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F I N D I N G S

An Issue Brief on Infection Control

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Copyright 2019 © The Center for Health Design. All Rights Reserved.

As discussed in the accompanying issue brief, Contact Transmission, Part 1: The

Role of Surfaces in Healthcare-Associated Infections (HAIs), there are many

factors to consider when selecting and specifying materials for healthcare

settings. This issue brief will take a closer look at the role of high-touch hard and

soft surfaces in infection transmission, including the design features of surfaces

that can facilitate or hinder cleanability as well as several emerging cleaning and

disinfection technologies.

Rutali Joshi, MS, PhD Student

Research Intern

Ellen Taylor, PhD, AIA, MBA, EDAC

Vice President for Research

https://www.healthdesign.org/insights-solutions/contact-transmission-part-1-role-surfaces-healthcare-associated-infections


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Figure 1 illustrates some of the research findings on surface contamination.

Infection transmission depends on both the frequency of contact and the level

of contamination. The Centers for Disease Control and Prevention (CDC)

classified surfaces into two categories: minimal hand contact (e.g., floors,

ceilings) and high-touch surfaces (Sehulster et al., 2004). The prolonged survival

of pathogens on any healthcare surface is undesirable due to the potential risk

of cross-contamination. Retention and transmission depend on several

variables, including surface and pathogen characteristics, environmental

conditions, cleaning methodology, operational factors, and human interaction

with the surface (Campoccia, Montanaro, & Arciola, 2013).

Hard surfaces have already been recognized as pathogen reservoirs and

potential vehicles of transmission. However, high-touch soft surfaces tend to be

overlooked due to a lack of intervention studies demonstrating direct links to

infection. Since surface contamination can occur quickly after cleaning, the use

of antimicrobial surfaces—those exhibiting prolonged biocidal activity—is seen

as a supplemental strategy for controlling contamination through surface

treatments, although evidence is still emergent. These include bioactive

surfaces of heavy metals or their derivatives (e.g., copper, silver); electrostatic

and inhibitory surfaces that repel microbial adhesion; ‘self-cleaning’ coatings

that rely upon hydrophilic and hydrophobic properties; and novel coatings (e.g.,

nanoparticles, micro-patterned surfaces) (Dancer, 2016; Querido, Aguiar,

Neves, Pereira, & Teixeira, 2019). Surfaces coated or impregnated with

antimicrobial agents or metals can have a prolonged antiseptic effect (Weber &

Rutala, 2013a), but there are increasing concerns about potential health risks

and antimicrobial stewardship. For example, in 2015, Kaiser Permanente

banned the use of 15 antimicrobial chemical treatments that may be toxic to

humans or contribute to the development of drug-resistant bacteria (Kaiser

Permanente, 2015).

In spite of increased awareness of the challenges associated with cleaning hard

and soft surfaces, and the opportunities created by technological advancements

to eliminate infectious agents, our understanding of assessing surface

disinfection is limited due to lagging regulations that have made objective

evaluations difficult (Sattar, 2010). When selecting materials, stakeholders

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should account for both the properties of each surface as well as the

epidemiology of infections (as discussed in Part 1). The primary takeaway from

the available research is that surface contamination can be reduced by

minimizing the number of joints or seams (including counters, flooring, and

related transitions between horizontal and vertical surfaces) and by selecting

material finishes that are smooth, non-porous (or impervious), durable (that do

not get damaged, scratched or pitted easily), stain- and water-resistant, and

easy to clean (Malone & Dellinger, 2011).

Traditional cleaning (including terminal cleaning) of surfaces has been found to

be episodic rather than continuous in reducing bioburden. As a result, the

properties of the materials in question are being investigated as part of a broad

approach to tackling HAIs (Esolen et al., 2018). The multifactorial nature of

infection prevention demands a systems approach integrating the built

environment, organizational values, and behavioral factors. Engaging a

multidisciplinary team in the design process is a key strategy to reduce surface

contamination and, in turn, HAIs.

As summarized in the Perception of Cleanliness issue brief, surfaces in the

healthcare setting can be classified as critical, semi-critical, or non-critical

according to their potential for infection transmission. Based on these

classifications and the level of care required, an individual surface may need to

be sterilized, disinfected, or cleaned (Quinn & Henneberger, 2015). The Facility

Guidelines Institute (FGI) Guidelines (2018) suggest that finishes should be

evaluated for their suitability, life cycle, quality, and safety (for both patients

and staff) . To achieve this goal, a thorough understanding of both surface

characteristics and cleaning methods is necessary.

