The facility's role in infection prevention

The success of any infection prevention and control program is reliant on collaboration with subject matter experts in infection control, safety, construction and building management. Infection prevention activities are important steps in the hospital’s efforts to reduce health care-associated infections (HAIs). 

From the physical environment to hand hygiene, these practices need to become a routine part of care, treatment and services. Everyone plays a role in infection prevention, including the facilities staff. 

Settings in health care vary widely in size and complexity of services. Patients expect and deserve hygienic and safe care at all times, and it is increasingly important for the facilities manager to be fully engaged in the infection control program. 

For instance, requests may be made to bring a fan into a patient room or install an alcohol-based hand-rub dispenser at a doctor’s office. It is important to understand the risks, policies and regulations that come into play in various settings.

Are portable fans safe?

Maintaining both comfort and safety of indoor air quality in health care facilities is essential for all occupants. Concerns have been raised regarding the use of fans in patient care areas. 

According to the Association for Professionals in Infection Control and Epidemiology (APIC), no studies or regulations have directly addressed whether fans affect health outcomes. Detection of pathogens in room air and buildings may suggest a possible indirect association between the surfaces in the environment and disease transmission. 

HAIs are transmitted by many different vectors, including person-to-person, through injection or insertion of medical devices, airborne contact of open wounds, and by respiration of airborne particles. A variety of airborne infections in susceptible hosts can result from exposures to clinically significant microorganisms. These microorganisms can be released into the air when environmental reservoirs such as soil, water, dust and decaying organic matter are disturbed. 

There are no Joint Commission standards that prohibit the use of fans; however, the infection control practitioner must evaluate the risk and establish a position on whether to allow fans under certain circumstances. Some surveyors may view the use of a fan as a red flag for potential problems with the HVAC system. 

From an infection control perspective, the concerns with fans in patient care areas is the potential to spread contaminants through the air. Particles of aerosolized pathogens often settle onto environmental surfaces in the immediate vicinity. This contamination can lead to a secondary vehicle of transmission or re-aerosolize through human or mechanical activity, such as vacuuming or distribution from the surface of a fan blade. 

There are many courses of action to reducing the risk of spreading airborne contaminants and pathogens through these secondary vehicles. 

One way to minimize the risk is to eliminate it altogether by prohibiting the use of fans. However, this option may not align with the fundamental part of nursing care — the compassion that caregivers are known for. 

For example, if a patient is uncomfortable, or near end of life, caregivers want to remain compassionate and sensitive to their needs. Denying the patient a fan for comfort could be thought of as insensitive. For these reasons, a health care organization may allow the use of fans. 

Conducting a risk assessment can aid in the decision process and policy development. The risk assessment should be inclusive of the facilities manager, infection control practitioner, quality and patient safety professional, and nursing representation. 

What does the facilities manager bring to the table? Helping the multidisciplinary group understand barriers to climate control, the effects that fans may have on maintaining pressure relationships, and supporting the education and communication of the risk assessment conclusions. 

The risk assessment should consider the following elements:

• Risks pertinent to the needs of the patient.
• Temperature and pressure relationships.
• Airborne particles and contamination.
• Procedures or treatment processes.
• Maintaining the cleanliness of fan blades and the housing.
• Potential trip hazards from cords.

Upon completion, a policy can be developed and implemented based on the risk assessment tool. When managers are asked to deploy a fan to a patient care room, they should make sure they have checked in with the infection control practitioner to ensure they have knowledge and understanding of the policy.

Hand-hygiene dispensers

Hand hygiene has been accepted as the most important measure to prevent transmission of infection. In 2002, a Healthcare Infection Control Practices Advisory Committee (HICPAC) and HICPAC/Society for Healthcare Epidemiology of America/APIC/Infectious Diseases Society of America Hand Hygiene Task Force reviewed data regarding hand-hygiene practices among health care workers and adherence to recommended practices.

Observational studies on hand-hygiene guidelines reported rates of compliance with hand washing of 40%. Poor compliance ranged from a lack of education, forgetfulness, the belief that gloves negated the need for hand washing, and lack of supplies like paper towels, soap and sinks. Following this observational study and data gathering, the Centers for Disease Control and Prevention (CDC) issued new guidelines for hand hygiene. 

Recommendations from the CDC included making alcohol-based hand rubs available at the entrance to the patient’s room or at the bedside, in other convenient locations, and in individual pocket-sized containers to be carried by health care workers. 

These guidelines were the beginning of a major shift in focus. The CDC and the World Health Organization clearly delineate administrative responsibility for making improved hand-hygiene adherence an institutional priority and for providing appropriate administrative support and financial resources.

An important aspect of reducing infections spread through surface contact involves providing environmental support for hand washing. The visibility and convenience of sinks, hand-washing liquid dispensers, and alcohol rubs can increase the practice of hand hygiene. 

It is important for facilities managers to know the code requirements for installing and testing alcohol-based hand-rub dispensers for the various occupancy types. Many facilities managers have responsibilities that go beyond the health care occupancy walls. Some have responsibilities for ambulatory health care occupancies and business occupancies. Code compliance alone is a daunting task but even more daunting when multiple occupancy types need to be managed. 

