basins in
the sluice.
F4.1 Hands need to be
washed on the way out of the
sluice as well as on the way
in.
A4.2 Separate hand washing
from equipment washing
B4.2 Could be trough –
type
C4.2 Bins should be silent
closers
D4.2 Trust – they should be
positioned by the door on the
way out.
E4.2 It's a “no-brainer”
you have to have one.
( Macerators and bed pan
washers not discussed)
A4.3 Hand washing is a must
in most procedures
B4.3 Siting of whb
critical– best near door
(but some have more than
one door)
C4.3 Bedpan washers are
prone to user error and
mechanical breakdown
E4.3 Needs to be near the
door on the way out to the
ward
A4.4 Seeing the actual
equipment not the drawings is
essential
C4.4 Preference was for
macerators
E4.4 There is a plethora of
guidance which is difficult
to coordinate.
A4.5 Value engineering is a
danger
E4.5 Replacement of bed
pan washers with
macerators, have a
Decomed for bedpan
holders
A4.6 Beware of small local
changes – Trust Guidance
issues
E4.6 Anticipated that
London Water is going to
ban macerators due to
effluent control.
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Sluice –
macerators vs.
bedpan washers
Hand wash basins
in sluice rooms
(cont.)
A4.7 Development and
estates and facilities need to
work closely together or be
amalgamated
E4.7 Some trust have
banished bed pan holders
and have gone to doubling
up disposable pans to
increase sturdiness.
E4.8 General move to
macerators.
A. CoI nurses and specialists B. Designers C. Microbiologists D. Facilities and
housekeeping management
E. Estates managers F. Patients group
5 Sensor taps A5.1 Sensor taps are more
vandal proof, engineers prefer
them, good quality are longer
lasting, would like them
everywhere
B5.1 Infection control
nurses believe they are
becoming more reliable.
C5.1 Need to utilise
consumer feed back
D5.1 Trust have experienced
problems with sensor taps in
new Path Lab. The new build
(PFI) is not providing them
due to unreliability. Now
changing to foot or knee
operated taps (not sure how
transferable this would be to
the ward environment)
E5.1 With blended water
– difficult for patients to
clean their teeth.
F5.1 Discussion around the
use of foot operated taps
although the group consensus
was that hand operated
sensors were easier for all.
A5.2 Trust have developed a
design directory with
requirements and product
specification
B5.2 Usage can be
measured – useful for IC
audit purposes.
C5.2 Cases of poor flow
and temperature control on
sensor taps
D5.2 Trust like sensor taps –
easy to clean
E5.2 One Trust has left
bathroom taps so that these
can be used for teeth
cleaning.
F5.2 Timing and water
temperature needed to be
addressed.
A5.3 HTMs are out of date B5.3 Can save water – but
this not certain.
C5.3 Minimum standard
needs to be – usability.
D5.3 Cleaning of sensors can
cause clouding this reduces
effectiveness off sensor.
E5.3 One Trust is
introducing a dedicated
cold tap per ward for
drinking water and to
address above.
F5.3 Toilets – Sensor
flushes for toilets strongly
supported - mention was
made of automatic and sensor
flushes to prevent
contamination; the risks of
door handles; the availability
of paper covers for toilet seats
(as in Europe/Japan);
„Superloos‟ which can be
cleaned completely as a unit
after each use.
A5.4 Not aware of any
evidence about choices
B5.4 Setting of temp is
critical
C5.4 Like sensor toilet
flushes
D5.4 Is there any evidence
that sensor taps has reducing
effect on water usage?
E5.4 Filling a bowl can
be difficult (for bed baths
etc)
F5.4 Foot operated pedal
bins were supported, as they
reduce the need to touch bin
lids.
B5.5 Trust said expensive
and unreliable. Lens has to
be clean. Setting of temp is
a big issue to avoid
Legionella etc. (Note
Lever taps allow user to set
temp)
D5.5 Sensors linked with
Hydraulic systems seem to
work well.
E5.5 Adjustments can
solve the bowl filling issue
- 127 -
Sensor taps
(cont.)
B5.6 Trust said cannot be
used in operating theatres
/scrub up.
E5.6 Some Trusts have
mixer taps on patient wash
basins, some replacing
with sensor (eliminates
risk and cost of the tap
being left on).