Infection transmission depends on both the frequency of contact with the

surface and the level of contamination. The CDC has classified surfaces into two

categories: those involving minimal hand contact (e.g., floors, ceilings) and those

involving frequent hand contact (“high-touch surfaces”) (Sehulster et al., 2004).

Only one study has quantitatively assessed the frequency of contact between

(Huslage et al., 2010).


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healthcare workers and surfaces; it defines high-touch surfaces as those

sustaining more than three contacts per interaction (Huslage, Rutala, Sickbert-

Bennett, & Weber, 2010).

The five high-touch surfaces identified in the immediate vicinity of the patient in

the ICU and the medical-surgical floor from this study were bed rails, bed

surfaces, supply carts, overbed tables, and intravenous pumps (Figure 2).

Curtains, chair cushions, door knobs, public seating, window sills, soap

dispensers, elevator buttons, tray tables, room sinks, and medical equipment all

fell into the medium-touch category, but these surfaces have shown high levels

of contamination in various studies (Pyrek, 2013; Solomon et al., 2018)

Materials are most often selected for comfort and aesthetics. Although these

features are important, there are other critical surface properties that should

be evaluated before making decisions. Tables 1a and 1b identify some of the

most frequently touched and contaminated surfaces in the healthcare setting,

the most commonly used material finishes for these surfaces, and the pathogens

that have been found to adhere to them.

Hard surfaces Material finishes Pathogens

Public surfaces

Public seating, tables, information desk Metal, molded plastic, stone, wood, glass, laminate ---

Elevator button Metal ---

Surfaces away from patient in patient room

Window sill Stone, wood, prefinished PVC sill

Sink counter top Stone, stainless steel, vitreous china (porcelain), enameled cast iron

Vancomycin-resistant Enterococci (VRE), Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. diff)

Toilet seat High-impact plastic or plastic coating, vitreous china (porcelain)

VRE, C. diff

Door knobs Metal (brass, copper, zinc) VRE, MRSA, C. diff

Chair Metal, molded plastic, stone, wood covered in fabric, leather

VRE, MRSA, C. diff

Bathroom light switch Plastic (e.g., Bakelite), antimicrobials (e.g., copper) ---

Surfaces near patient in patient room

Bed rail Polypropene, stainless steel, polyester-coated steel VRE, MRSA, C. diff

Bedside table Metal, molded plastic, stone, wood, glass, laminate VRE, MRSA

Tray table and supply cart Polypropene, stainless steel, polyester-coated steel, molded plastic

VRE, MRSA

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Call box Plastic (e.g., Bakelite), antimicrobials (e.g., copper) VRE, MRSA, C. diff

Medical equipment/devices (e.g., pulse oximeters, thermometers, stethoscopes)

Glass, metal, plastic MRSA, Acinetobacter baumannii

IV pole grab area Stainless steel C. diff

--- indicates lack or absence of research specific to surface and pathogens

Soft surfaces Material finishes Pathogens

Privacy curtains 100% cotton, cotton/polyester blend, polyethylene plastic, polyurethane, nylon/spandex blend

C. diff, MRSA, VRE, Acinetobacter baumannii

Furniture upholstery 100% cotton, 100% polyester, cotton/polyester blend

VRE

Carpets 100% cotton, 100% polyester, cotton/polyester blend, olefin, nylon, olefin/nylon blend

C. diff, MRSA, VRE, Acinetobacter baumannii

Other textiles (e.g., scrubs, drapes, towels, pressure garments, keyboard cover)

100% cotton, cotton/polyester blend, nylon/spandex blend, polyurethane, polyvinyl

MRSA, VRE

Specifically patterned hard surfaces (or sometimes ad hoc-designed nano-

surfaces) can direct the alignment of pathogen cells and reduce the area of

contact. This affects the surface properties and should be considered during the

design process (Campoccia et al., 2013). As shown in Figure 3, surface features

whose dimensions greatly exceed those of the microorganisms will reduce

retention because the cells can be washed out fairly easily. Within larger

features, however, there could be micro-topographies and nano-topographies

that provide attachment points for the microbial cells (Edwards & Rutenberg,

2001; Verran, Packer, Kelly, & Whitehead, 2009). Non-porous surfaces like

acrylic, glass, laminates, metals, and plastics may have cracks or crevices making

them porous. These increases in porosity can make surfaces rougher, promoting

entrapment and immobilization of microorganisms (Ali, Moore, & Wilson, 2012).

