Key considerations for a successful project

Preventing infections arising from the built environment in a new healthcare facility is a different entity to the traditional understanding of infection prevention and control (an Infection Control team patrolling the wards, and adherence to handwashing protocols etc). Any stakeholder can inadvertently take an action which results in a patient acquiring infection. This could, for example, be a manufacturer, an architect, a member of the design team, or one of the contractors on the site (this list is by no means exhaustive). The approach to mitigating these risks is quite different, and beyond the remit/skills of the Infection Prevention and Control team (see Figure 1).

Within working hospitals, it has taken time to establish that infection prevention was everyone’s responsibility, and not not just that of the Infection Prevention team. Likewise, it should become the responsibility of all stakeholders in any project to minimise the risk of their actions on patient safety.

Empowered through training

Every stakeholder needs to be empowered through training, risk assessment, and continuous feedback from issues arising in the built environment within their area of expertise. The goal is to achieve informed governance — a situation where everyone understands the consequences of their actions on patient safety. This aspect of infection prevention might be better referred to as occupant safety to distinguish it from traditional infection control. Introduction of an effective safety culture system utilising the whole of the Heinrich ratio — including ‘near misses’ feeding into a risk-based approach — will intuitively help deliver occupant safety.

HBN 00-09 is titled Infection control in the built environment. This is a good first attempt at informing Infection Control teams of where their ‘traditional skills’ are required. However, it requires updating, and some of the wider issues should come under the remit of project-specific safety groups (Water, Ventilation etc), as these groups should have the necessary skills to mitigate the identified risks.

There is a further important aspect to infection control and the built environment, which is highlighted in Figure 2. Disturbingly, the routine barriers put in place to prevent transmission of infection are ineffective in controlling such transmission from the built environment, in particular by water or wastewater. This is further compounded by the low sensitivity in establishing that an infection originated from the built environment (see right of image in Figure 2).

Masking the issue

The inability to see a large portion of the damage inflicted by organisms originating from the built environment masks the issue, and prevents a proportionate response. Up until now the UK national action plan to prevent the progression of antimicrobial resistance has not included the built environment — a major omission.

Highly antibiotic-resistant organisms are naturally carried within the human bowel, where most of the time they cause no harm. Such organisms will invariably enter wastewater systems. Since 2012 publications have highlighted that wastewater systems can provide a ‘superhighway’ for dispersal of antimicrobial resistance within healthcare facilities. A Manchester hospital has been an ongoing source of highly resistant organisms for over a decade, the wastewater systems playing a significant role. The design of wastewater systems has remained unchanged for over 30 years. The New Hospital Programme (NHP) will be designing and building hospitals which will be operating when antimicrobial resistance is predicted
to be at its fiercest. NHP has the opportunity to be the first organisation to design and construct hospitals from the outset to minimise the dispersal of antimicrobial resistance from wastewater systems.

There is a subtlety and complexity to competence, which is often not readily apparent or appreciated. It moves beyond competence of an individual. No one would question that to be effective the project Water Safety Group collectively must have all the necessary competencies around the table or access to them. To deliver this involves:

1. Identifying what competencies are required for the project.

2. Identifying whether individuals have the necessary competencies.

1. Identifying what competencies are required
For healthcare this will involve:

A Identifying high-risk patient groups (where the risks and their mitigation from water services may be different to standard patients).

B Identifying all the water systems, specialist water services (hydrotherapy pool, RO systems), novel water system components, and monitoring or treatment systems.

These assessments are in effect ‘critical control points’, as failing to identify an area requiring expertise places both the project and patient safety at risk. These risk assessments need to be conducted with the appropriate rigour, and recorded. Although yet to be formally recognised, it is advised that the periphery of the water system be regarded as an area requiring competency in its own right. This assessment will provide the range of expertise/competency necessary to deliver the project.

2. Identifying whether individuals have the necessary competencies

As discussed elsewhere in this article, individuals must be appointed by training / expertise, and not by job title. Competence must be accompanied by the individual having sufficient time for the project, as well as coming under the project governance / management structure. This is particularly important with NHS personnel, who may be unreasonably expected to carry out 
their day-to-day duties in the existing hospital and absorb the new work. Such practices are dangerous to both the 
old and new facility under construction. Lack of training /expertise cannot be masked / substituted by following guidance. (This is contrary to historical / current practices).

Appointing Infection Control personnel

Infection control personnel may be appointed as they have been trained in the built environment. However it is exceedingly unlikely that one person has all the necessary expertise, requiring at least two individuals — one to cover water / wastewater, and another ventilation etc. The same would apply to an AE(W); the expectation that they would know everything about water / wastewater systems is unreasonable. Having several AE(W)s in the Water Safety Group of a large project to ensure expertise in all areas should become the norm. A project should have a safety groups relevant to each engineering discipline. Just because someone is already part of the project, must not mean that they are automatically accepted onto a group without checking their expertise.

Group competence

Even with all the assembled skills, a group can be dysfunctional. A supportive learning environment where individuals understand the importance of group dynamics, where each person’s views are valid, is equally important as individual competence. For someone to feel confident to say they do not have the requisite knowledge to make a decision is essential. Being able to say this is a strength, not a weakness. (Not disclosing that something is outside one’s remit is a weakness.) The supportive learning environment should create a system where anyone can access anyone else’s expertise to get answers, thereby ensuring that their competence is utilised, rather than just another paper exercise.

