Shifts in Healthcare Design Create Demand for New Products  

Major shifts are under way in the healthcare sector. Driven by changing demographics and the Patient Protection and Affordable Care Act, institutions are getting leaner as they look for greater efficiencies. New construction is shifting from the mega hospital to flexible satellite outpatient facilities that serve changing community needs, while small specialty surgical centers continue to grow to meet consumer demand for personal service and convenience. As baby boomers age, long-term care providers increasingly recognize that facilities which look and feel like home rather than a high-rise institution are proving to be effective, feasible, and sustainable. Even more significant is the continuing demand for sustainable construction, which, matched with stringent budgets, is a perfect combination of green and lean.

But healthcare facilities also have the critical requirement of supporting best practices in healthcare processes in order to combat hospital-associated infections (HAIs). As Florence Nightingale wrote in “Notes on Hospitals” (1863): “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle.”

In a special issue of HERD (Health Environments Research & Design),¹ Kendall K. Hall, MD, MS and Douglas B. Kamerow, MD, MPH, note that HAIs are a serious and costly threat to public health in the U.S., afflict an estimated one in 20 hospitalized patients at any given time, and that hospital-acquired infections alone were responsible for between $28 billion and $33 billion in excess healthcare costs in 2002 (U.S. Department of Health & Human Services, 2012). In the same HERD publication, James P. Steinberg et al report that many pathogens causing HAIs can survive for weeks to months on dry surfaces. Organisms such as Clostridium difficile (C. difficile) can form spores that allow for prolonged survival and are relatively resistant to disinfection. Common causes of HAIs, notably Staphylococcus aureus (S. aureus) and Enterococcus (VRE), and their antibiotic-resistant strains also frequently contaminate the environment.

The most telling article focuses on a new awareness of sources of HAIs. Craig Zimring, Ph.D., et al report that HAI prevention has focused primarily on improving clinical practices. But that recently there has been growing recognition by both the infection prevention and design communities that the built environment—including fixed components that healthcare workers, patients, and families touch or interact—is an important component in the transmission of pathogens. (A review of articles relating to surface contamination and the spread of infectious pathogens was published in 2012.²) As Steinberg et al found, “the failure of routine cleaning to remove pathogens from the environment is not due to ineffective disinfectants, but rather to the lack of strict adherence to cleaning protocols.”

Design professionals would do well, therefore, to evaluate every cleaning system in terms of their applicability to the shifting trends in healthcare delivery. Do they serve home-like long-term care facilities and smaller-scale ambulatory surgery centers? Does their return on investment make budgetary sense? Is there evidence of sustainability and contribution to USGBC Leadership in Energy & Environmental Design (LEED®) Healthcare certification? Above all, do they help prevent HAIs? There are a number of cleaning systems on the market that meet these criteria.

Dishwashers

After decades of long-term care providers opting for the code-compliant, multi-floor, hospital-like model, there is a changing trend towards smaller-scale facilities that build out rather than up. In a literature analysis of long-term care facility design in terms of both physical and psychological needs, Wang CH and CUO NW³ found that creating a home-like environment was the top priority in long-term facility design, followed by Universal Design concepts and clustering living units to replace hospital-like wards. More and more providers are adopting the Green House® Project model that is transforming the culture of long-term care. A Green House home is created from the ground up to foster the same feeling and experience found in a real home. Each home is designed for 10-12 residents who have private bedrooms and bathrooms, a kitchen, dining room, and spaces for socializing. An innovative staff model gives residents four times more contact and reduces staff turnover. Research funded by Robert Wood Johnson Foundation that focused on quality of care, quality of life, and cost of care found that hospitalizations and total Medicare and Medicaid costs per resident were less than those in traditional nursing homes.

Yet, despite the commitment to a residential kitchen, providers and design professionals still face the problem of specifying code compliant home-scale kitchen appliances. Dishwashers that are American Disabilities Act (ADA) compliant and NSF/ANSI 3 approved for sanitization and answer the design and practical needs of a residential-scale kitchen that serves 20 or fewer residents are the major challenge.