If they are not adequately cleaned following spills of blood or bodily fluids,

porous areas retain moisture and allow pathogens to proliferate (Sehulster et

al., 2004). Pitting and degradation of glazed ceramics may also result in porosity,

leading to micro-holes that can be difficult to clean (Kronberg et al., 2007).

Some physicochemical properties such as adhesion (i.e., the angle and area of

contact between surfaces and soil) and hydrophobicity/hydrophilicity (i.e., the

ability to attract or repel water) can also impact the cleanability of a given

surface and should be taken into consideration (Decuzzi & Ferrari, 2010; Detry,

Sindic, & Deroanne, 2010; Verran et al., 2009).

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The survival and transmission of microbes on soft surfaces has proven more

complex than their behavior on hard surfaces due to the porous and three-

dimensional nature of soft surfaces (Rogina-Car, Budimir, & Katovic, 2017;

Yeargin, Buckley, Fraser, & Jiang, 2016). Some soft surfaces are easy to remove

and launder (e.g., pillows, bedding, towels, patient gowns, surgical gowns, scrub

suits, lab coats, splash aprons, privacy drapes/curtains), while others are less so

(e.g., carpet, upholstery, window drapes) (McQueen & Ehnes, 2018; Yeargin et

al., 2016). Some hospitals use disposable materials for high-touch soft surfaces

like privacy curtains and drapes. Others prefer to wash and reuse materials due

to ecological and financial constraints.

In one study, Noskin et al. (2000) found that VRE was recovered from 30% of

the seat cushions sampled, and disinfection with quaternary ammonium

solution failed to remove VRE from 100% of the fabric chairs. Alternative

solutions, such as folding absorbent, non-porous protector sheets in multiple

layers over the fabric, were found to prevent contamination of the chairs. The

results of this study indicate that evaluating pore size, fabric permeability, and

fabric seam type is essential to the reduction of soft surface contamination.

Conventional sewing techniques (interlacing or interloping threads) can leave

holes in the fabric, making them ineffective microbial barriers (Rogina-Car et al.,

2017).

Another factor to consider when selecting fabrics or finishes is location.

Carpeting, for example, should be avoided in high-risk and/or high-traffic areas

like ICUs, ORs, and burn units, as well as any areas where blood or other bodily

fluids may be spilled (e.g., patient unit hallways). Vacuuming or dry cleaning can

help temporarily reduce pathogens, but carpeting that remains damp is a

perfect setting for microbes to thrive (Sehulster et al., 2014).

Cleaning surfaces is a critical part of infection control. However, the quality and

standard of cleaning in a given environment may be compromised due to factors

such as the choice of products, manufacturer specifications, inaccessibility,

inadequate monitoring because of time crunch or high patient volumes, and

staff shortage/turnover in the Environmental Services (EVS) department. Hard

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surfaces encountering minimal hand contact may not require as much cleaning

as high-touch surfaces (Sehulster et al., 2004; Solomon et al., 2018), but routine

cleaning and disinfection (including terminal cleaning) are still recommended.

Unfortunately, less than 50% of surfaces are cleaned during terminal cleaning

(Carling et al., 2008). Some launderable surfaces, like privacy curtains, are only

cleaned if found visibly soiled and can remain contaminated for long periods

(Kukla, 2013; McQueen & Ehnes, 2018).

Surfaces like textured acrylic walls, brushed stainless steel, and fabrics of

varying weaves can be challenging to clean. Most hospital furniture is made up

of a combination of materials and textiles with various seams, joints, and batten

strips, making it difficult (or impossible) to clean between surface materials

(Malone & Dellinger, 2011). In some cases, each material requires a different

disinfectant and cleaning method, adding to the existing burden of the staff

(Lankford et al., 2007) or resulting in damage to the furniture.

When selecting materials, stakeholders should keep the topographical and

morphological properties of each surface material in mind, along with the

epidemiology of infections (see Part 1 for more information). It is possible to

reduce surface contamination by using flush surfaces (or minimizing the number

of joints and seams) and by selecting finishes that are smooth, non-porous (or

impervious), durable (not easily damaged, scratched, or pitted), stain- and

water-resistant, and easy to clean or wipe down (Malone & Dellinger, 2011).