B5.7 Consensus was that
yes they should be used in
patient and visitor areas.
However not to be used for
drinking water
A. CoI nurses and specialists B. Designers C. Microbiologists D. Facilities and
housekeeping management
E. Estates managers F. Patients group
6 Changing
facilities for ward
staff
A6.1 Public perception – do
not want to see staff in
uniforms outside hospital
B6.1 Trust said that
location is crucial. Needs
to be close to entrance of
dept. and not centralised.
C6.1 If you expect staff to
change you must supply a
changing area.
D6.1 Believe this need to be
in or next to Dept to
encourage use.
E6.1 Often too small, just
not adequate even in
theatres.
F6.1 Facilities should be of a
high standard that encourages
staff to maintain good
hygiene practices, including
good showers.
A6.2 No real issue of
infection spread
B6.2 Trust said that dress
code should ensure that
staff should be in uniform
inc. doctors.
C6.2 Usually areas
supplied are too small, not
kept clean, are insecure,
smelly (lack of air
changes), steamy of
showers are in use. Should
aim for these areas to be as
good a standard as at
swimming pools.
D6.2 Our policy is for
uniform not to be worn
outside trust
E6.2 Critical care, A&E
and FM need separate
changing facilities.
F6.2 Evidence that a good
environment affects
behaviour positively, as a
clean environment
encourages people to keep it
clean and tidy.
A6.3 Dress code requires that
coat is worn over uniform
outside
B6.3 Rules are needed re
wearing of uniforms when
travelling to/from work
place.
C6.3 Uniforms for doctors
at one Trust.
D6.3 We have installed clog
washers in Theatres
E6.3 Minimum one
changing area on each
level (central).
F6.3 Laundering of uniforms
on site was supported.
Uniforms should not be worn
outside of the hospital.
A6.4 Centralised changing
leads to staff changing in
wcs, changing must be
adjacent to work area
C6.4 In another Trust
doctors have short-sleeved
white coats – available
from a dispenser – these
are laundered by the Trust.
D6.4 Staff should not leave
Dept in clinical uniform –
need to change colour when
outside Dept.
E6.4 Need to consider
what relatives and staff do
with clothes i.e. secure
coat storage for relatives
on ITU.
F6.4 One hospital has asked
local shops not to serve staff
who come in wearing
uniform to help with
compliance to their uniform
policy.
A6.5 Doctors tunics are
laundered by Trust
C6.5 Feel Trust should
launder all staff uniforms –
but do not at present. This
could ensure cleaning to
the required standard.
D6.5 People change in toilets
and cleaning rooms – not
appropriate – design can
prevent this
E6.5 Infection Prevention
and control is short sighted
– fire fighting, dealing
with the here and now not
looking to the future.
A6.6 Issue of contamination
of home for nurses
C6.6 Clog washers –
aesthetically pleasing –
D6.6 need numbers of lockers
to be adequate – swimming
pool changing room system
E6.6 Management/culture
doctors in medical coats
vs. mufti.
- 128 -
put in place but wasn‟t
policed. Need places to put
shoes
Changing
facilities for ward
staff (cont.)
A6.7 Ideal would be to
provide local changing and
institutional washing – not
really provided
C6.7 Hygiene is good –
we must be clean and the
environment should be
clean.
D6.7 Uniform dispensers in
theatres – colours to be
different in theatres and out –
Blue in and Raspberry out
E6.7 The system in use for
labs should be examined to
see how it could transfer
into general ward areas.
A6.8 Bio burden – UCH
work on sufficient dilution
with low temperature
washing
C6.8 Where there is no
evidence follow infection
control principles
C6.9 If cycling to work is
to be encouraged – need
shower and changing
facilities
A. CoI nurses and specialists B. Designers C. Microbiologists D. Facilities and
housekeeping management
E. Estates managers F. Patients group
7 Centralised ward
equipment
decontamination
areas
A7.1 Some are setting up
central decontamination areas
periodic and infectious
incident cleaning
B7.1 Considered that a
centralised facility was
good for audit purposes.
C7.1 Decontamination
requires people/ time/
equipment + cost
D7.1 We have centralised
decontamination area for
commodes and wheel chairs
but it requires logistics and
supplies management –
managed by Sterile services.