For those health care organizations that provide clinical services not falling under the auspices of health care occupancies or ambulatory health care occupancies, the provisions of Chapters 38 and 39 of the 2012 edition of the National Fire Protection Association’s NFPA 101^®, Life Safety Code^®, must be met. 

If the facility is considering installing alcohol-based hand-rub dispensers in a business occupancy, Chapters 38 and 39 need to be reviewed and, in doing so, one will notice that these chapters do not have similar language as found in Chapters 18 and 19 for health care occupancies to allow alcohol-based hand-rub dispensers to be placed in corridors. 

However, Sections 38/39.3.2.1 provide the code path for flammable liquids such as alcohol-based hand rubs. These sections apply to “hazardous areas” and points the code user to Section 8.7. Reading Section 8.7 in its entirety, one will see that Section 8.7.3.2 prohibits flammable liquids or gases from being stored or used in any location where such storage would jeopardize egress from the structure. In other words, alcohol-based hand rubs are not permitted in egress corridors within business occupancies. 

This does not prohibit alcohol-based hand rubs from being used in offices, exam rooms and other spaces within business occupancies, as long as these areas are separated from egress corridors. On the contrary, Sections 18/19.3.2.6 permit alcohol-based hand-rub dispensers in corridors with health care occupancies as long as an extensive list of requirements are met. 

Among other requirements, these sections mandate that dispensers be separated from each other by horizontal spacing of not less than 48 inches. The operation of the dispenser must also meet the following criteria:

• The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation.
• Any activation of the dispenser shall occur only when an object is placed within 4 inches of the sensing device.
• An object placed within the activation zone and left in place shall not cause more than one activation.
• The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with label instructions.
• The dispenser shall be designed, constructed and operated in a manner that ensures the accidental or malicious activation of the dispensing device is minimized.

How are these operational criteria verified? The final measure requires the dispenser shall be tested in accordance with the manufacturer’s care and use instructions each time a new refill is installed. 

After a review of several of the popular hand sanitizer brands and the instructions provided for installing the hand sanitizers, there was little information provided for testing. One of the brands instructions for use is to place the palm of the hand 2 inches below the sensor and the product will dispense within 1 second.

Understanding the role of inanimate objects and surfaces in the environment and the continued problems in compliance with infection control measures and hand hygiene are of utmost importance. 

The role of surfaces and equipment such as portable fans in the spread of HAIs is controversial. Although contamination of surfaces by microorganisms has long been recognized, its significance is unclear. Data suggests that contaminated fomites lead to HAIs indirectly. 

Strategies to reduce the rates of HAIs with pathogens should conform to established guidelines, with an emphasis on thorough environmental cleaning and robust hand-hygiene practices.

Looking at fomites

Humans and animals are the main contributors of microbial-laden particles found indoors. Aerosolization of microbes from biofilm and dust are other principal contributors to the particulate matter of indoor air. As ubiquitous microorganisms, fungi pose a health threat in indoor environments. Fungal infections can be particularly serious in immunocompromised patients, especially airborne spores of Aspergillus. 

These spores are aerosolized through dust and effectively transported over long distances by wind and air currents. These fungi can be found in dust, furniture, carpets and ventilation systems at concentrations ranging from zero to 1,000 colony forming units per cubic meter (CFU/m³). 

Recognizing that human pathogens can be transmitted via indoor air emphasizes the need for the development of control procedures that limit exposure and reduce the risk of infection in susceptible individuals. 

Prevention of infection in patients requires attention to both human and environmental factors. A susceptible person can potentially become infected by touching a pathogen-contaminated surface, also called fomites, and then touching susceptible sites on their body. 

Can surface and hand hygiene prevent the fomite transmission of pathogens? If so, how frequently should hands and surfaces be cleaned? 

It is difficult to draw conclusions from many existing studies of surfaces and objects because hand hygiene or environmental cleaning are rarely measured and may represent important confounders of the environment-transmission association. 

The objective of cleaning efforts should be to keep surfaces visibly clean, disinfect high-touch surfaces and clean up spills promptly. Patient care rooms should be cleaned on a daily basis and undergo “terminal cleaning” after patient discharge from the hospital. 

During terminal cleaning, noncritical surfaces in the inanimate environment can be thoroughly cleaned using a disinfectant. Effective cleaning combined with good hand-hygiene compliance would seem intuitively to be an important factor in the control of pathogens. 

There are many studies available on these two topics, but few have been studied together. 

An important difference

An effective infection prevention effort requires an approach that includes experts from throughout the hospital, including infection control, safety, construction and building management.

The issues discussed in this article illustrate only a few of the areas where health care facilities managers can make an important difference between an infection prevention effort’s success or failure.

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Melissa Braskie, CHFM, CHSP, is environmental health and safety director at University Hospitals Cleveland Medical Center in Ohio. She can be reached at Melissa.Braskie@UHhospitals.org.