Antimicrobial Resistance Prevention - Engineering and Facilities Management Perspective

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Issue and Revision Record

Revision Date Originator Checker Approver Description

0 24.01.2020 Ramazan Behic Kenneth Birrell Sarah Dobson Issue

Document reference:

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Contents

Executive summary 1

1 Design Stage AMR Prevention Measures 3

2 Operation Stage AMR Prevention Measures 5

3 Conclusion and Recommendations 16

Tables

Table 1: Recommendations before Construction Phase 3

Table 2: Recommendations (KPI) for Operations Phase 5

Figures

Figure 1.1: Stages where Engineers and FM advisors could make an input 2

Figure 2.1: Posters to encourage hand washing 13

Figure 2.2: Typical Operating room HEPA Filter application 14

Figure 2.3: ASHRAE 170- Table 6.1 Minumum Filter Efficiencies 14

Figure 2.4: ASHRAE 170- Table 7.1 Design Parameters 15

Photos

Photo 2.1: Polyclinic Room 8

Photo 2.2: Surgery Preparation Area 9

Photo 2.3: Intensive Care Units (ICU) 9

Photo 2.4: Entrance of a Patient Ward 10

Photo 2.5: Patient room 11

Photo 2.6: Nurse Station 12

Maps

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Charts

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Executive summary

According to World Health Organization (WHO), Antimicrobial Resistance (AMR) is:” the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antivirals and antimalarials) from working against it. As a result, standard treatments become ineffective, infections persist and may spread to others.”

AMR presents a significant threat to human health, food, security and development today. If the current rate continues, the WHO anticipates that 10 million people will die (more people than currently die from cancer) and 66 trillion pound would be needed to tackle AMR by 2050. World leaders have agreed that tackling AMR will require addressing both health and agriculture concerns with a focus on prevention. Improving infection prevention and control (IPC) and water, sanitation, and hygiene (WASH) is one of the five objectives in the World Health Organization’s (WHO) AMR Global Action Plan. Nowhere is reducing infection more important than in health care facilities. Joint, immediate action to address Infection prevention and control (IPC) and WASH is essential.

Water, sanitation and hygiene (WASH) in healthcare facilities are the cornerstone of IPC according to WHO. According to the WHO, the implementation of WASH measures could reduce the demand for antibiotics and therefore curb their overuse in specific categories by as much as 60% in low and middle-income countries.

Whilst basic measures such as contact precautions, hand washing, and proper cleaning can play a significant role in preventing the spread of bacteria between patients they are often neglected.

As the spread of AMR is often unnoticed, each patient should be treated as if they are carrying drug-resistant bacteria.

At Mott MacDonald, we’re leading the way, working across countries and sectors to help our clients understand and respond to the threat of AMR through a programme of technical and professional excellence activities.

There are many published papers, websites, NGO’s, notes and blogs that are highlighting the danger of AMR and suggesting prevention incentives. This report will analyse the incentives, from an Engineering and Facilities Management perspective, that could be put in place at Design, Construction and Operation phase of a healthcare building.

Please see below figure showing the stages where Engineers and FM advisors could make an input by introducing AMR preventive measures into the work they carry out.

Figure 1.1: Stages where Engineers and FM advisors could make an input

Source: Mott MacDonald

1 Design Stage AMR Prevention Measures

It is important to put in place AMR preventative requirements at Design stage because of the difficulties to make adjustments to the building design during construction and operational stage.

In general, before the actual construction of a healthcare building starts, technical specifications are produced where the design, building materials, equipment, systems, capacities and workmanship requirements are specified. After the production of technical specification, construction drawings and schedules are produced according to the technical specification. Then, these documents are used as a guideline for construction and procurement. The above workflow shows that it is important to have AMR preventative Requirements at the technical specification.

Also, in some projects, Environmental and Social Impact Assessments (ESIA) would be prepared, and according to the Assessment, a plan called “Environmental and Social Action Plan (ESAP)” and a Management system called “Environmental and Social Management System (ESMS)” would be prepared before the construction and operation phase of the healthcare building. It is equally important, to introduce AMR preventative requirements in these systems and plans to address AMR.

The Table below provides some examples of requirements that can be included in the technical specification.

Table 1: Recommendations before Construction Phase

No Subject Requirement

1 Air Filtration in a Healthcare Building

2 HEPA Filtration

3 Adequate provision of suitable antimicrobial hand rubs where appropriate

4 Wash Basin Installation

5 Air Handling unit (AHU) type at Operating Rooms

6 AHU type at Emergency Department

Minimum filter efficiencies to be specified in the Technical Specification according to Table 6-4 of ASHRAE Standard 170-2013 or equivalent international standards. Please see Figure 2.3.

