JONA
Volume 44, Number 3, pp 129-132
Health Facility Design
Facility Design and
Healthcare-Acquired
Infections
State of the Science
Jaynelle F. Stichler, DNS, RN, NEA-BC, EDAC, FACHE, FAAN
Healthcare-associated infections
(HAIs) are a serious threat to pa-
tients and healthcare providers.
Although human factors are com-
monly studied in an attempt to re-
duce HAIs, less is known about
the effect of specific facility design
features on mitigating the trans-
mission of pathogens from human
to human. This facility design de-
partment aims to expand nurse
leaders’ knowledge and competen-
cies in health facility design. This
article discusses the state of the
science in the relationship of facil-
ity design on reducing HAIs.
Healthcare-associated infections
(HAIs) are widely recognized as
significant causes of morbidity and
mortality among patients, a danger
to healthcare providers, and an op-
erational and financial challenge to
healthcare organizations.1 Healthcare-
Author Affiliation: Professor Emerita
(Dr Stichler), School of Nursing, San Diego
State University and Research & Professional
Development, Sharp Metro Campus, California.
The author has no funding or conflicts
of interest to disclose.
Correspondence: Dr Stichler, PO Box
28278, San Diego, CA 92198 (jstichler@aol.com).
DOI: 10.1097/NNA.0000000000000039
JONA  Vol. 44, No. 3  March 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
associated infections are generally
preventable, but surgical site, respi-
ratory, urinary tract, bloodstream,
and other types of infections are
major healthcare problems that are
estimated to afflict nearly 1 in 20
hospitalized patients in the United
States.1 Healthcare leaders are of-
ten seeking new innovations and
initiatives to reduce the rate of HAIs
and to improve adherence to pre-
ventive practices known to reduce
the transmission of pathogens.2 New
research is needed to better under-
stand the effect of the physical
environment on the contact trans-
mission of pathogens, airborne
transmission of infectious organ-
isms, and the effect of moisture and
waterborne organisms on infections.3
The purpose of this article was to
describe the state of the science
related to the effect of healthcare
design on HAIs and to inform nurse
leaders about design features and
cleaning processes that should be
considered when designing new and
renovated structures for healthcare.
The US Department of Health
and Human Services, the Agency
for Healthcare Research and Qual-
ity (AHRQ), Centers for Medicare
Copyright B 2014 Wolters Kluwer Health |
Lippincott Williams & Wilkins
& Medicaid Services, and other
similar organizations and agencies
including the American Nurses As-
sociation have developed action
plans, position papers, and finan-
cial methods to incentivize hospi-
tals to improve practices to reduce
HAIs.1,4 While it is widely recog-
nized that nurses and other
healthcare providers are instru-
mental in the prevention and mit-
igation of HAIs, it is also known
that the physical environment also
plays a significant role.4 Hand wash-
ing is the single most effective method
of reducing the transmission of
pathogens from human to human,
and therefore healthcare designers
are attempting to place hand-
washing sinks in the direct path
from the door of the patient room
to the bedside. In addition to the
strategic location of hand-washing
sinks, hand gel dispensers have
also been placed in multiple loca-
tions inside the patient room and
throughout the nursing unit.5
The transmission of HAIs seems
to be a contact sport. In a recent
qualitative study interviewing a panel
of experts in hospital administration,
healthcare design, epidemiology and
129
 Health Facility Design
infection control, and air and water
quality,6 participants identified that
the facility, and specifically the pa-
tient room, was a major catalyst for
the transmission of pathogens. As
additional furniture is added to the
patient room to accommodate the
needs of the family and visitors,
and additional personal equipment
added to the room to support the
patient such as personal handheld
entertainment and computer de-
vices and control mechanisms to
adjust room lighting and window
treatments, greater opportunities
exist for the contact transmission
of HAIs. Other sources of contact
are cubicle curtains, push plates on
hand gel dispensers, bedside and
overbed tables, and mobile medical
equipment that is moved from
room to room. Many newer models
of patient chairs are made of a
mesh material that may be diffi-
cult to clean after patient use in-
creasing potential for transmission
of pathogens.
In this same study,6 the partic-
ipants cited the enormous threats
of the ‘‘superbugs’’ with airborne
transmissions that challenge what
we know about facility design and
air handling systems (heating, ven-
tilation, air, and cooling [HVAC]).
