Architects, design teams, construction companies, and manufacturers; the skills of you all are required in the fight against antimicrobial resistance (AMR). Surely – such personnel might think – this is a mistake? Is this indeed not the province of pharmaceutical companies, doctors, nurses, pharmacists, and veterinarians? While the latter professionals undoubtedly have an important role, the skills of all the stakeholders involved in the construction and manufacturing industry are required. In this article we seek to explain why and how such professionals’ expertise is required, and the opportunities available, not just in the UK market, but globally, as this is a worldwide issue.
For those who embrace the challenge there is the potential to save and improve many more lives than any healthcare professional can achieve in their entire career, and – simultaneously – the size of the financial market for solutions is immense. The healthcare built environment has been placed at the forefront of the 2024 UK 5-year national action plan (NAP) to tackle AMR.1
What is AMR?
There are few people alive who remember the pre antibiotic era, when individuals would go into hospital with trivial complaints and frequently not survive due to a complicating infection. The advent of effective antibiotics revolutionised the management of infectious diseases; the wards housing patients with untreatable infections disappeared, as these diseases could now be simply treated at an early stage with a pill, out in the community. However, the honeymoon period is over. We are now seeing bacteria resistant to last-line antibiotics, and patients with infections that are untreatable. Soon we will find ourselves in the post-antibiotic era.
Antibiotics are used not just to treat patients with infections, but also to protect patients when they are made susceptible during many of the interventions required for modern medicine. Without effective antimicrobials, many of the advances in medicine we take for granted will either carry a high mortality, or no longer be an option, since without these agents they no longer offer patients survival advantages. The European Centre for Disease Control is already warning some Western European countries that key medical interventions such as organ transplantation, intensive care medicine, or major surgery, are at risk.
Predictions of an end to the ‘antibiotic era’
The predictions are that the antibiotic era will end by 2050 (if not earlier), having a global economic impact of $100 trillion, and with 10 million extra deaths year-on-year globally. AMR is set to become one of the leading causes of death.
The first AMR NAP was released five years ago, with a predominant focus on antimicrobial stewardship and the need to develop new classes of antibiotic. To date no new classes of antibiotic have been developed, and, despite improvements in antimicrobial stewardship, AMR is on the rise. The healthcare built environment has been placed at the forefront of the 2024 UK 5 year NAP to tackle AMR.1 On page 20 it states:
‘Designed-in IPC for healthcare facilities means that designers, architects, engineers, facilities managers, and planners, work with IPC teams, other healthcare staff, patients, and visitors, to deliver facilities in which IPC needs have been anticipated, planned for, and met.’
In other words, success requires a multidisciplinary approach. Key to successful implementation is how this multidisciplinary approach can be achieved, which of course also requires input from several other stakeholders, importantly including manufacturers.
Healthcare facilities are breeding grounds for AMR. As antimicrobial resistance spreads like a tsunami across a country, it is exploiting and highlighting the deficiencies in the built environment.
The role of the healthcare built environment
he purpose of this article is to highlight some of the key areas requiring this multidisciplinary approach. It is not designed to be exhaustive, but merely to try and highlight the opportunities, and why such a wide variety of skillsets are needed. The healthcare built environment will be considered under the following headings:
1 Current issues with the design, construction, and commissioning, of new healthcare facilities.
2 Water and wastewater systems.
3 Equipment, including sanitaryware – improving its design functionality, ease of decontamination, and incorporating innovation.
Other developments which have a bearing on these topics include:
Hot-off-the-press guidance for water systems in healthcare in response to the mycobacteria contamination of Papworth Hospital – addendum to Health Technical Memoranda HTM 04-01 published on 27 August 2024.4
The New Hospital Programme.
Worldwide deficiency in trained nursing and medical staff.
The latest healthcare facility to make the headlines for the wrong reasons is the new maternity hospital in Belfast. Due to extensive issues, including contamination of water systems, this £80 m building has been prevented from opening, and faces a potential multi-million pound bill to rectify. The matter would have been substantially worse had patients been admitted to the building and infections been contracted.