Items cleaned locally with
detergent then sent to central
area for hydrogen peroxide
clean. Beds won‟t fit but do
have a central bed store –
most beds cleaned on the
ward – hotel services clean
and steam clean beds in situ.
E7.1 Bed cleaning areas
had gone out of fashion but
are now being brought
back. One Trust has put in
a centralised pressure
relieving mattress cleaning
area.
F7.1 The group liked the
idea of centralised
decontamination though
noted that more furniture and
equipment would be needed
to allow for decant and
replacement.
A7.2 Large investment of
space – EU directives are
mandatory ( not sure what
this refers to)
B7.2 One Trust had built a
decontamination unit for
mops etc.
C7.2 Our beds are steam
cleaned between patients
by a cleaning team
D7.2 Lack of designated
cleaning rooms at ward level
E7.2 Think there should
be a central area or one on
each floor. Needs a drain
in the floor.
F7.2 Space would need to
be allocated in an appropriate
area and this could be a
problem with competing
space needs. This should
include storage for mattresses
ready to be delivered as
required.
A7.3 Advantages of
centralisation are no local
variation, nurses won‟t be
doing it , audit trail
B7.3 Single rooms allow
cleaning with hydrogen
peroxide, and can include
pieces of equipment
simultaneously.
C7.3 Beds are complicated
and get dirty
D7.3 Cleaning library – once
items cleaned shrink wrapped
and bar-coded.
E7.3 Should there be a
dirty corridor in theatres
Y/N – you can ask many
times and you will always
get a different answer.
F7.3 The system could be
managed by a „hotel services‟
administrator, as per in hotels
– many hospitals have similar
roles.
- 129 -
A7.4 Works with centralised
equipment libraries ( which
allow less equipment and
maintenance)
B7.4 One PFI has two
types of decontamination
rooms- 1. Clean equipment
2. Dirty equipment.
C7.4 Commodes sent for
cleaning
E7.4 Equipment should be
cleaned locally before
going to a centralised area
for sterilisation.
F7.4 Comment that the time
between patients is so short
that this might not be
practical.
A7.5 In community hospitals
it is done locally
B7.5 Consensus was that
centralised
decontamination is better
than cleaning in location,
but actual evidence
needed.
C7.5 “What is reasonable”
vs. affordability
E7.5 Can be linked to a
ward equipment library,
general/planned
maintenance, audit and
replacement as required.
F7.5 Could/did nurses and
doctors have a role in
cleaning equipment after use?
A7.6 Issue of transportation
of contaminated items –
logistics of separate routes for
clean and dirty – we are using
the same vehicle
B7.6 How many bugs
does moving a bed thru
Hospital distribute?
E7.6 Amsterdam – total
separation of inpatient and
out patient activity.
A7.7 Off site
decontamination means 3
items for each one used.
E7.7 Think there should be
segregation of lifts i.e.
patients/clean goods/ dirty
goods.
A7.8 Storage for items after
decontamination
E7.8 Should be dedicated
lifts to theatres.
E7.9 There used to be a
separate patient entrance
and a separate FM entrance
a few years ago, not so
popular now.
A. CoI nurses and specialists B. Designers C. Microbiologists D. Facilities and
housekeeping management
E. Estates managers F. Patients group
8 Single side rooms
/ patient isolation
A8.1 Single rooms are not
adequate – must have en-suite
bathroom and air handling
B8.1 Need for single
rooms was a matter of
perception - that need for
single rooms is a multi
faced decision, of which
IC is only one issue
C8.1 Provide a physical
barrier.
D8.1 We consider single
rooms as great for IC and
cleaning, although on balance
the Trust favours multi bed
bays.
E8.1 What is isolation? It
is designed for separation.
Depends on patients do
they like it? Perception that
they don't like being on
their own. This is a
management issue –
patients need to be
empowered to come out of
their rooms.
F8.1 Some patients would
not choose to be in a single
room. They didn‟t want to be
alone, assistance may be
more readily available and
observation better.
A8.2 HBN4 supplement
provides standards
B8.2 Consultant
passionately in favour of
single rooms:
C8.2 Enables
containment.
D8.2 Design of single rooms
needs to consider ease of
cleaning, perception is that
they are harder to clean as
patients are more likely to be
“in” as not trying to escape
E8.2 Average length of
stay now around 4 days
does this have an issue n
how patients feel?
