Around 24 million square metres of NHS premises are cleaned every day – the equivalent of approximately 3360 football pitches (Carding, 2019). Although that implies a lot of cleaning, it is worth noting that individuals release their own personalised microbial clouds, shedding about 10 million particles (>0.5 μm diameter) every hour, many of which will harbour bacteria that contribute to the microbial load of buildings (Meadow et al, 2015).
With microbe-enriched environments being the rule rather than the exception in healthcare, where patients and health professionals are in close proximity to each other, the possibility of cross-infection must be minimised. This requires implementing practices in relation to hand hygiene – the single most effective infection control measure – and personal protective equipment (NHS England and NHS Improvement, 2019).
‘With microbe-enriched environments being the rule rather than the exception in healthcare, where patients and health professionals are in close proximity to each other, the possibility of cross-infection must be minimised. This requires implementing practices in relation to hand hygiene – the single most effective infection control measure – and personal protective equipment’
Yet when the World Health Organization (WHO) (2009) reviewed 77 peer-reviewed articles on hand hygiene published between 1981 and 2008, it reported that the baseline rates of health professionals' adherence to recommended hand hygiene procedures ranged from 5–89%, with an overall average of 38.7%.
Infrastructure
To what extent might better building design enhance infection control in health facilities? Iyendo et al (2016) noted that Florence Nightingale first recognised how a patient's physical surroundings could impact their health. Iyendo et al (2016) also highlighted how factors such as air quality can influence infection rates.
Hand hygiene is crucial to preventing the spread of infection in all healthcare settings, and vigilance with this practice is not at a high enough rate
Gedikoglu et al (2012) reported that indoor volatile organic compounds can pose significant health risks. These compounds originate from either phenolic and benzene-like compounds in building materials and office furniture, or from moulds (fungi) that grow inside improperly ventilated or sealed buildings.
The authors proposed that volcanic materials, clays and minerals – such as volcanic tuff, modified clay montmorillonite and mineral clinoptilolite – could function as:
‘Synthetic lungs in building walls, breathing and filtering [volatile organic compounds], and thus limiting human exposure to disease.’
In practical terms, these materials could be mixed with building concrete or mortar to confer anti-fungal properties, thereby boosting hygiene in the environment. In addition, the authors noted that:
‘[M]odified tuff and montmorillonite (as well as some smectites, montmorillonite's close relative) also possesses strong antibacterial efficacy.’
Privacy curtains
Considering fixtures and fittings, hospital and clinic privacy curtains harbour many human pathogens, including Micrococcus species sp., Bacillus sp., Escherichia coli, coagulase-negative Staphylococcus and Staphylococcus aureus:
‘[S]ome of these bacteria may still persist even after laundry of curtains.’
Ghani et al (2016) recommended that healthcare providers should establish appropriate curtain-changing protocols. This was underlined by researchers at Nottingham University Hospitals NHS Trust, who described an outbreak of invasive group A Strep infection involving privacy curtains as a potential source of infection (Mahida et al, 2014).
Doors
As for doors, in an observational study of door handle design, Wojgani et al (2012) found that when compared to push-plate designs, pull handles had a five-fold higher level of bacterial contamination. The authors stated that:
‘Largely ignored issues of handle and environmental design can support or undermine strategies designed to limit avoidable pathogen transmission.’
To address such challenges, Wojgani et al (2012) suggested that a multidisciplinary approach beyond traditional boundaries that might generate options to counter and prevent avoidable microbial transmission.
It appears that such a multidisciplinary approach has yielded an option that could reduce the microbial loads on door handles across various healthcare facilities. In a Scottish innovation, Muirhead et al (2017) developed and tested a new prototype patent-protected door handle. This door handle design is not only steel-framed, vertically aligned with the hand grip portion encased by a unique surface material, but it also allows for the continuous transmission of:
‘An antibacterial fluid to continuously wet the grip of the handle. The product is self-sanitising with no moving parts, power or pressurised containers.’
Muirhead et al (2017) undertook a successful pilot study with Staphylococcus aureus using a household antiseptic solution:
‘But the nature of the simple design for fluid dispersion and surface sanitisation means that there are other choices of fluids suitable for the test handle […] Given the nature of the leading pathogens in hospitals nowadays, an antiseptic active against norovirus and Clostridium difficile would be of much interest, and preferable to alcohol.’
This recently launched product (which can be found at https://axiene.com/) could be expected to augment existing infection control protocols and help to address problems caused by low rates of handwashing among health professionals.
Conclusion
In October 1943, when Winston Churchill was considering how the House of Commons should be rebuilt after a German air raid, he said:
‘We shape our buildings, and afterwards our buildings shape us.’
This is applicable to infection control, where the potential for microbial mayhem can be reduced by correct handwashing behaviour, recognition of the role played by furnishings such as privacy curtains, and the imaginative application of innovative technologies such as improved door handle design and function.