Seepage under assemblies where water is continually present has been shown

to encourage layer delamination and invite mold, mildew, and bacteria. Per the

2018 FGI Guidelines, water-resistant materials, sealed-seam construction

methods, and moisture-impervious surfaces should be selected for work or sink

areas. The location of the surface, frequency of touch, and associated user

behavior should be evaluated when determining both surface design and

cleaning protocols.

Three approaches to cleaning are described below, including design, selection,

and specification considerations. (For more information, see Part 1.)



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Some of the most commonly used disinfectants for manual cleaning in

healthcare are chlorine-releasing compounds (hypochlorites), hydrogen

peroxide liquid disinfectant (accelerated/improved), and quaternary ammonium

compounds (Villapún, Dover, Cross, & González, 2016). Only products

formulated according to Environmental Protection Agency (EPA) and Food and

Drug Administration (FDA) guidance have been cleared for use (Rutala, 2008).

Furniture and medical equipment come with cleaning recommendations from

the manufacturer. However, the cleaning process is often complicated by

unique specifications for various materials and surfaces and the time required

for EVS staff to understand them, which can influence turnover and, in turn,

cost. The surface material, application method, and choice of applicator (e.g.,

microfiber/cotton mops or wipes vs. pre-moistened wipes) can also impact the

efficiency of manual cleaning efforts. Table 2 summarizes the mixed findings of

multiple studies on the use of various disinfectants on healthcare surfaces.

Chemical disinfectants Impact on surfaces

Chlorine (hypochlorites)

While hypochlorites (the most commonly used chlorine-based disinfectants) are bactericidal, fungicidal, virucidal, mycobactericidal, and sporicidal, they are corrosive to metals, can discolor fabrics, may irritate skin and eyes, and are harmful to the environment by developing biocide and antibiotic resistance (Dettenkofer & Block, 2005; Leas et al., 2015).

Wiping surfaces sprayed with these disinfectants can transfer spores to clean surfaces (Cadnum, Hurless, Kundrapu, & Donskey, 2013).

Hypochlorous acid (electrolyzed water) is a promising strategy shown to be more effective than quaternary ammonium solutions (Meakin, Bowman, Lewis, & Dancer, 2012). It can be left to dry on surfaces without leaving any toxic residue (Boyce, 2016).

Chlorine bleach is an economical, broad-spectrum chemical germicide that enhances the effectiveness of the laundering process. Chlorine bleach is not, however, an appropriate laundry additive for all fabrics (Sehulster et al., 2004).

Accelerated/improved hydrogen peroxide liquid disinfectants

Improved hydrogen peroxide (IHP) disinfectants are EPA-registered and have been shown to reduce bacterial levels on hard surfaces (Rutala, Gergen, & Weber, 2012).

IHP has also proven effective against multidrug-resistant pathogens on soft surfaces like privacy curtains. It is non-corrosive, unaffected by organic matter, and safe for EVS staff, though discoloration has been observed on upholstery disinfected with IHP (Leas et al., 2015).

Some limitations of IHP include higher costs (compared with other disinfectants) and a lack of activity against C. diff spores (Cadnum et al., 2015).

Quaternary ammonium compounds (QACs)

QACs (or quats) are widely used, EPA-registered healthcare disinfectants that are generally regarded as effective when left undisturbed on non-critical surfaces. However, they are not sporicidal.

Using QACs with materials like cotton has shown diminished microbial activity (Sattar & Maillard, 2013).

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Routine laundering, water cleaning, and vacuuming are assumed to be adequate

cleaning procedures for removable upholstery (Malik, Allwood, Hedberg, &

Goyal, 2006). Successful laundering depends on factors including the type of

linen and microorganism in question; the duration, mechanical action, dosage,

filling ratio, and temperature of the cycle; the detergent or disinfectant used;

and the conditions surrounding the laundering process, such as drying

(Bockmühl, 2017; Fijan & Turk, 2012). If one variable is changed, the others

must be adjusted to maintain an optimized effect. Other considerations with

design implications are the post-laundering process, including sorting, folding,

packing, and delivery (Mitchell, Spencer, & Edmiston, 2015), as well as access to

laundry facilities on or off site. The CDC, EPA, and other government agencies

have issued guidance on laundering contaminated textiles with registered

antimicrobial agents in order to standardize this process. Design decisions must

take into account any potential effects on facility operations.