F8.2 Some patients are
scared of being on their own.
- 130 -
from others in a bay.
A8.3 Need to understand
different types of isolation –
definitions , use of language
B8.3 Can be naturally or
mech. vented – en suite
can be negative pressure.
C8.3 Should always have
an en-suite.
D8.3 Terminal cleans much
easier than in a bay
E8.3 Unclear on the work
force implications off
100% single rooms.
F8.3 Nursing care at night is
a worry for patients and
relatives in single rooms.
Single side rooms
/ patient isolation
(cont.)
A8.4 Good guidance for
levels of provision; Nigel
Tomlinson has a research
base for levels of provision –
centralised or decentralised
by speciality
B8.4 Low energy / low
carbon solution.
C8.4 It sorts out single sex
accommodation if all beds
are in single rooms (not an
infection control issue).
D8.4 Food delivery to
patients is slower with single
rooms (logistics) feeding and
being able to see other
patients is harder too.
E8.4 There is a
management issue around
communication with a high
proportion f single rooms.
Staff being able to find
staff and patients and
relatives being able to find
staff.
F8.4 Suggested modular
nursing stations rather than
centralised nursing stations.
A8.5 Less good guidance for
non ventilated rooms
B8.5 Resolves gender
P&D issue
C8.5 Need to be used for
isolation and not private
patients.
D8.5 Hydrogen peroxide
needs time to settle – can put
a single room out of use for
24 hours à capacity problem.
E8.5 All isolation rooms
have lobbies – some that a
bed can pass through and
others that do not.
F8.5 Patients required
adequate systems of call
alarms etc which needed to be
responded to promptly.
B8.6 Better therapeutics,
acoustics
C8.6 Should be designed
so that you can see patients
with out entering the room.
D8.6 General design should
have – no tiles, easily cleaned
flat surfaces, loose corners
and junctions, en-suites – wet
room style favoured by this
group.
E8.6 Positive and negative
pressure rooms need to be
separated with clear
instructions to the staff on
how they are to be used.
F8.6 Concerns raised for
those who cannot seek
assistance for themselves –
with no one around to seek
help for them (which you
often have in a multi bed
bay).
B8.7 Higher occupancy
therfore less bedrooms
C8.7 Single rooms have
been found to be ad hoc
offices.
D8.7 Implications of side
rooms and staffing levels –
lots more cleaning to do
(multiple en-suites and sinks
in room referenced Lewisham
) – Guys looking at wards of
the future
E8.7 Staff training is key
– what is and what isn't an
isolation room and
designed use in practice.
F8.7 Concerns raised that
staff cannot hear/do not
respond promptly to alarms
on medical equipment in
single rooms.
B8.8 Treatments can be
carried out in single rooms
– future technological
developments by Philips,
GE, etc. will enhance this.
C8.8 Additional equipment
is required – shared
equipment between rooms
defeats the isolation
principle.
E8.8 HTM4, HBN304 –
generally isolation rooms
don't meet the regulations.
F8.8 All single rooms
should have en-suite facilities
and these should always
include a shower.
B8.9 Proportion of single
rooms debased:
C8.9 More single rooms
required to prevent Novo
virus closing wards
E8.9 ITU may need
derivation from fire
regulations.
F8.9 All en-suite showers
should be accessible to allow
patients to maintain hygiene
standards. Pull down seats
should be installed in all
showers.
B8.10 Recent research
which compared infection
rates in UK hospitals with
C8.10 Airflows must be
managed with +ve pressure
in lobbies and corridors to
E8.10 In the Wirral –
Arrow park has converted
to 50% single rooms but
F8.10 One person
reported patients using their
mobile phones to call the
- 131 -
proportion of single rooms
which was not conclusive.
Also MARU one
dissertation suggests 85%
optimum.
prevent contamination
being blown out of rooms
into shared space.
has been at the expense of
overall bed numbers.
nurse base to get assistance.
Single side rooms
/ patient isolation
(cont.)
B8.11 Refered to new
PFIs, Hexham and
Pembury, which have
100% single rooms. These
should have been built
earlier so that research and
testing could have
influenced later PFIs
C8.11 Rooms used for
isolation - Key issue is
keeping the doors closed –
is there a system that
would alarm if door was
open for more than a
minute (or a defined
period).
