1. 1 Fighting the Spread of Infection in the NICU Environment Megan E. Denham, MAEd, EDAC SimTigrate Design Lab, College of Architecture Georgia Institute of Technology

2. 2 LEARNING OBJECTIVES 1.Identify the 3 primary mechanisms of transmission for HAIs through the NICU environment 2.Identify common approaches to interrupt the chain of transmission through the NICU environment 3.Recognize NICU design components that can mitigate the risk of infection 4.Explore the gaps in the current evidence and illustrate how multidisciplinary collaboration can bridge those gaps

3. 3 At any given time, ~1 in 25 hospitalized patients in the US have at a healthcare-associated infection Patients admitted to ICU rooms in which the previous occupant had MRSA and VRE showed a 40% INCREASED RISK of acquiring those infections There was more than a 2 FOLD RISK of acquiring C. difficile in ICU rooms in which the previous occupant had this infection HAI OVERVIEW

4. 4 HOW DOES INFECTION SPREAD?

5. COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors CONCEPTUAL FRAMEWORK FOR THE CHAIN OF TRANSMISSION COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors HAI Human Reservoirs Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers) - airborne/droplet Environmental sources and reservoirs of pathogens RESERVOIR or SOURCE IN THE HOSPITAL RESERVOIR or SOURCE IN THE HOSPITAL EXTERNAL SOURCE Transmission event Reservoir – Place (human or environmental) where organisms reside and multiply Source – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument) 5

6. 6 3 MECHANISMS OF TRANSMISSION I.Air –Pathogens release into air, we breathe them –Pathogens released into air, land on surfaces II.Water –Contaminated water lands on surfaces –Contaminants become aerosolized, we breathe them III.Contact –Direct Contact (skin to skin) –Indirect (touch a contaminated surface)

7. 7 WHAT ROLE DOES THE NICU ENVIRONMENT PLAY IN PREVENTING THE SPREAD OF HAIs?

8. COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors CHAIN OF TRANSMISSION INTERVENTIONS MODEL COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors HAI Human Reservoirs Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers) - airborne/droplet Environmental sources and reservoirs of pathogens RESERVOIR or SOURCE IN THE HOSPITAL RESERVOIR or SOURCE IN THE HOSPITAL EXTERNAL SOURCE Transmission event Reservoir – Place (human or environmental) where organisms reside and multiply Source – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument) Barriers Filters Design Elements Barriers Filters Design Elements Opportunities for interventions through the built environment Disinfect Decontaminate Eliminate Disinfect Decontaminate Eliminate Hand hygiene Other barriers Isolation Design Elements Hand hygiene Other barriers Isolation Design Elements Hand hygiene Isolation Design Elements Hand hygiene Isolation Design Elements Hand hygiene Other barriers Isolation Design Elements Hand hygiene Other barriers Isolation Design Elements

9. 9 AIRBORNE TRANSMISSION (Viruses, TB)

10. 10

11. COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors Air Chain of Transmission Interventions Model COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors HAI Human Reservoirs Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers) - airborne/droplet Environmental sources and reservoirs of pathogens RESERVOIR or SOURCE IN THE HOSPITAL RESERVOIR or SOURCE IN THE HOSPITAL EXTERNAL SOURCE Transmission event Reservoir – Place (human or environmental) where organisms reside and multiply Source – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument) HVAC Filtration HVAC Filtration Opportunities for interventions through the built environment Ventilation Filtration Decontamination Isolation Ventilation Filtration Decontamination Isolation Ventilation Filtration Decontamination Isolation Ventilation Filtration Decontamination Isolation Ventilation Filtration Decontamination Isolation Ventilation Filtration Decontamination Isolation Hand hygiene Isolation Hand hygiene Isolation 11

12. 12 I.Ventilation: Replace contaminated air with fresh, clean air II.Decontamination: Technologies such as Ultraviolet Germicidal Irradiation (UVGI) to kill bacteria in the air III.Filtration: Trap pathogens in filters while letting clean air through IV.Isolation: Separation to prevent cross-contamination AIRBORNE TRANSMISSION OPPORTUNITIES FOR INTERVENTION

