There is growing recognition that the risks and hazards of injury and harm associated with healthcare are a result of problems with the design of systems of care rather than of poor performance by individual providers .” — Linda Dickey , RN , MPH , CIC , CPHQ , FAPIC
healthcare are a result of problems with the design of systems of care rather than of poor performance by individual providers . Furthermore , substantial evidence suggests that the design of hospital physical environments contributes to medical errors , increased rates of infection and injuries from falls , and to slow patient recovery and high nurse turnover .” They state further , “ Hospitals occupy a unique place in our sensibilities . For some , they are safe havens ; for others , they are the locus of dynamic civic and financial activity ; and for still others , they have an image of being stressful places that provide only fragmented or even unsafe care . These mixed messages have created interest in obtaining a greater understanding of the relationship between quality of care and the physical environment . One of the dangers in any emerging concept is that it will be taken over by forces that borrow the language but ignore the detail . Such appears to be the case in ‘ patient-safe ’ design for health care buildings . The need for a new approach to health care design is a byproduct of the national movement to reduce medical errors and prevent hospital-acquired infections .”
The Institute of Medicine ( IOM ), in its seminal 1999 report , To Err Is Human , noted that medical errors are a product of systems of care rather than the fault of individuals , meaning that causation is related to the design of systems and to the culture of care , rather than to individual human failures . The EOC can cause or discourage healthcare-acquired infections ( HAIs ) related to air quality , ventilation rates , the presence of handwashing stations , the number of room occupants , and finishes on furniture , surfaces , or objects , for example , according to Noskin and Peterson ( 2003 ).
Linda Dickey points to concepts developed by the Center for Health Design and others who promoted utilization of a safety risk assessment to help drive healthcare facility design .
“ Whether a facility is renovating or designing an entirely new space , I think the idea of reviewing internal incident reports and examining events that have occurred to inform your decision-making going forward about the design and flow and functionality of the space is critically important . Someone within the institution who analyses root- and apparent-cause events to understand why errors happened and to identify the factors involved does so to prevent future occurrences . It ’ s the same with near-misses ; there are times when the healthcare built-environment contributes to these events . So , being able to have a process in place , such as a safety risk assessment performed prior to design or renovation , makes use of these data to help inform re-shaping for the built environment and create a less error-prone space .”
As we have seen , while healthcare personnel accountability for HAIs cannot be dismissed , it is important to understand that personnel and the environment in which they work are entwined and causational . As Zimring , et al . ( 2013 ) acknowledge , “ Transmission of pathogens in a hospital is complex , with multiple potential transmission pathways , hosts , reservoirs , and sources . Pathogens can enter the hospital through infected or colonized humans , including patients , or come from external sources , such as construction projects . Some infections are caused by organisms that patients harbor prior to hospital admission . Pathogens have varying abilities to persist and to cause disease , posing the greatest risk to immunocompromised patients . Environmental sources or reservoirs in hospitals may go undiscovered , as many common pathogens causing HAIs can survive for weeks to months on surfaces . The transmission of pathogens is affected by variations and practices of human behaviors , such as hand hygiene compliance or the effectiveness of room cleaning . There are multiple opportunities within the built environment to interrupt the transmission of pathogens , including reducing or preventing contamination of surfaces or water sources , providing barriers to interrupt transmission events , and influencing human behavior , such as by promoting hand hygiene compliance .”
Despite the challenges of establishing definitive links between the built environment and HAIs , Zimring , et al . ( 2013 ) note that “… sufficiently strong evidence exists to inform design and design guidelines .” They say that interventions involving the built environment in healthcare can generally be divided into three categories :
➊ Interventions that prevent transmission by direct or indirect contact
➋ Interventions directed at eliminating transmission of pathogens through airborne routes
➌ Interventions aimed at eliminating water sources of infection
As we know , contact transmission occurs either via person-to-person contact or with the environment as an intermediary , and is the primary mechanism by which organisms are transmitted in healthcare settings . Zimring , et al . ( 2013 ) note that , “ The built environment can decrease contact transmission through barriers and spatial separation , including private rooms . An optimized environment can also support behaviors that minimize contact transmission ; an example is the promotion of hand hygiene through strategic placement of alcohol hand-rub dispensers in highly visible locations .”
Regarding air , Zimring , et al . ( 2013 ) assert that , “ The optimal ventilation system for most hospital areas is unknown ,” adding , “ Laminar , unidirectional , turbulent , and displacement airflow systems have been tested in selected settings , particularly operating rooms , without clear evidence of superiority of a single system . Each has strengths and weaknesses , which are influenced by factors such as adequate system size , placement of intakes and vents , and the system ’ s ability to maintain appropriate air changes per hour . Filtration technologies can augment the ability of ventilation systems to eliminate airborne pathogens . www . healthcarehygienemagazine . com • august 2023
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