In 2018 two key reports on the construction industry were released within months of each other – the Cole report,5 in Scotland, and the Hackitt report,6 in England. The publication of the Scottish report was driven by the walls in brand new schools collapsing – the subsequent enquiry examined other schools using the same construction technique, and at the same time looked at f ire safety – it found major deficits in both systems. The Hackitt report was driven by the appalling Grenfell Tower incident. However, this was more than a report on high rise buildings and cladding – the tragedy was a symptom of a much wider malaise within the industry, described by Dame Judith Hackitt as ‘a race to the bottom’.
The report identified an absolute requirement for a change in culture across the industry. Guidance and compliance – the mainstay of the industry, have a strong track record of failure across many sectors. The Hackitt report recommended a move to a risk-based approach, ensuring the requisite training and competence of all of those involved, and no longer blindly following guidance. It also introduced the concept of ‘occupant safety’.
You might reasonably ask what this has to do with AMR? Correct design, construction, and installation practices are key to prevent AMR spreading through hospitals. To give an example – if wastewater systems are not installed correctly (i.e. burrs are left on cut drainage pipes), they will predispose to blockages, which in turn predispose to the dispersal of AMR. The idea that architects and design teams need only consult the Health Building Notes and Health Technical Memoranda to design a safe building is dangerously flawed (see Figure 4).
Implicit to this is understanding that ‘compliant’ does not equate to ‘safe’. The desire to be compliant should not be underestimated, even to the extent of undermining patient safety.
Derogations
Derogations from compliance are seen as an area to be avoided, and understandably in some instances this is correct, as this has been used as a way to downgrade new facilities to save money. However a risk-based approach demands that there will be deviations from guidance where enhancements are required to improve patient safety (see Figure 4). Ideally all guidance should come with a user’s guide that provides an explanation of how to use it safely, its implicit limitations, and that enhancements (i.e. deviation from guidance is necessary and acceptable) are expected where a risk-based approach shows that safety can be improved.
Although water and wastewater systems are inextricably linked, it is predominantly the wastewater system which provides a superhighway for the movement of AMR throughout a healthcare facility, while simultaneously allowing it to escape within the building to reach patients.
Hospitals have the perfect storm of a high concentration of AMR pathogens from unwell patients, antibiotic pressures, and a vulnerable population to infect when the pathogens come back out of the drains. More alarming is that AMR pathogens are not confined to the drain they are deposited in. There is movement of bacteria from one drain to another, via growth back and forth in the biofilm lining pipes, which has been implicated in outbreaks. Yet the drainage systems of hospitals resemble those in other domestic and commercial settings, without, however, cognisance of the heightened risk.
The same organisms which threaten the end of the antibiotic era have taken up residence within the very fabric of buildings designed to protect the most vulnerable patients in society. Why should this be the case? The antibiotic-resistant organisms which we most fear naturally reside within the human gut. The large bowel of a human being contains more bacteria than people on the planet, or cells in the human body. For most these organisms pose no risk unless they become unwell. It is inevitable that AMR will enter the wastewater systems of healthcare facilities. These drains are home to a living community, with constant movement of pathogens from patient to drain, and then back to the patient.
Sudden awareness?
Why have the issues with the wastewater system only recently come to light? Wastewater systems were originally designed to prevent faecal contamination of water systems with cholera and typhoid. These are mostly diseases of the past, and there has been little change in the design of wastewater systems for over 50 years. Of concern is that many innovations which are being introduced in the name of sustainability – such as low volume flush toilets, are making matters worse, certainly within the healthcare setting. As the volume of water is reduced, so is the ability to move toilet contents along the more horizontal pipes; if this doesn’t happen, blockages increase. Another innovation which has backfired is the deliberate slowing down of filling of the toilet cistern. In areas where there is a high demand for toilet use, the cistern has often not filled in time for the next person, so material cannot be flushed, and again predisposes to blockages. However, this is moving away from answering the question – which is why are these problems only being recognised now? The answer is that if there is any solace to be gained from AMR, it is the fact that bacteria become more visible within the healthcare setting as they stand out. AMR pathogens have specific, often alarming, antibiotic susceptibility patterns, making outbreaks easier to notice compared with more sensitive pathogens. This is now identifying routes of transmission which until now have gone unrecognised, but have been used by the more sensitive bacteria in the past.
