Healthcare design must follow best practice

The nation is expending huge amounts of capital (somewhat belatedly), replacing outdated and incompetent healthcare assets. We might have expected to see the emergence of a brave new world of innovative stock competent to carry us forward into this new millennium, but what we seem to be getting is a “gold plated” version of the sort of stock we were building over a quarter of a century ago. We are seeing soaring atria, modern exterior finishes and attractive indoor landscaping, with the provision of commercial malls for the benefit of patients, visitors and staff, but little change in the clinical areas. Operationally we continue to suffer from the continuance of the HAI problem. One of the commentators in Health Estate Journal said: “Effective cleaning starts with design, construction and maintenance of hospitals”, (“Good practice in hospital hygiene”, HEJ Aug 05). This is, of course, very true, but must also apply to any built facility. Design should aim to provide a safe, healthy, and comfortable environment, as a given. Why then do we still see solutions in clinical accommodation which fail to address “best practice”? Paint on plasterboard is hardly an acceptable solution for walls, and “tee” section aluminium bars suspended on wires, with “dropped in” tiles, (some of which seem to be made of a material resembling Weetabix) are not suitable either. The need to access engineering elements above ceilings in clinical areas is not really very sensible either. Since cleaning is likely to be aggressive and may involve chemical and heat processes, perhaps a highdensity board with a laminate face and properly engineered joints might be better. In addition, floors need to be free of joints and linoleum is a good solution. All unnecessary horizontal surfaces, (“flat topped” architraves, and skirting and window sills for example), should be designed out, so as to reduce surfaces on which detritus may settle. The provision of central domestic vacuum systems needs to be investigated. Portable vacuum cleaners bring a hazard into the clinical environment – their exhaust air causes gross disturbances to the air, resulting in detritus being moved around. The same article refers to the excellent and innovative work (previously reported in HEJ) carried out by the estates manager at the Paget Hospital – he has successfully applied a total PIR control solution to all the over-basin taps, and included the abandonment of cistern fed manual WC flushing in favour of automatic PIR valves fed from the tank supply. Not only have these carefully monitored and designed features shown an outstanding success in reducing utility costs, the maintenance requirement has also reduced, which has meant less intrusion into the clinical spaces by maintenance technicians, thus contributing further to HAI reduction achieved by the provision of a system that enables and encourages the use of proper handwashing protocols. Given the availability of such proven solutions, why are we still seeing the specifying of elbow action taps in new projects? Another article, “Guide to natural ventilation”, gave pause for thought. It succinctly and accurately indicated that “natural ventilation” for clinical areas ought to be regarded as finally laid to rest. There may well be applications outside hospitals, where “natural ventilation” is adequate and acceptable, but there can be no doubt that such solutions can never provide:  A safe and healthy environment (i.e. removal of pollens, detritus, insects, carbon spheres, moulds and other detritus from the clinical environment). With “natural ventilation” there cannot be control of directional air flow to help protect the patient, and also the necessary air changes cannot be guaranteed.  A comfortable environment (i.e. one in which an acceptable temperature is maintained – while the outside air may vary between extremes, and in which humidity within either the clinical requirement or within the comfort band is provided). Only a mechanical system is capable of meeting these requirements. Why then do we still see designers proposing solutions using “natural ventilation”? There are many new materials available that inhibit the growth of organisms (often by incorporating silver iodide crystals). They can be used for many items used in healthcare, for example, electrical switches and sockets, door furniture etc. but they are as yet, rarely specified. The use of “tack mats”, or other devices to reduce the amount of dirt carried into the building are not seen either. Power operated doors are often specified for the main entrance, but they are rarely used for access to the clinical rooms. Current DoH guidance is to provide 50% of single en-suite rooms, but the logic behind this arbitrary figure is not clear. Considering the “consumerism” surveys, it seems that patients “prefer the association and communion” with other patients to having a single room with en-suite sanitary facilities. However, perhaps if those same patients were advised that they had a much greater risk of being infected by a dangerous pathogen in a multi-bed environment, the answer might be different! The consumerism surveys also show that one of the most disliked features of hospital stays is the need to share sanitary facilities, (particularly where shared between sexes). If the provision of single en-suite rooms is a viable tool in preventing HAIs, (and patient isolation is a proven and effective tool), why then set a figure of anything below 100%? Since it seems likely that many types of microorganism will continue to evolve and change as counter measures to control them are introduced, it is likely that isolation will become more necessary. One other apparent omission from our recent designs is the provision of whole bed sterilisers/disinfectors – this solution is widely seen in many continental countries. Considering the above, where are the design innovators who can aspire to Dr Reid’s proposals. When Secretary of State for Health, he said: “We would seek out the best in the world and take it forward into our new projects.”