controlling hospital acquired infection in the ward environment

141 Pages·2010·1.57 MB·English

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
Table of Contents
ABSTRACT
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
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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
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 Sensor taps Cleaning method
ward entrances
Sluice room clinical hand wash Centralised ward equipment Single rooms
basins and macerators vs. decontamination
Flooring
bedpan washers

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.

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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.
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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.

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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.
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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 

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