Everyday procedures in a hospital, previously unchallenged, are now being identified as a risk of spread of AMR. Filling a bowl with water to wash a patient, filling a jug of water to give to a patient, and even a patient taking a shower, are increasingly now recognised as ways that AMR is being spread within the hospital environment.
The risks from wastewater systems are not just within the immediate vicinity of the patient either. Hospital-wide outbreaks have originated from hospitals’ main kitchens. Splashing of wastewater from drains of nearby sinks onto salads, or jet hosing of floor drainage systems, has led to multi-drug organisms reaching patients on uncooked food.
Large amounts of biologically active antibiotics enter hospital wastewater systems throughout the day in patient urine, faeces, or direct discharge of unused antibiotics into sinks. The consequences of this on the microbial flora of the wastewater system are incompletely understood, but it might be this very exposure which is driving AMR. The damage is not just within the healthcare facility, but extends further, as many of these drugs are very stable in the environment, and will have an impact on the municipal wastewater systems and sewage treatment areas.
One company has developed a system which removes drugs and microbial resistance from the healthcare facility wastewater system before it enters the municipal system. Although people in their own homes may be taking antibiotics which enter the municipal wastewater system, there is a major difference between the types of antibiotics used in hospital, and those in a home environment. In hospitals, our last-line antibiotics, which retain effectiveness against AMR, are administered to sick patients and then excreted in the urine, making their way to hospital wastewater. Mixing our last line of antibiotic defence with gut bacteria in hospital wastewater seems imprudent, but we do not understand the consequences of this set-up, and if it drives AMR, the consequences are devastating.
A previous article in Health Estate Journal addressed the topic of wastewater systems in greater detail.7 The purpose of this article is to provide a glimpse into some of the issues being encountered, hopefully to stimulate the dialogue and the multidisciplinary approach required between the NHS and stakeholders.
Water and wastewater are leading to dispersal of AMR and infections on a daily basis within healthcare facilities. These infections result in avoidable use of antibiotics, prolonged stay length, increased healthcare costs, and patient mortality. The extent of the problem is highlighted by the extreme lengths some units have had to adopt to terminate outbreaks. What is becoming apparent is that routine hospital defences, such as Standard Infection Control Precautions (SICP), designed as a ‘catch all’ to prevent the spread of infection between patients and staff, are largely ineffective in preventing transmission events from water and wastewater systems. Therefore, units are adopting ‘water-free’ patient care, whereby most of the plumbed in water and drainage services are removed to control the outbreak. It is the risk from the wastewater system which predominantly drives this approach. The term ‘water-free’ is a misnomer, as water is still used in these areas.
The water system’s periphery
Most water transmission events originate from the periphery of the water system – this is arbitrarily defined as the last two metres of pipework, connected device (e.g. basin or ice machine), and associated wastewater system. The design, placement, maintenance, and how staff interact with these services, fundamentally affect whether these plumbed in services are safe, or represent a risk to patient safety.
Up until now there has been a significant missing part of the jigsaw when it comes to the design and choice of equipment, where it is installed, and how it is maintained and used. This likely stems from the difficulty individuals have in trying to envisage how these items can adversely impact patient care. Thus it is not uncommon for a contractor to decide on a choice of sanitaryware for a healthcare facility, as no one sees the risk. Unless it is recognised and acknowledged at all levels that these pieces of equipment are responsible for large numbers of patient deaths, then the current situation is likely to be perpetuated.
The new HTM 04-01 addendum4 recognises, for the first time, the importance of the periphery of the water system as an area requiring specific expertise, training, and competence.
