No one contests the primacy of rigorous housekeeping in hospital infection control. But what few are willing to discuss is, are hospitals designed to be efficiently cleaned? Or does their very layout interfere with the cleaning process? If this is the case, how can existing hospitals be modified and how should new hospitals be designed to be more housekeeper- and engineer-friendly?
Dr Anjali Tewari, Director – Lab Sciences and Medical Superintendent, Regency Hospital Ltd, Kanpur and Dr Upasana Arora, Director, Yashoda Super Speciality Hospitals, Ghaziabad discuss design interventions for implementing hygiene in hospitals.
When you look at a typical hospital today, what design flaws do you see that pose challenges to effective cleaning and infection control?
Dr Tewari: We have two types of healthcare infrastructure at our disposal. The first is existing hospitals, which are typically old-fashioned structures with no ‘friendly’ surfaces or smooth or seamless flooring. When cleaning and maintaining hygiene are taken into account, such surfaces become a challenge.
When we look at the private sector or small nursing homes or hospitals, we don’t have the luxury of first deciding on our processes and then designing hospitals. Most of the time, buildings where hospitals exist were not designed to be hospitals; these buildings are sometimes acquired and then converted into hospitals. Maintaining hygiene in such healthcare facilities becomes even more difficult.
To begin with, most hospitals have a single common entry and exit point, which is quite unsanitary. There is no separate entrance for the emergency area, and the conditions are not conducive.
Other critical areas such as ICUs or OTs may not have preoperative and postoperative areas. There will be no separate rooms for that. As a result, unidirectional flow is frequently absent in these areas.
The majority of hospitals lack an HVAC system. Separate air conditioners are kept, and they are sometimes too cluttered to clean.
Most of the time, buildings where hospitals exist were not designed to be hospitals; these buildings are sometimes acquired and then converted into hospitals. Maintaining hygiene in such healthcare facilities becomes even more difficult.
–Dr Anjali Tewari
What low cost interventions can be made to make sure that a building is cleaning-friendly for the housekeeping staff, thus promoting infection control?
Dr Arora: Hospital architects must be well-versed in illuminating a facility with sunlight, which is critical in hospitals. Sunlight is a natural infection control source. Bacteria are naturally reduced in areas where there is sunlight.
We need to make hospitals that are very open and covered with glass while also not making grooves where there is a gap between tiles, because cleaning this part becomes a pain point for housekeeping.
If we want to remain economical, we should make our hospital environment-friendly by using copper, a material known for its antibacterial properties. At least in the early stages, we can use such items.
It cannot be overstated how important it is for dirty corridors and clean corridors to be distinct. If your CSSD is located on a different floor that is far from the OT area, it can be difficult to maintain both the clean and dirty corridors.
Dr Tewari: Nursing stations should be there. The beds should have enough space around them. The paint that should be used is one that can be washed. When storing linen, it is mandatory to separate clean linen from dirty linen.
Where does handwashing fit into the larger goal of hospital infection control?
Dr Arora: Housekeeping staff must understand the importance of handwashing. More hand washing stations can be placed so that they can at least wash their hands.
Dr Tewari: Hospitals face difficulties in convincing doctors that hand sanitising is critical. We insist that our nursing staff refrain from handing over files to doctors until they have washed their hands. This is one way to ensure hands are sanitised before and after every treatment. This way, we can show we are role models for our staff.
We need to make hospitals that are very open and covered with glass while also not making grooves where there is a gap between tiles, because cleaning this part becomes a pain point for housekeeping.
–Dr Upasana Arora
The HVAC system seems to be the most neglected aspect of hospital management. What should be the approach towards its cleaning and calibration?
Dr Tewari: When discussing HVAC systems, three critical factors must be considered: temperature control, humidity control, and air changes.
These are determined by the hospital’s location. OTs require about 28 air changes per hour, while intensive care units require 10-12 air changes with at least two or four fresh air changes.
When talking about filters, where they are placed is very important and we must always prioritise their deep cleaning as well.
Dr Arora: At the time of Covid, we realised certain things like how to separate and define areas in terms of air circulation. You need to create certain policies, innovate to achieve what you need and experiment with new technologies to keep your facilities safe and clean.
Dr Tewari: There should be separate entrances in critical areas, and laminar airflow should come from the head end of each bed. It is important to ensure corridors throughout the ICU and the OT, as well as to maintain isolation as needed.
When we are opening new hospitals, it has to be a green hospital, where we are not adding to air pollution. Sound proofing is another important aspect, especially when we are using glass. Openable windows are needed to counteract any problems with the central air conditioning, which could add to infection.
Dr Arora: The drainage system is equally important. Hospitals should maintain a checklist to clean this at regular intervals. This is also a very important aspect of cleanliness and hygiene.
If someone really wants to keep their hospitals safe and clean, then they should go for accreditation. NABH will teach them everything they need to know.