Modern no-touch disinfection (NTD) technologies continue to reduce the

multitude of challenges that accompany manual cleaning and disinfection. NTD

technologies cannot, however, replace routine cleaning procedures; instead,

they are best used in terminal or discharge cleaning to reduce staff workload

and limit their contact with reservoirs of infection (Otter, Yezli, & French, 2014).

Every NTD system differs in its mechanics, efficiency, effectiveness, and

usability. Some are designed to target only easily visible surfaces in a single

operation and may need to be run more than once. This can affect turnover

time, which has cost implications for the system. As such, cleaning tools and

strategies should be based on a mindful consideration of the available evidence,

proposed applications, cost implications, staff training requirements, and

equipment logistics. Table 3 summarizes some increasingly used cleaning

technologies and their impact on healthcare surfaces.

NTD technologies Impact on surfaces

Steam vapor Minimal research exists on the effects of steam vapor, but it has been used in routine and outbreak situations.

Oxidizing agents (e.g., ozone)

Dancer (2014) has summarized the findings of studies in which ozone was successfully incorporated into laundry decontamination, reducing the E. coli count.

There is not yet any evidence on ozone’s impact on surfaces carrying bacterial and fungal spores.

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Another mechanism used to reduce contamination is introducing antimicrobial

agents (heavy metals or germicides) to render a surface “self-disinfecting” or

“self-sanitizing.” In theory, treated surfaces have the potential to reduce HAIs

(Butler, 2018; McQueen & Ehnes, 2018), but several variables—including

coating or impregnation fabrication techniques, surface characteristics,

pathogen characteristics, and environmental conditions—can affect the results.

What with the ongoing prevalence of HAIs and a growing movement for

antimicrobial stewardship to minimize the development of antimicrobial

resistance (Doron & Davidson, 2011; Turner, 2017), there has been an

increasing interest in surfaces or textiles impregnated or coated with heavy

metals like silver, silver ions, copper, etc. Copper alloys and surfaces containing

copper oxide are growing in popularity due to their potential to reduce

microorganisms in the environment (Barnes, 2017; Casey et al., 2010; Michels &

Michels, 2017; Salgado et al., 2013). Though antimicrobial copper and silver are

both EPA-registered, and research on surface treatments with these two metals

continues to gain ground (Weber & Rutala, 2013b), other metals like titanium

are currently under examination (Villapún et al., 2016; Wojcieszak et al., 2016).

Table 4 summarizes the current evidence from multiple studies on the impact of

these strategies on different surfaces.

Hydrogen peroxide (HP) vapor/aerosol

Hydrogen peroxide vapors and aerosols have been designed in various concentrations for low-level and high-level disinfection of semi-critical surfaces in healthcare settings.

HP is found to be effective on a range of surfaces, including glass, plastics, and ceramic tiles (Bentley et al., 2012).

Vapor systems have demonstrated increased efficacy, shorter duration cycles, and more equal distribution as compared with aerosolized hydrogen peroxide (Boyce, 2016).

Though UV systems have a faster turnaround, HP vapor is considered to be better overall (Dancer, 2014).

UV-C/pulsed xenon light The advantages of UV-C technology include microbicidal activity against a wide range of healthcare-associated pathogens (e.g., C. diff) on both hard surfaces (Leas et al., 2015) and textiles (Bentley et al., 2016; Smolle et al., 2018).

UV-C technologies have proven more efficient in decontamination compared with hydrogen peroxide systems (Leas et al., 2015).

The location of the device and the reflectivity of surfaces around the room affected the extent of decontamination and treatment times (Tande, Carson, Rutala, & Guerrero, 2014).

UV-C light used in conjunction with a UV-reflective wall coating reduced decontamination times from ∼25 minutes to ∼3 minutes for MRSA and from ∼43 minutes to ∼9 minutes for C. diff spores (Leas et al., 2015).

Some limitations of this technology include high costs and the need for the room to be vacated and cleaned prior to terminal disinfection (Leas et al., 2015).

https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0000894

https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0000894

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It is a common practice to coat or impregnate surfaces with germicides like

quaternary ammonium compounds, triclosan, or N-Halamines. One relevant

concern, however, is that pathogens might develop resistance to these

Strategy Commonly includes Impact on surfaces

Self-disinfecting surfaces

Surfaces coated or impregnated with heavy metal

Silver

Silver has demonstrated a broad spectrum of antimicrobial activity against bacteria, fungi, and viruses. There have been positive results from the use of silver on medical devices and textile fibers (e.g., uniforms and privacy curtains) (Hicks et al., 2016; Monteiro et al., 2009; Ortí-Lucas & Muñoz-Miguel, 2017).