E8.11 NHS Scotland have
said all new hospitals are
to be 100% single rooms.
B8.12 Pembury decision
for 100% not just due to
IC.
B8.13 100% single rooms
adds 20% to capital cost. If
bedrooms are naturally
vented these can be built
within cost allowances, but
not if air conditioned.
B8.14 Concerned that this
solution cannot match with
100% of the NHS Estate –
another solution the
“cohort” ward concept as a
way of managing IC.
B8.15 FLEXIBILITY OF
USE - Use of spaces need
to be optimised to improve
performance.
B8.16 Research needed to
achieve correct balance
between flexibility and
cost. Needs good health
planning at start of design
process.
B8.17 Referred to danger
of tailor made design.
B8.18 Referred to use of
standard / generic rooms
proposed in forth coming
HBN 11 for primary care.
- 132 -
B8.19 North Bristol PFI
has different levels of
generic rooms
Single side rooms
/ patient isolation
(cont.)
B8.20 Recommended
narrow plan form not deep
plan. Narrow plans are
easier to re plan/ refurb.
(Esp. Nucleus Hospitals).
Hence more flexible for
future change.
B8.21 I believe PFI could
produce more flexible
buildings – but user
consultation prevents it.
Break points in project
could be used review
design changes. Change is
painful in PFI and hence
need for flexibility
/standardisation.
B8.22 Flexibility needs to
be considered throughout
life of project. The time
delay between design and
commissioning did not
help
A. CoI nurses and specialists B. Designers C. Microbiologists D. Facilities and
housekeeping management
E. Estates managers F. Patients group
9 Ward storage A9.1 Lack of space eg
cleaning equipment etc stored
all over the place
B9.1 Good planning
concepts needed at start.
C9.1 Wards need lots
of storage space
D9.1 One Trust adopting
“Omni system” from USA –
1st in UK. Takes clutter out
of ward to keep content clean.
It‟s a managed / topping up
system. Staff have to key in
what they have removed to
enable top up to be
maintained. Aims to reduce
hoarding and out of date
stock.
E9.1 No clear guidance on
ward storage.
F9.1 There was very little
evidence about storage but
the group agreed that it was
important in ensuring that the
reduction in associated clutter
made for easier cleaning.
A9.2 Storage systems
available are often difficult to
clean
B9.2 Proposed use of
trolleys and chutes
C9.2 Don‟t store what
you don‟t need
D9.2 Ward storage needs to
be central to the clinical area
E9.2 Scandinavia have
decentralisation of storage
-with a small medical/
surgical store module in
each room.
F9.2 It was noted that the
„Productive Ward‟
programme addressed this
issue.
- 133 -
A9.3 Logging systems like
vending machines
B9.3 Use of robotic
technology e.g. in Italy.
C9.3 Store items off
the floor to facilitate
cleaning
D9.3 Adequate storage space
for waste
E9.3 Northern Ireland
model: clean utility,
pharmacy prep room,
consumable store – this
blow 12m² of storage out
of the water!
F9.3 Many reports of
inadequate storage,
particularly for linen, which
required closed storage.
A9.4 About stock control
more than storage
B9.4 Referred to
introduction of clean and
dirty routes.
C9.4 Sliding shelving
can maximise space
D9.4 Productive ward helps
to focus staff on their storage
requirements and where they
need to be.
E9.4 CQC visit raised
issues with clinical storage
areas, with over stocking,
with items stored on the
floor. Now shelving in
place four inches from the
floor.
F9.4 A swipe card system
to restrict access to
equipment storage areas was
suggested.
A9.5 If there is not enough
storage items are placed in
inappropriate space
B9.5 Considered storage
could be solved by timing
and frequency of
deliveries. Process
management issue.
C9.5 Storage should
be enclosed to prevent
contamination.
D9.5 Central Equipment
Library is a good idea
E9.5 Some have removes
static shelving and put in
mobile to facilitate
cleaning.
F9.5 Power points were
required in store rooms for
charging of equipment.
B9.6 Consensus: more
evidence needed
C9.6 A good system of
top up, urgent supplies and
stock rotation and control
are essential.
E9.6 Doors being put on
open storage.