NSF International is accredited by the American National Standards Institute to develop voluntary standards for public health and safety. NSF/ANSI 3 covers commercial warewashing (the cleaning and sanitizing of equipment and utensils). Most commercial dishwashers are tank systems, which recirculate dirty water until the final rinse and use caustic chemicals to achieve sanitation. Moreover, many NSF-certified commercial dishwashers have a 90-second wash. They sanitize rather than wash, so dishes must be sprayed down before being put in the dishwasher.

Dishwasher noise is also a factor. Since most continuing care retirement communities' (CCRC) residents have hearing issues, a quiet environment is critical. “Sound is such a major factor of the environment. Background noise is distracting from people's concentration, conversation and socialization,” says Constantine L. Tsomides, NCARB, AIA, principal/CEO, Tsomides Associates Architects Planners, a leader in the planning and design of senior living facilities. “An architect can design a beautiful space, but if the place isn't quiet, and if the appliances and equipment are noisy, that's going to detract from the comfortable ambience of the environment.”

One high-end model, the only NSF/ANSI 3 approved/ADA-height compliant freshwater commercial dishwasher, uses fresh water intake for each new fill with no need for caustic chemicals or fear of cross-contamination. Its high temperature final rinse meets sanitation requirements. Other features are its 25-minute cycle based on 140°F hot water connection and its quietness rated at around 5 dBA.

Washer-Disinfectors

Eighty percent of hospitals are planning outpatient expansion in the next two years. There has also been a significant increase in the number of outpatient ambulatory surgery centers since 2006. With the introduction of the Affordable Care Act and economic upturn, IBISWorld, a provider of industry research, predicts an acceleration of growth in the next five years. Over 90 percent of the 6,000-plus centers currently in the U.S. are for-profit. Most frequently performed procedures are cataract surgeries, followed by endoscopies and colonoscopies. The greatest growth in outpatient procedures, however, has been in cosmetic plastic surgeries with 15.1 million performed in 2013—many of which take place in the expanding number of cosmetic surgery centers across the country.

With the increasing volume of freestanding surgery facilities—and publicized occurrences of HIV and hepatitis B and C infections due to inadequate processing of instruments—it is beneficial for providers and design professionals to specify effective washing and disinfecting systems. Particularly since the increase in popularity of minimally invasive surgery has led to the use of many complex instruments that are more difficult to process than basic instruments.

One manufacturer has worked closely with hygiene specialists, instrument manufacturers and end-users to deliver a model for medical settings including ambulatory, ophthalmology and cosmetic surgery centers. An under counter model with several programs for different requirements, it can effectively clean and provide intermediate level thermal disinfection for a wide variety of laparoscopic and rigid endoscopes and their disassembled parts as well as general surgical instruments. Rated at 53 dBA for quiet operation, it has been tested and proven to properly clean and disinfect instruments that have blood dried on them for up to six hours. The washer also offers a rinse program that can remove gross debris

Laundry Systems: Cleaning Microfiber Mops

While hospitals specify cleaning supplies, it can be important for design professionals to know how and if a cleaning system impacts space requirements at the time of planning or in the future. It also behooves design professionals to be knowledgeable about any cleaning system that is energy efficient, cost saving, and can benefit their clients. The use of microfiber mops and cloths and their laundering systems is one such example.

Over a decade ago the Environmental Protection Agency (EPA)⁴ reported on the merits of using microfiber mops in healthcare facilities rather than conventional loop mops for wet mopping of patient-care areas, citing a case study at the University of California Davis Medical Center (UCDMC) in Sacramento, California. Since then an increasing number of hospital environmental services departments, are opting for microfiber products to help prevent cross-contamination. Microfiber mop heads are typically changed after cleaning one patient room, in contrast to the common practice of changing and disposing of gallons of cleaning solution after mopping every two or three rooms with a loop mop.