It has been suggested that the impregnation of silver into a coating can be more effective than direct surface coating alone.

Copper

Door knobs impregnated with copper have shown high corrosion resistance. However, actual hand contact has shown high corrosion rates and discoloration (Fredj, Kolar, Prichard, & Burleigh, 2013).

Antimicrobial copper objects were found to reduce microbial burden in a PICU study by Schmidt et al. (2016), but McQueen & Ehnes (2018) expressed concerns about the effects of introducing NTDs in settings with antimicrobial metal surfaces.

Bacterial contamination on standard curtains and complex element compound curtains (i.e., curtains treated with antimicrobial agents like silver) did not differ after 10 days following installation. Research suggests that cleaning and abrasion may render the metal less effective over time, requiring regular replacement (Schweizer et al., 2012).

Copper-oxide-impregnated non-biocidal linens and pillow covers reduced the number of HAIs in a long-term care brain injury ward (Lazary et al., 2014).

8 types of high-touch items made of copper alloys (e.g., door handles, toilet seats, grab rails, light switches, overbed tables, commodes) had significantly lower microbial counts compared with those made of standard materials (Karpanen et al., 2012).

Surfaces coated or impregnated with germicide

Triclosan, while demonstrating antibacterial efficacy in synthetic polymers (Greenhalgh & Walker, 2017), has recently come under scrutiny as a possible environmental and human health hazard (Dancer, 2014).

Paints with quaternary ammonium compounds have been used to coat textiles, but seem to wear off with continued washing and show no activity against certain pathogens (Schettler, 2016). Quaternary ammonium molecules, combined with organosilanes (silicon chemicals), show conflicting results when applied to textiles or hard surfaces (Boyce, 2016).

High-touch surfaces in patient rooms showed no significant antimicrobial activity after applying two organosilane products (Boyce, Havill, Guercia, Schweon, & Moore, 2014).

A reduction in bacteria and antibiotic-resistant pathogens was found on ICU surfaces coated with similar antimicrobial agents (Tamimi, Carlino, & Gerba, 2014).

N-Halamine is another promising broad-spectrum biocide currently being incorporated into textiles and hard surfaces. To date, most testing has been done in laboratories rather than healthcare settings (2017). However, the treated textiles have been found to leave chlorine residue on the surface, resulting in stains and odors (McQueen & Ehnes, 2018; Schettler, 2016).

Advanced technologies

Light-activated microbial surfaces

There have been no conclusive findings about the efficacy of this technique on surface finishes (Wang et al., 2017).

Altered topography It is assumed that this technology can be retrofitted to practically any surface in the environment; however, data from real-world applications is not currently available.

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treatments. Triclosan has also come under scrutiny as a potential environmental

and human health hazard (Dancer, 2014). It is one of the 15 chemical

treatments banned by Kaiser Permanente (2015), a list that includes a range of

applications such as adhesives; ceilings; wood and wood composites;

engineered wood and resilient flooring; floor sealants, coatings, and finishes;

high-performance coatings; natural oil wood finishes; toilet seats; carpet and

carpet backing; acoustical ceiling components; paint; and high-performance

coatings:

Benzisothiazolin-3-one (BIT)

4,4-dimethyloxazolidine

Diiodomethyl p-tolyl sulfone

Kathon 886 (CIT/MIT mixture)

Methylchloroisothiazolinone (CIT, CMIT)

Methylisothiazolinone (MIT)

N-octadecyldimethyl [3-(trimethoxysilyl) propyl]

Quaternary ammonium compounds, benzyl-C8-16-alkyldimethyl,

chlorides

Silver sodium hydrogen zirconium phosphate

Zinc pyrithione

Silver (nano)

Silver zinc zeolites

Hexamethylenetetramines.

Research into self-disinfecting surfaces has included investigation of reactive

radicals: light-activated antimicrobial agents such as surface coatings with

titanium-dioxide-based catalyst or an embedded photosensitizer (Dancer,

2014). This approach aims at multiple targets within the microbe instead of just

one, reducing the chance that antimicrobial resistance will develop (Wilson,

2003). According to Wilson, these applications are best suited for spaces with

higher illumination levels (e.g., treatment areas with exam lights, operating

rooms).