13. 13 WATERBORNE TRANSMISSION (Legionella)

14. COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors Water Chain of Transmission Interventions Model COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors HAI Human Reservoirs Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers) - airborne/droplet Environmental sources and reservoirs of pathogens RESERVOIR or SOURCE IN THE HOSPITAL RESERVOIR or SOURCE IN THE HOSPITAL EXTERNAL SOURCE Transmission event Reservoir – Place (human or environmental) where organisms reside and multiply Source – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument) Safe Plumbing Practices Decontamination Safe Plumbing Practices Decontamination Opportunities for interventions through the built environment Safe Plumbing Practices Decontamination Design Elements Safe Plumbing Practices Decontamination Design Elements Safe Plumbing Practices Decontamination Design Elements Safe Plumbing Practices Decontamination Design Elements Hand hygiene Isolation Hand hygiene Isolation Safe Plumbing Practices Decontamination Design Elements Safe Plumbing Practices Decontamination Design Elements 14

15. 15 I.Safe Plumbing Practices: Maintain optimal water temperature, adequate pressure, eliminate dead ends II.Decontamination: Kill bacteria with chemicals (chlorine), super-heating water, or technologies such as UVGI or copper-silver ionization III.Filtration: Point of use filters IV.Design Elements: Electronic faucets, sink design, and proper care of decorative water features WATERBORNE TRANSMISSION OPPORTUNITIES FOR INTERVENTION

16. 16 CONTACT TRANSMISSION (MRSA, C. difficile)

17. COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors CONTACT CHAIN OF TRANSMISSION INTERVENTIONS MODEL COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors HAI Human Reservoirs Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers) - airborne/droplet Environmental sources and reservoirs of pathogens RESERVOIR or SOURCE IN THE HOSPITAL RESERVOIR or SOURCE IN THE HOSPITAL EXTERNAL SOURCE Transmission event Cleaning Strategies Hand Hygiene Surfaces Physical Barriers Cleaning Strategies Hand Hygiene Surfaces Physical Barriers Opportunities for interventions through the built environment Cleaning Strategies Surfaces Physical Barriers Cleaning Strategies Surfaces Physical Barriers Hand Hygiene Touchless Systems Physical Barriers Hand Hygiene Touchless Systems Physical Barriers Cleaning Strategies Hand Hygiene Touchless Systems Physical Barriers Surfaces Cleaning Strategies Hand Hygiene Touchless Systems Physical Barriers Surfaces Hand hygiene Private rooms Isolation Hand hygiene Private rooms Isolation Reservoir – Place (human or environmental) where organisms reside and multiply Source – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument)

18. 18 I.Cleaning Strategies and Technologies II.Surface Material III.Physical Barriers IV.Hand Hygiene Infrastructure CONTACT TRANSMISSION OPPORTUNITIES FOR INTERVENTION

19. 19 Cleaning Strategies and Technologies: Targeting surface contamination with better cleaning adherence, and augmenting with terminal cleaning technologies (UVGI, HPV) CONTACT TRANSMISSION OPPORTUNITIES FOR INTERVENTION

20. 20 Surface Material: Nonporous, cleanable, antimicrobial surface materials (e.g. copper) CONTACT TRANSMISSION OPPORTUNITIES FOR INTERVENTION

21. 21 Physical Barriers: Spatial separation such as single-patient rooms, isolation and privacy curtains CONTACT TRANSMISSION OPPORTUNITIES FOR INTERVENTION

22. 22 Hand Hygiene Infrastructure: Strategic placement of alcohol rubs and sinks, and technologies to monitor hand hygiene compliance CONTACT TRANSMISSION OPPORTUNITIES FOR INTERVENTION

23. 23 WHY ARE WATER AND AIR IMPORTANT IN THE CONTEXT OF CONTACT TRANSMISSION?

24. COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors CHAIN OF TRANSMISSION INTERVENTIONS MODEL COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors HAI Human Reservoirs Transmission Event - direct or indirect contact including transient carriage (e.g. hands of healthcare workers) - airborne/droplet Environmental sources and reservoirs of pathogens RESERVOIR or SOURCE IN THE HOSPITAL RESERVOIR or SOURCE IN THE HOSPITAL EXTERNAL SOURCE Transmission event Reservoir – Place (human or environmental) where organisms reside and multiply Source – Place from which an organism is transmitted to the host. Source may be the same as the reservoir or become contaminated from the reservoir (e.g. a surface or instrument) Barriers Filters Design Elements Barriers Filters Design Elements Opportunities for interventions through the built environment Disinfect Decontaminate Eliminate Disinfect Decontaminate Eliminate Hand hygiene Other barriers Isolation Design Elements Hand hygiene Other barriers Isolation Design Elements Hand hygiene Isolation Design Elements Hand hygiene Isolation Design Elements Hand hygiene Other barriers Isolation Design Elements Hand hygiene Other barriers Isolation Design Elements

25. 25 EVALUATING THE EVIDENCE

26. 26 EBM AND EBD: COMPARATIVE APPROACHES Evidence Based Medicine Evidence Based Design Integration of best research evidence with clinical expertise and patient values Quantitative: rigorous clinical studies with hypothesis testing Focus: patient Ideal: randomized controlled trial Highly “standardized” Continuously evolving Integration of technical expertise and organizational/patient values with the best research evidence Qualitative: informed by research studies, based on ideas Focus: patient and organization Ideal: experiential Avoids “one-size-fits-all” approach Continuously evolving

27. 27 Elevator Inpatient Hemodialysis Tile Floor* Ventilation system Antimicrobial surfaces Cleans* Critical Emergency department Room Shower* Sink* Surfaces Sanitary Disinfection Table* Toilet* Upholstery Hospital wards Inpatient acute care Interior design Layout Light Fixture Fabric Isolation Quarantine Faucet Fixture Surveillance Furnishings Ventilation Human factors engineering Water fountain Window* Workstation Cohorting patients Inpatient rehabilitation facility Intensive care unit Incubator Construction Patients’ rooms Wall Colonization Contamination Renovation Cleaning Disinfect* Copper Lighting Paint Ultraviolet irradiation Medical Waste disposal Long term acute care Décor Engineering Cost-benefit analysis Infection Control Decontamination MeSH Design Medical

28. 28 EVALUATING THE EVIDENCE

29. 29 PATHOGENS TABLE

30. 30 EVALUATING THE EVIDENCE: DETERMINE IMPORTANCE HVAC components had moderate to heavy contamination pre-UVGI installation All HVAC cultures negative at 6 months post Surface and air samples had moderate to heavy contamination pre-UVGI installation All surface cultures negative at 6 months post 74% of throat cultures were positive for pathogens such as Pseudomonas aeruginosa and Klebsiella pneumonial pre-UVGI installation 55% of throat cultures were positive at 6 months post 44% of throat cultures were positive at 18 months post

31. 31 The quantity of evidence needed to declare something is safe… …the evidence needed to declare something poses an unnecessary risk! EVALUATING THE EVIDENCE

32. 32 Not yet widely adopted… UVGI to clean surfaces: Lots of evidence that it reduces contamination BUT Not enough evidence that it reduces infection WHY? Not enough evidence to determine ROI EVALUATING THE EVIDENCE

33. 33 EVALUATING THE EVIDENCE But we don’t have sufficient evidence to say with confidence that a single component of the BE reduces infection There is evidence that there are many interventions to reduce contamination There is evidence that reducing contamination reduces the risk of infection UVGI HPV Cu DANGER OF INFECTION

34. 34 CONCLUSIONS Modes of transmission well understood Impact of design on proxy marker well understood, but not on clinical endpoints Design interventions based on evidence, best practices and values Collaboration, often and early, essential Many gaps to address

35. 35 QUESTIONS?