Microfibers are densely constructed, polyester and polyamide (nylon) fibers manufactured to create more surfaces so that they pick up bacteria, fomites, dust, and debris. The material enables it to hold six times its weight in water, making it more absorbent than a conventional, cotton loop mop. Also, the positively charged microfibers attract dust (which has a negative charge). Since the fiber is not organic, unlike cotton, it does not harbor bacteria growth. Moreover, cotton string mops are used with harsh chemicals such as quaternary ammonium chlorides and butoxyethanol, which can be harmful to human health and the environment.

The case study at UCDMC in Sacramento, California, where cotton mops were replaced with microfiber mops, revealed: 60 percent lifetime cost savings for mops; 95 percent reduction in chemical costs associated with mopping tasks; 95 percent reduction in water used for mopping; and 20 percent labor savings per day.

Another study⁵ found that the microfiber system removed more microbes than cotton string mops when the latter was used with a detergent cleaner.

But a more significant finding was that the use of a disinfectant in a microfiber mop did not improve microbial elimination. This means that bleach and/or other chemicals are not required when laundering microfiber mops. But usual hospital practice requires all mops to be treated with chemicals before use.

In theory, using microfiber mops to mop floors and microfiber cloths to wipe bed rails, doorknobs and surfaces touched by patients, saves money, but the critical issue is laundering. “If you don't manage that properly, you are losing the investment you've made,” says Tom Murphy, Murphy Consulting Group that analyzes healthcare facility management systems. See sidebar “Microfiber Mop Cleaning System: Return on Investment.”

Microfiber mops are especially designed for repeated use and most premium brands are designed to withstand 500 detergent laundering cycles, but if bleach is used that cycle number can be substantially reduced to as low as 200 cycles. To extend the life of the mops for maximum return on investment, mop heads must be cleaned carefully but thoroughly and without bleach. Mop heads should also not be exposed to excessive heat in a dryer since that will melt the nylon microfibers and make them less effective.

Some facilities contract with a mop rental or laundry company, which typically uses tunnel washers (a large scale computerized washing system consisting of a large long metal tube called a tunnel with a metal spiral agitator). This adds extra steps for shipping mops back and forth and runs the risk of loss and deterioration through the use of bleach and excess heat. Using in-house tunnel or standard laundry machines will run the same risks.

One laundry system that has been successfully used in Europe for many years is specifically engineered to wash microfiber mops and cloths using features that are not offered by standard machines. The manufacturer has developed a patented convex-pattern honeycomb drum used on all washer and most dryer models that enhances cleaning and reduces microfiber and fabric wear. The size of the drum's water exit holes is smaller and a network of water channels create a skim water layer that cushions fabrics or laundry while the drum rotates. The honeycomb design allows virtually no penetration of fabric through the drum. (In traditional washing drums, the fabric penetrates the water exit holes, which shortens lifespan.)

Laundry Systems: H₂O Dryer

More than two-thirds of energy used in the laundry process is consumed in the drying. One of the most energy-efficient commercial laundry technologies available is H₂O drying. Introduced to the U.S. in 2013 and used in Europe for several years, the H₂O dryer uses heat energy from hot water to dry laundry. It can be installed anywhere there is a source of hot water from solar thermal energy and geothermal energy to co-generation plants.

The hot water is used to heat process air in a heat exchanger. The dryer's programs are specially designed to take care of laundry at lower process air temperatures. This new type of heating is available on tumble dryers with various load capacities. The new H₂O dryer reduces laundry heating costs to virtually zero if the source of heat is a co-generation plant. In this case, the hot water is a by-product of cooling the generation plant and does not need to be heated separately. This approach also offers the additional benefit of cooling the water in the H₂O dryer for reuse again as cooling water in co-generation.