Another novel approach to prevent and reduce biofilm formation is engineered

altered topography (Leas et al., 2015; Weber, Anderson, & Rutala, 2013). This

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approach incorporates a surface that is harder for microbes to attach to, a bio-

inspired concept born from the ability of plants and animals to prevent

pathogen colonization on their own surfaces (Glinel, Thebault, Humblot,

Pradier, & Jouenne, 2012). A similar technique known as “antifouling” has been

used in the marine industry to prevent the settlement of microorganisms on

ship hulls. One related product currently being promoted in the healthcare

industry is an engineered micro-pattern imparted onto the microstructure of

the surface to mimic the properties of shark skin (Leas et al., 2015; Platt &

Greene, 2017; Weber et al., 2013). More research is necessary to weigh the

pros and cons of each of these strategies.

A search of healthcare research in 2017 revealed that copper, silver, and

organosilanes were the most commonly studied metal-based antimicrobial

surfaces (Ahonen et al., 2017). However, a lack of conclusive evidence suggests

that more research on antimicrobial treatment of fabrics and surfaces is

required once related cleaning methodologies can be simplified and

standardized (Greenhalgh & Walker, 2017; Malone & Dellinger, 2011).

It is important to note that one surface selection or treatment does not

eliminate the need for other infection prevention practices. For example, the

EPA has established the following standards for labeling bactericidal copper:

“Antimicrobial copper containing surface products must be cleaned and

disinfected according to standard practice. Health care facilities must maintain

the product in accordance with infection control guidelines; users must

continue to follow all current infection control practices, including those

practices related to disinfection of environmental surfaces. This copper surface

material has been shown to reduce microbial contamination, but does not

necessarily prevent cross contamination. This product must not be waxed,

painted, lacquered, varnished, or otherwise coated by any material” (EPA,

2016).

There are many factors to consider in tackling HAIs via contact transmission:

surface materials and fabrics, cleaning and disinfection solutions, environmental

design, affordable and applicable technologies, staff operations and workflow,

and the available research. This means an interdisciplinary approach is the best

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way forward. The design team should include experts in infection prevention

from diverse backgrounds such as medicine, microbiology, interior design,

engineering, and facility management, so that each member can contribute their

specialized knowledge to the design process (see the Tool for Engaging

Interdisciplinary Teams for more information). The broad range of insights a

multidisciplinary team can offer will be crucial in developing a systems approach

that examines infection control at the intersection of

organizational/operational factors, people and behaviors, and the physical

environment (Figure 4).

https://www.healthdesign.org/insights-solutions/infection-prevention-teams-engaging-interdisciplinary-experts-tool

https://www.healthdesign.org/insights-solutions/infection-prevention-teams-engaging-interdisciplinary-experts-tool

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The conditions leading to HAIs can develop when particular pathogens interact

in particular ways with particular surfaces. The FGI Guidelines require that an

infection control risk assessment (ICRA) is conducted throughout the design

process, including an examination of all surfaces in patient care areas that

facilitate cleaning and disinfection (Facility Guidelines Institute, 2018). A wide

range of products related to surface materials and fabrics, cleaning strategies,

and disinfection technologies is available in the marketplace. The Guidelines

also provide fundamental requirements for the selection of surfaces (e.g.,

monolithic flooring) for specific areas of the healthcare setting (e.g., surgery)

depending on their individual needs (e.g., the ability to withstand chemical

cleaning or scrubbing).

Moreover, there is a need to bridge the gap between existing regulations,

expectations, and practices, and our ever-evolving understanding of the

epidemiology of infections. It is only by overcoming these obstacles—a limited

empirical knowledge of the available products and cleaning methods, the

challenges faced by EVS personnel, and shortfalls in organizational infection

control policies—that we can work toward better outcomes, from patient and

staff safety to overall quality of care (Storr, Wigglesworth, & Kilpatrick, 2013).

For more information on the pros and cons of existing cleaning strategies, refer

to the Tool for Selection of Cleaning Methods. The Top Design Strategies can

help start the discussion and provide guidance throughout the decision-making

process.

For more information on HAIs, refer to Contact Transmission, Part 1: The Role

of Surfaces in HAIs.

The Center for Health Design:

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advances best practices and

empowers healthcare leaders

with quality research providing

the value of design in improving

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