There is a mutual benefit of closer working relationships between NHS procurement personnel and manufacturers – at the moment there is no feedback in the system. This creates a problem – through no fault of their own, NHS procurement personnel may not appreciate the risks, differences in solutions, or what the right criteria might be, to help prevent infections from a product. Secondly, choice of item may then become solely based on cost – this may disadvantage better designs which may have a slightly higher purchase cost, but which will be recouped very rapidly via their clinical benefits.
This lack of feedback not only starves manufacturers of vital information to improve their products, but also prevents those choosing the products from being able to make an informed decision. For example, to many individuals there is no way to be able to distinguish between outlet design for a clinical handwash station. Thus, rather than being predicated on patient safety, choice is often purely driven by price. However, there are significant differences, for example, between water outlets in terms of risk to patient. Where initial purchase price is the main selection criterion, safety standards may inadvertently be reduced if the safer outlets are slightly more expensive. Such small differences in purchase cost are readily recouped should a slightly more expensive improved design result in one less infection (a single Pseudomonas infection on ITU is estimated to cost at least £15,000) during its lifetime of use.
As a network of healthcare facilities, the NHS has a tremendous untapped resource of staff using products, whose feedback can provide vital information to manufacturers to improve product design and improve patient safety. In this modern era, where individuals continually feed back on almost every product available why cannot this be the case for something as vital as healthcare products?
Ward level decontamination A recent study has shown ward level decontamination to be ineffective and dangerous, with infections being reduced by a third when additional dedicated cleaning is provided – see Figure 8 for an explanation of the CLEEN Study.8
Ward level decontamination of equipment is also time consuming, and takes trained staff away from their prime function. This is important, as there is a global shortage of trained nursing and medical staff. Anything which can relieve them of these tasks, and perform to a higher standard, will not only prevent the spread of AMR, but will also more widely improve outcomes by allowing staff time to be spent on direct patient care.
Unfortunately, even common cleaning practices can exacerbate the problem of AMR. A recent outbreak report describes how floor scrubbers spread a highly resistant pathogen throughout a hospital.9 These machines were not designed for healthcare settings. Processes need to be dissected to identify the risks for AMR pathogen transmission
However, there is another aspect to this. Many items that need to be decontaminated between patients are poorly designed from the perspective of ease of decontamination. To prevent the spread of AMR and reduce infection rates, ease of decontamination needs to become a priority – from both a design perspective and for those purchasing equipment.
Innovation
Innovation is required in many areas, as AMR continues to demonstrate deficiencies in current designs and practices. However, without an interface between the NHS and manufacturers, the chances of developing the right innovations in a timely way is very much reduced. Professionals involved with new build and refurbishment projects, from whatever capacity – clinical, non-clinical, operational, or manufacturing, must recognise the impact of their contribution on patient safety. If professionals can realise and see how they can use their skillsets to contribute to and improve the built environment, then innovation for the betterment of the patient will flourish.
AMR is termed the ‘silent pandemic’. Many talk about preparedness for the next pandemic, unaware we are already going through one. The AMR pandemic is forecast to deliver disruption and human suffering on a scale which up to now has never been realised. Time is a luxury that spread of AMR does not offer. It is very difficult to mobilise society to realise the magnitude of the impending threat.
The new UK AMR national action plan has made a good start by recognising the importance of the built environment. Leaving AMR to the remit of doctors and pharmacists is no longer an option, however. Developing new antibiotics and prudent use of existing such drugs is essential, but will not turn the tide.
Although the NAP places the built environment as central to the problem of AMR, it does not describe how hospitals spread AMR. Messaging is crucial to engage the key players – from designers to cleaners; otherwise the potential for patient harm may not be realised until too late. In the case of construction, financial costs for remediation may also be exorbitant.
Clinical healthcare professionals cannot solve these problems alone. We need multidisciplinary forums established to articulate the problems and draw in industry expertise to make improvements that reduce risk. The manufacturing and construction industries rightly pride themselves on being innovative when it comes to design and construction. This expertise needs exposure to the clinical environment and patient safety to create new ways of working, new products, and new aspects of design, all focused on what must be the new common aim – improving patient and occupant safety.