The new H₂O commercial drying technology can cut energy costs of a commercial tumble dryer by up to 96 percent depending on the heat source. “If you review the whole process of linen cleaning, the tumble dryers are by far the most energy-consuming step,” says Miele Professional laundry specialist Celeste Kopyscianski.

The H₂O dryer has the same patented honeycomb drum cleaning benefits as the microfiber mop laundry system.

LEED Certification

Of the more than 20,000 commercial projects that have earned LEED certification, more than 600 are healthcare facilities. In recognition of the unique nature of healthcare facilities, their strict regulatory requirements, 24/7 operations, and specific programmatic demands that make pursuing LEED NC difficult, USGBC released LEED for Healthcare in 2011.

LEED-HC acknowledges these differences by both modifying existing credits and creating new, healthcare-specific credits. For example, most of the Indoor Environmental Quality credits have been modified to align the need for infection control, to protect patients from contaminants.

LEED for Healthcare was written primarily for inpatient and outpatient care facilities and licensed long term care facilities. The rating system may also be used for medical offices, assisted living facilities and medical education and research centers. LEED for Healthcare addresses design and construction activities for both new buildings and major renovations of existing buildings.

Cleaning systems that save energy, monitor water usage, and reduce the amount of chemicals used may contribute to LEED credits for new construction and renovation in the following categories:

LEED-HC

WE Prerequisite 1: Water Use Reduction

Intent: Increase water efficiency within buildings to reduce the burden on municipal water supply and wastewater system

WE Credit 2: Water Use Reduction

Measurement and Verification

1-2 Points

Intent: Provide for the ongoing accountability and optimization of building water consumption performance over time.

WE Credit 3: Water Use

1-3 Points

Intent: Maximize water efficiency within buildings to reduce the burden on municipal water supply and wastewater systems. (This might not apply if the equipment flow rate/water use is regulated by health codes.)

EA Prerequisite 1

Fundamental Commissioning of Building Energy Systems

EA Prerequisite 2: Minimum Energy Performance

Intent: Establish the minimum level of energy efficiency for the proposed building and systems to reduce environmental and economic impacts associated with excessive energy use.

EA Credit 1: Optimize Energy Performance

1-24 Points

Intent: Achieve increasing levels of energy performance beyond the prerequisite standard to reduce environmental and economic impacts associated with excessive energy use.

EA Credit 5: Measurement and Verification

2 Points

Intent: Provide for the ongoing accountability of building energy consumption over time

IE Q Credit 2: Acoustic Environment (room noise)

1-2 Points

Intent: Provide building occupants with an indoor healing environment free of intrusive or disruptive levels of ID credit for Green Cleaning.

Pilot Credit 3: Medical and Process Equipment Efficiency

Intent: To reduce energy consumption by using efficient medical and other equipment.

LEED Recertification

Recertification LEED for Existing Buildings: Operations & Maintenance

IEQ Prerequisite 3: Green Cleaning Policy

Intent: To reduce the exposure of building occupants and maintenance personnel to potentially hazardous chemical, biological, and particulate contaminants, which adversely affect air quality, human health, building finishes, building systems, and the environment.

Conclusion

Green, leaner, and addressing HAIs are today's goals for all sectors of healthcare delivery that includes hospitals, ambulatory surgery and rehabilitation centers, and long-term care communities which are moving towards a home-like model. There is now recognition that the built environment plays a role in the transmission of pathogens and that effective and time-saving cleaning systems that use less chemicals can help meet those goals. Laundry systems for microfiber mops and cloths, washer disinfectors for reprocessing instruments, code-compliant quiet dishwashers for homescale continuing care retirement communities, and new dryers that use hot water to dry are some of the products on the market. They can also help contribute to LEED for Healthcare certification.

 

Miele Professional is the commercial products division of Miele, Inc. The professional division leads the way in the development of innovative technology and meets the highest demands in washing, dishwashing, cleaning, and disinfection in commercial applications. www.miele-pro.com