F9.6 Size of ward
equipment needs to be
thought of to ensure storage
supplied is adequate. Store
areas need to be safe and
secure but also accessible for
both retrieving items and
stocking up.
C9.7 Against roller shutter
doors on storage as gathers
dust then spreads it then
operated.
E9.7 “Neatness” is what is
being strived for.
F9.7 Some hospitals are
moving to just in time
deliveries of stock to reduce
amount held at ward level.
C9.8 Avoid clutter in
bathrooms – increases risk
of Legionella (items get
wet and not dried properly)
E9.8 UHL now has mobile
med/surg storage – works
well.
C9.9 Storage solutions
should have sloping tops or
be fitted up to the ceiling
to prevent dust gathering
E9.9 Modular storage can
be useful in refurbishment.
C9.10 Drip stands need
appropriate
accommodation.
E9.10 Glass door being
used so that the contents of
cupboards can be seen –
this reduces frequency of
door opening and therefore
risk of contamination.
E9.11 HTM71 – materials
management.
- 134 -
A. CoI nurses and specialists B. Designers C. Microbiologists D. Facilities and
housekeeping management
E. Estates managers F. Patients group
10 Choice of
cleaning method
C10.1 Design for easy
cleaning and to look clean
D10.1 Trust changing over to
microfibre system – decisions
due to IC. \have chosen the
laundry option over
disposables but use
disposables for “terminal
cleans” (following an
infectious patient
E10. More cleaning hasn't
necessarily reduced
infection rates.
F10.1 The group were
interested to know whether
any research had compared
cleaning methods.
C10.2 Disinfectants
don‟t have to be licensed,
this is under investigation
D10.2 Trust also moving to
microfibre system – due to
evidence. Needs dedicated
laundry to be built, and still
requires dept. cleaners rooms
designed to separate
clean/dirty. No other
activities to be permitted in
cleaners room e.g.
storage/staff change. Sizes
need to be re-assessed in
operational polices.
E10.2 Many using
microfibre but does need
designated laundry
services if using reusable
cloths and mop heads.
F10.2 The research from
Leicester was discussed, in
which contact plated were
used to look at infection
presence before and after
cleaning. It was noted that
wards were back to previous
„bug‟ levels within 2 days
which reinforced the need for
continuous cleaning.
C10.3 Open visiting
restricts cleaning and
frequency
D10.3 Need to have local
storage facilities for paper
towels, soap, toilet tissue,
detergent and disposable
curtains (if used)
E10.3 Steam cleaning
being used for rooms and
beds.
F10.3 The group suggested
that some comparison of the
effectiveness of different
cleaning methods would be
useful.
C10.4 The cleaners have
a poorly paid and
unpleasant job – value
your teams who clean.
The status of the job is
improved if they feel
important
D10.4 Trust do not use
Hydrogen peroxide
E10.4 Hydrogen peroxide
bombing very effective but
time consuming – room
has to be cleaned first and
then has to be left for a set
number of hours before it
can be used again.
F10.4 It was agreed that if
some of the more hazardous
cleaning methods were used
(i.e. hydrogen peroxide) users
should be made fully aware
of the risks.
C10.5 Simple cleaning
methods make it easily for
cleaners
D10.5 Trust use steam
cleaners but it is “dry “ steam
so can be used in ward areas
E10.5 Vacuum cleaners
being used for offices and
corridors only.
F10.5 One member of the
group raised the issue of
female members of staff
wearing heavy make up and
whether this constituted an
infection risk.
C10.6 Giving cleaners
dedicated wards to clean
helps them to take pride in
their job
D10.6 Trust reviewing Ultra
violet cleaning methods
F10.6 It was suggested that
the responsibility for keeping
hand gel containers always
full (which was often not the
case) should lie with the
cleaning team.
- 135 -
Choice of
cleaning method
(cont.)
C10.7 In shared
bathrooms source of C.
Diff have been found to be
nurse calls – it was no ones
responsibility to clean
these.
D10.7 Have looked at
“fogging” systems this
requires doors or screens at
bay entrances
F10.6 Most common calls to
the Patients Association are
about cleaning and the
frequency of cleaning.
C10.8 “Super loos” like
the concept of loos that
completely wash down
after use + in ski resorts
have seen self cleaning
toilet seats
- 136 -
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