Superbugs such as the severe acute
respiratory syndrome (SARS) and
even tuberculosis require new
thinking about zoned isolation sys-
tems, room pressurization, and air
handling and high-quality filtration
systems to prevent the transmission
of these deadly diseases. The par-
ticipants cited the need for more
guidance for facility design, but the
healthcare design industry is chal-
lenged with the lack of credible
evidence to support design decisions.
Much of the existing evidence con-
sists of published postoccupancy
evaluations, case studies, expert opin-
130
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ion, and multiple guidelines from
professional organizationsVall lower
levels of evidence using traditional
appraisal methods.6,7
Patients and families have be-
come more aware of the dangers
in the healthcare setting for the
transmission of infectious diseases
supported by hospital-developed
safety campaigns. Hospitals have
informed providers to be vigilant in
their practice to prevent the trans-
mission of infectious illnesses.
Most knowledge to date is related
to the effect of human factors on
the transmission of infections from
human to human, but there has
been recent interest in researching
how design can play a significant
role in reducing the transmission
of pathogens.8 Using a ‘‘chain of
transmission’’ conceptual model, a
multiprofessional panel of research-
ers and clinicians including indi-
viduals from the AHRQ9 mapped
common pathogens seen in HAIs,
their human source, their charac-
teristic behavior on environmental
surfaces, and the clinical significance
of the pathogen in healthcare. As an
example, the chain of transmission
map for Staphylococcus aureus in-
cluding methicillin-resistant S aureus
(MRSA) was noted to be found on
human skin, mucosa, and inanimate
surfaces and could survive from days
to months on surfaces such as med-
ical equipment, light switches, fau-
cets, and furniture.9
Scratching the Surface
Surfaces and healthcare settings
have been recognized as a common
source of contamination and the
colonization of specific pathogens.10
Many of these organisms can sur-
vive on wet and dry services for
months and may be resistant to
usual disinfection methods. There
is evidence that patients who are
placed in a room previously occu-
pied by a patient with MRSA,
vancomycin-resistant enterococcus,
or multidrug-resistant organisms
(MDROs) are at greater risk for
acquiring the infection,11,12 which
speaks to the importance of judi-
ciously cleaning surfaces in room
and terminal cleaning between
patients.13 High-touch surfaces
must also be routinely cleaned to
remove pathogens from the environ-
ment. Researchers suggest monitor-
ing the effectiveness of the cleaning
using bioluminescence techniques
and providing the environmental
service workers with feedback re-
lated to the quality of the room
cleaning.14 Other researchers note
that the transmission of Clostrid-
ium difficile from a patient in a
room previously occupied by an-
other patient with the illness can
be greatly reduced when the room
was disinfected with bleach solu-
tion.15 Although expensive, UV
germicidal irradiation (UVGI) has
been shown to be an effective sur-
face decontaminant, but the UVGI
is effective only on surfaces directly
exposed to the light. If the patho-
gen is tucked away in seams of
chairs, countertops made of porous
materials, or crevices in bedside
tables, the UVGI light may not be
effective in killing the C difficile
spores. Seamless surfaces on coun-
ters, equipment, and furniture can
prevent this problem. Other draw-
backs of UVGI are the cost and
that it takes approximately 1 hour
to kill C difficile spores, although
other organisms seem to be more
easily eradicated.16
Other authors describe the
efficacy of using hydrogen perox-
ide vapor or mist for terminal
cleaning of rooms previously occu-
pied by infected patients with
MDROs.17 Currently, the systems
JONA  Vol. 44, No. 3  March 2014

for delivering hydrogen peroxide
take approximately 3 to 5 hours
for decontaminating the room and
require that the entire room and
the ventilation ducts be sealed dur-
ing the administration of the hy-
drogen peroxide vapor. Although
traditional terminal cleaning methods,
UVGI, and hydrogen peroxide clean-
ing are generally effective when done
properly, more research is needed
to investigate the efficacy of these
methods in eradicating harmful path-
ogens, thus reducing the risk of in-
fections to patients.
New materials for surfaces in
patient rooms are being investigated.
There is evidence that copper has
antimicrobial properties, and re-
searchers have been investigating
the application of copper materials
to high-touch areas such as bed
rails, door handles, door push
plates, intravenous poles, bed side
rails plumbing fixtures, computer
keyboard surfaces, and even ink
pens used by providers. Sharpe
and Schmidt18 report that after
terminal cleaning with traditional
methods, bacteria and pathogens
reappear on commonly used sur-
faces such as the bedside table,
overbed table, and side rails within
1 hour of the terminal cleaning. Sur-
faces coated with copper alloys
are naturally antimicrobial and con-
tinue to kill the bacteria rather than
allow it to grow on the surface after
terminal cleaning. More research
is needed to study the efficacy and
cost-effectiveness of recladding
high-touch areas with copper alloy
materials.