Design teams normally model a new water system based around a specification and guidance. A risk-based approach is quite different. The question or challenge to the design team now becomes ‘How are you going to ensure that the design of this new water system is safe?’ This is a massive departure in culture, focusing the work on safety.

Developing a methodology to mitigate risks

Table 1 highlights some of the issues with the current system of healthcare design, construction, and commissioning. The following example of moving to a risk-based approach is based around water safety, but is equally applicable to all the other engineering disciplines.

1. At the inception of a project all parties need to be trained in why and how a risk-based approach is required to ensure occupant safety and project success.

2. The Chief Executive of the Trust should be appointed as Duty-Holder for the project, holding accountability for safety and outcomes.

3. The first assessment is whether water/wastewater is a risk in the new-build process? — inevitably for a new hospital the answer will be ‘yes’.

4. What high-risk patient groups will be housed in the facility?

5. A project Water Safety Group will be established consisting of architect, design team, and construction personnel, as well as the required Trust members of the Water Safety Group.

6. Members of the project Water Safety Group to be appointed on the basis of expertise and training rather than job title (job title does not necessarily guarantee individuals with the requisite expertise).*

7. A gap analysis is undertaken next to ensure that there are individuals with the required expertise and sufficient time available to fully partake in the project.

8. A Trust Board member to be appointed as director responsible for water safety. This individual is there to support the project Water Safety Group, with regular dialogue between the two parties. Any difficulties which the project Water Safety Group is unable to resolve are to be escalated to the director responsible for water safety, who then escalates within the senior project team. The director will need to receive specific training on what the risks are, what the project Water Safety Group should be delivering, and how to monitor their performance.

9. The project Water Safety Group should anticipate all the potential risks across all the building stages (design, construction, commissioning, and occupation) at the inception of the project, in order that all the necessary mitigations are included within the final business case.

10. Once the risks have been identified, the skills of the individuals around the table can be fully utilised.**

11. The periphery of the water system, arbitrarily defined as the last 2 m of pipework-connected devices and the associated wastewater system, need to be recognised as an area requiring specialist expertise and training. The majority of the water/wastewater transmission events occur from here, yet at present anyone can decide the location of a device which places patients at risk.

12. Moving to a risk-based approach should identify critical control points in processes. These are areas requiring special emphasis, as if these fail they are likely to have a significant impact on outcomes. This also includes auditing such points.

13. Pressurising and commissioning of water systems is an example of a critical control point. A publication from 2020 highlights that incorrect commissioning of water systems is a major cause of waterborne transmission events soon after buildings open. Of concern is that 
this problem has been going on for almost 50 years without any improvement, the authors commenting that the resultant infections are preventable, and that poor commissioning should no longer be regarded as incidental or accidental. Within the industry pressurising and commissioning of water systems is often seen as a bolt-on, and many incorrectly perceive that the dosing of a water system with chlorine will eliminate any microbial issue. Despite a plethora of guidance on commissioning, it is carried out very poorly. The project Water Safety Group needs to ensure that the commissioning plan is completed at FBC, and that the process is under the control of the project Water Safety Group.

14. The project Water Safety Group must also ensure that the necessary governance is laid down to ensure that the correct processes occur and monitored. For example it may be written into the construction brief that water pipes will be capped. However, there is nothing to support what is written down on paper — where is the training, who is responsible and accountable, who will be monitoring the process, and how will this be demonstrated to the client? With 
a risk-based approach all of these issues should be identified upfront, and the necessary processes put in place.

The methodology outlined above should be applied across the board; while the examples are specific to water, it is equally applicable and essential to success of other engineering disciplines.

* Many infection control practitioners — through no fault of their own, 
have received no training on the
risks from the built environment. In the past these individuals have been appointed to new-build project teams, but bring no added value to the table. The lack of appropriate training is not restricted to Infection Control. Addressing the problem is essential 
to patient safety. However, when 
talking to one project director, they refused to ask the Infection Control personnel whether they had sufficient expertise and training, on the basis that they had worked at the hospital for a number of years, were senior colleagues, and that it would be disrespectful to do so.

** A meeting was set up between a Design Team and Estates/Infection Control personnel who had an interest in wastewater systems. The design team was initially reluctant to attend, 
as they felt they knew everything 
about wastewater systems. The meeting went ahead, and the attitude of the Design Team changed fairly quickly. It was clear to begin with 
that they felt they were wasting their time, but when the issues experienced with wastewater systems were explained to them, they suddenly became engaged. Prior to this no one had communicated the issues experienced when a hospital became operational. Now that they were aware of the issues (risks to patient safety), they were able to utilise their skills to come up with solutions.

References

1 Pseudomonas aeruginosa infection in augmented care: the molecular ecology and transmission dynamics in four large UK hospitals. Halstead FD, Quick J, Niebel M, Garvey M, Cumley N, Smith R
et al. J Hosp Infect 2021; May;111:162-168. doi: 10.1016/j.jhin.2021.01.020. Epub 2021 Feb 1. PMID: 33539934.

2 Sinks in patient rooms in ICUs are associated with higher rates of hospital-acquired infection: a retrospective analysis of 552 ICUs. Fucini GB, Geffers C, Schwab F, Behnke M, Sunder W, Moellmann J et al. J Hosp Infect 2023; Sep;139:99-105. doi: 10.1016/j.jhin.2023.05.018. Epub 2023 Jun 10. PMID: 37308060.