Designers need to better understand the risks

As healthcare architects, we cover a vast array of topics in a day — from Net Zero Carbon to digital transformation, wellbeing, and clinical services. At the heart of everything we do is safety, and the recent Building Safety Act, whilst inherently focused on fire compliance issues post-Grenfell, also stresses the overarching requirement for people to be safe in our buildings. There is a necessity for patients to feel protected in our healthcare facilities, and for staff to feel assured that they can deliver their services without harm.

How unsafe can a hospital building be?

But just how unsafe can a hospital building be? When in hospital for a recent operation, brown water came out the tap in my pre-admission room while I was washing my hands. I immediately called Alyson Prince, Consultant nurse specialist, RGN, BSC, and a Built Environment Infection Control Consultant, knowing that she would advise exactly what that meant and what to do. ‘It’s rusty water from corroded pipework,’ she said, and then guided me through the correct hand-sanitising procedure. Spend just a few moments with Alyson, and it’s not difficult to see where her passions lie. Thanks 
to her, the words ‘pathogens’ and ‘biofilms’ frequent the HLM Healthcare team’s healthcare vocabulary now. It’s fair to say that she opened our eyes and ears to some of the ‘invisible’ issues that our healthcare — and particularly our hospital buildings face, with catastrophic consequences.

Infection Prevention Control (IPC) incidents are not on the decline. The ever more complex hospital and other healthcare sites and projects that we see these days pose challenges through all stages of a project, which can dramatically affect outcomes. Truth be told, however, and patient safety and IPC considerations are still not often front and centre in our healthcare building designs, instead in some cases being relegated until such a point that they can be seen as tokenistic. While there have been numerous revised publications issued post-pandemic focusing on staff infection control measures, how relevant is HTM 00-09: Infection control in the built environment today, and what are the challenges healthcare design teams face when it comes to IPC matters?

Armed with Alyson’s narrative, we invited her to undertake six one-hour education sessions across our healthcare team. These were not intended to scare our colleagues, although one did say that they might struggle to leave their home without a full kit of PPE going forward. Instead, the intention was to open their eyes and empower them to actively consider infection prevention and control all the way through our design development, and to be very clear on where the real risks lay. The sessions’ content included:

Session 1: Healthcare planning and design, and infection prevention and control

• Infection prevention and control — what are the roles and responsibilities?
• Healthcare-associated infection (HAI) standards: What are they, and how do they apply to design schedules?

Session 2: IPC and the law — compliance and assurance

• IPC stages of risk assessment in the built environment.
• Non-clinical space considerations — support facilities — waste, cleaning, linen, storage.
• Clean to dirty patient flow: why is it important?

Session 3: Water safety in healthcare environments —
Key risks and considerations

• Waterborne pathogens and transmission, and at-risk patient cohorts.
• Introduction to biofilms / microbial risks within a complex water system.
• Project water safety plan and design roles within the Water Safety Group.
• Project governance and accountability.

Session 4: Preventing an incident / outbreak

• Learning scenarios — risk assessment and mitigation.

Session 5: Ventilation in healthcare settings

• Airborne pathogens, transmission, and at-risk patient cohorts.
• High-risk patient groups / settings.
• Plant spaces: What are the IPC considerations? — design considerations from IPC perspectives.
• Specific considerations for planned construction/renovation activity.

Session 6: HAI-SCRIBE (Healthcare Associated Infection — Systems for Controlling Risk in the Built Environment)

• Risk assessments and IPC. 

All the sessions were recorded, so that participants could go back and re-watch deeply thought-provoking presentations and follow on discussions. Some of the issues and questions that the sessions raised included:

• ‘We’re encouraged to reduce Net to Gross internal area percentages as much as possible — including reducing circulation spaces — compromising the separation of clean and dirty flows.’
•  ‘Should we be raising infection prevention and control risks, and ventilation and water safety, as residual risks that require ongoing management by the end-user to minimise and mitigate prevalent and known risks?’
• ‘When we start a new project at an existing hospital — as designers, should we be asking to see the Trust’s / Health Board’s Water Safety Plan and Ventilation Safety Group notes?’

Following on, the sessions kickstarted internal revisions to the way in which we work. Among the key outcomes were:

• Colleagues reported an increased awareness around healthcare-associated infections, especially around the relative revelation that clinical basins were not necessarily a source of cleanliness, more a point of disposal, and could potentially introduce contamination to a space.
• A better understanding around external influences such as adjacencies to factories or industrial processes, which could have a detrimental effect on air quality supplied to a space, especially if there is not sufficient remediation in the air-handling unit, such as filters.
• Greater understanding of waterborne and airborne pathogens, along with the external, construction, and maintenance implications, and the need to consider IPC at the earliest stage.
• Greater insight into the complexities and importance of the commissioning and witnessing process, and how construction management can undermine satisfactory installations. This included discussions around MMC (Modern Methods of Construction), and prefabricated elements such as IPS panels and en suite bathroom pods, which can be constructed outside the controlled environment, and were then installed and commissioned as part of the overall system
• Wider understanding of our role within IPC design, and the need to provide robust specifications, but also better considerations around future maintenance — making this easy, and inclusion of future maintenance of sanitaryware installations as a residual risk to be managed by the end-user, in turn reducing lifecycle risks to the site.
• An enhanced understanding around the interface between IPC and CDM (Construction Design and Management Regulation 2015), especially around the pathogenic contaminants that a construction project can inherently create, and the need to manage this during the works.
• The development of an improved IPC internal protocol, aligned to IPC principles, and derived from guidance such as HTM 00-09, along with best practice, aims to ensure that all elements of design are considered from an IPC perspective, and the allocation of a RAG rating / Risk flagging system that at a glance highlights some of the emerging IPC risks and clinical risk profile.

Following the pandemic, the NHS demonstrably upskilled its workforce with documents such as The infection prevention and control education framework in March 2023. This followed on from publications such as A rapid review of aerosol generating procedures (AGPs) in June 2022. Realising that IPC guidance was spread across multiple sources, the Healthcare Associated Infection (HCAI) compendium of guidance and resources was released by NHS England in February 2023. With a recent revision and update in August 2024, this remains an excellent source of all things IPC, and a good starting point for upskilling not just the NHS workforce, but also those who design and deliver facilities for them. In our final article of this series on IPC, we will be looking at the development of HLM’s improved infection control tool.