Suggestions looking ahead
We suggest the following would help establish the necessary processes and momentum to move this forward:
Training – while the built environment may be seen as the province of Infection Prevention and Control teams (IPC), through no fault of their own, many IPC personnel have had no training in this area. A brief review of the major IPC textbooks shows the built environment not to feature.
The Hackitt report is now over six years’ old, but the cultural change that it highlights as necessary to improve building design, construction, and commissioning, is yet to be realised. This requires translation into the healthcare sector. Again, training is vital.
This is reinforced by the new HTM 04-01 addendum.4
NHS Procurement – through engagement both with manufacturers and hospital staff – has an important opportunity to positively impact patient safety and reduce the spread of AMR. This will ensure the required multidisciplinary approach. The New Hospital Programme is due to design, construct, and commission, a large part of the English healthcare infrastructure. If the Programme is to succeed, then perhaps the challenge is for those managing it to pick up the gauntlet thrown down by the new AMR national action plan and develop and implement the necessary actions and solutions required.
Dr Michael Weinbren
Dr Michael Weinbren is a consultant medical microbiologist, a Specialist advisor for microbiology to the New Hospital Programme, and Chair of the Healthcare Infection Society Working Party on water/wastewater.
George McCracken
George McCracken joined the NHS in 1993 as a hospital engineer in Down Lisburn Trust, before this working in industry – in cable manufacture and foundry works. In 2002 he moved to the Royal Group of Hospitals, Belfast, as a senior engineer, before in 2007 being appointed head of Estates Risk and Environment in the new Belfast Health and Social Care Trust, one of the UK’s largest NHS Trusts. He holds a First Class Honours Degree in Construction Engineering & Management, is a Chartered Member of the Institute of Building, and a member of IHEEM. He currently leads a Risk Team that ‘continues to provide an innovative approach to the management of risk within a healthcare estates environment’.
Dr Simon Pybus
Dr Simon Pybus is a specialist registrar in medical microbiology and infectious diseases in Glasgow. He holds the Graham Ayliffe Training Fellowship, funded by the Healthcare Infection Society, working with ARHAI Scotland and NHS Scotland Assure, with his work focused on infection prevention related to the healthcare built environment.
References
1 Department of Health and Social Care. UK 5-year action plan for antimicrobial resistance 2024 to 2029. 8 May 2024. https://tinyurl.com/yjcctzy6
2 Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet 2022; 399 (10325): 622-695.
3 Institute for Health Metrics and Evaluation (IHME), Global Burden of Disease Study 2019 (GBD 2019) Disease and Injury Burden 1990-2019. https://ghdx.healthdata.org/gbd-2019
4 NHS Estates Technical Bulletin. Addendum (NETB) No 2024/3 to HTM 04-01: Designing safe spaces for patients at high risk of infection from nontuberculous mycobacteria and other waterborne pathogens. 27 August 2024. https://tinyurl. com/3fy9tp5j
5 Report of the Independent Inquiry into the Construction of Edinburgh Schools. February 2017. https://tinyurl. com/5ffuryzh
6 Building a Safer Future. Independent Review of Building Regulations and Fire Safety: Final Report. May 2018. https:// tinyurl.com/mry8x3z6
7 Weinbren M. Are wastewater systems a nursery for microorganisms? HEJ April 2023; 77(4).
8 Browne K et al. Investigating the effect of enhanced cleaning and disinfection of shared medical equipment on health-care associated infections in Australia (CLEEN): a stepped-wedge, cluster randomised, controlled trial. Lancet Infect Dis 2024 13 August 2024.
9 Benbow A et al. Hospital-wide healthcare-associated carbapenemase-producing Enterobacterales outbreak: risks of electric floor scrubbers in catering facilities and kitchens. J Hosp Infect April 2024; 146: 59-65