Floor coverings are another
possible source for the transmis-
sion of deadly pathogens. Although
carpets have been noted to reduce
nurse fatigue, they are harder to
clean and can support the growth
of C difficile spores and other
JONA  Vol. 44, No. 3  March 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Health Facility Design
fungal spores and pathogens. Be-
cause of the difficulty in cleaning
carpets, it is recommended that they
be avoided in patient rooms. Nurse
leaders who are seeking evidence
regarding the use of specific mate-
rials for surface areas in patient
rooms or terminal cleaning of pa-
tient rooms or surfaces should re-
view the contact evidence table
outlined in the article by Steinberg
et al.10
Infection Is Nothing to
Sneeze at
Many infectious organisms are trans-
mitted through the air, and there
are multiple technologies and regu-
lations to control the HVAC sys-
tems in hospital design. Pathogens
are transmitted from the skin cells
of healthcare providers in operating
rooms, routine care activities in the
patient rooms such as bed making
(flipping bed linens), and simple
movements. Surgical environments
have much stricter airflow and air
exchange requirements, and many
operating rooms have included lam-
inar airflow (LAF) as a method of
moving air that has been cleaned
in a high-efficiency particulate air
filter over the patient to reduce mi-
croparticulate contamination. There
is evidence that the LAF system re-
duces the colonization of bacteria
on open culture plates placed in these
environments.19
The use of isolation with con-
trolled airflow is a common mech-
anism to prevent the transmission of
airborne illnesses. Negative-pressure
isolation rooms are typically used
for patients with highly conta-
gious illnesses such as tuberculosis,
chickenpox, and measles to prevent
the spread of the illnesses, but they
can also be used to protect patients
who are neutropenic from their
illness or the result of chemother-
apy. Zoned isolation has been most
recently considered to prevent the
transmission of highly contagious
illnesses such as SARS or various
forms of contagious influenza.
More research and innovation are
needed to determine the best pos-
sible methods to reduce the trans-
mission of airborne diseases and to
ensure optimal air quality in health-
care settings.
Water, Water Everywhere
Water is everywhere in the healthcare
environment. Water has the po-
tential to transmit harmful patho-
gens, although there are fewer
HAIs associated with waterborne
transmission than other forms of
transmission such as contact and
air. Bacterial growth can occur in
water that is pooled on countertop
surfaces or within vessels used by
the patient such as water pitchers.
Some surface materials are porous
and can harbor harmful bacteria
that can be transmitted through
contact. Water transmission of
harmful bacteria, mold, and spores
can occur in therapy pools, bath
fixtures, and plumbing devices in-
cluding showers, bedpan washers,
and toilets. It has been recently
noted that faucets that dispense
water directly into the drain hole
can create an aerosol of contami-
nated water from the drain. Newer
sink designs include an offset drain
hole to prevent this problem.
Electronic faucets have been
noted to have a higher incidence
of Legionella and were replaced
in some neonatal ICU settings and
areas where patients were immune
compromised.20 Decorative foun-
tains have also been noted to be
an infectious risk for Legionella,
and it is recommended that these
fountains be avoided in high-risk
131
 Health Facility Design
patient areas. Should decorative
fountains be used, it is recom-
mended that the water is cleaned
regularly to reduce microbial growth.
An excellent water evidence table is
available for nurse leaders to re-
view when searching for evidence
related to waterborne transmission
of infectious diseases.20
Conclusions
The state of the science related
to the effect of the facility design
and the built environment on HAIs
is still somewhat immature but
growing, and more research is
needed to determine the efficacy
and effectiveness of various mate-
rials, surfaces, HVAC systems, and
specific design features on reducing
the transmission of HAIs. The
healthcare setting is replete with
opportunities to transmit harmful
pathogens from 1 human to another
through direct contact, movement
of air, and deposits of water. Nurse
leaders involved in the process of
healthcare design must arm them-
selves with the latest evidence, ex-
pert opinion, and information as
to how specific design details can
reduce the transmission of HAIs and
improve the safety of the healthcare
environment for patients, families,
and providers. Nurse leaders must
also lead the efforts to measure the
effectiveness of specific design fea-
tures in order to guide future design
decisions and to build the state of
the science.
132
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JONA  Vol. 44, No. 3  March 2014