HEPA filters are recommended to be installed in areas such as Operating Rooms, Isolation Rooms and Protective Environment (Cancer treatment) Rooms. The areas that needs HEPA filter are outlined in the international guidelines. Please see Figure 2.2.

Establishment of disinfection stations at all patient facing areas such as patient ward entrance, Polyclinical rooms, Surgery Preparation rooms and Nurse Stations. Alcohol-based hand rubs should be located according to the characteristics of the relevant patient care area, such as each bedside, between two beds or located in a position where the healthcare personnel can easily reach during patient care.

Please see Photo 2.1, Photo 2.2, Photo 2.3, Photo 2.4, Photo 2.5, Photo 2.6.

Wash Basins to be installed at each patient room, ICU room, Nurse Station, Polyclinical rooms, Surgery Preparation rooms.

Please see Photo 2.1, Photo 2.2, Photo 2.3, Photo 2.4, Photo 2.5, Photo 2.6.

Each operating room should have its own dedicated AHU. The air-handling unit for the operating room should be designed to operate with 50% outside air. The unit serving the operating rooms will be provided with HEPA, filters and should be sized to deliver appropriate air changes per hour (ACH) in each operating room. Number of Air Changes required for the area could be found from ASHREA 170 Table 7.1.

Please see Figure 2.4.

The emergency department air handling unit should be designed to operate in an infection control mode such that the air handling unit supplies 100% outside air. The whole emergency department is maintained at a negative pressure to all surrounding hospital areas to control the migration of airborne contaminates.

No Subject Requirement

Number of Air Changes required for the area could be found from ASHREA 170 Table 7.1. Please see Figure 2.4.

7 Infectious isolation exhausts The infectious isolation exhausts should be centralized manifold systems and should be dedicated to serve only infection control isolation rooms and the patient bathrooms of infection control isolation rooms. The manifolded infections isolation system should have two fans with variable frequency drives, each sized at 100% of the load. These exhaust systems should not serve any other spaces.

8 Provide secure adequate isolation facilities and Laboratory areas.

9 Single-occupancy patient rooms

Access control system should be required which is an electronic control system that recognizes, authenticates and authorizes entry of a person to enter into the premise thereby giving protection and ensuring security with the system. Number of Air Changes required for the area could be found from ASHREA 170 Table 7.1. Please see Figure 2.4.

Prioritize single-occupancy patient rooms when designing new healthcare facilities despite short-term costs to alleviate the long-term AMR burden

10 Wastewater Treatment Healthcare facilities are contributing to the development and spread of AMR; drugresistant bacteria not only leave hospitals via patients, but they can also spread through wastewater systems. Healthcare facilities do not typically have wastewater treatment plant at the point of discharge to municipality drainage line, but the options should be analyzed.

11 Include AMR specific incentives to the ESAP and ESMS documents.

ESAP and ESMS documentation would be prepared and these documentations would be approved by the Lenders, Administration and therefore it would be part of the Facility Management Companies scope of work to monitor the activities against the requirements. Therefore, having AMR specific incentives in the ESAP and ESMS documents could make a significant difference.

Source: Mott MacDonald

2 Operation Stage AMR Prevention Measures

After the construction phase, the healthcare buildings will be occupied by the healthcare personnel to provide health services and by Facility Management personnel to provide Hard and Soft FM services.

Typically a service agreement will be signed with the Facility Management (FM) Company. The counterpart of this agreement will vary depending on the Healthcare contracting model (PPP, Public, private). The service agreement will detail the scope of the work undertaken by the FM company. It is important to have adequate provisions in regard to Antimicrobial resistance in the service agreement as the FM Company staff would typically be involved from MEP equipment maintenance/ replacement to Soft FM services such cleaning, disinfection, waste, etc. The Service agreement should contain specific requirements or KPIs in regard to AMR or antibiotic stewardship.

Environmental and Social Action Plans (ESAP) and Environmental Social Managements Systems (ESMS) might be available in some projects where such plan and systems is annexed to the Service Agreement. Provisions in regard to AMR could be introduced to the ESAP.

It is also important to have an Infection Control Committee (ICC) established in the healthcare building to control and monitor the work, trainings and activities provided by the FM company staff and the Administration staff during the Operation phase.

To minimise the risk of infection in the hospitals, it is acknowledged that there needs to be systems in place to manage and monitor the prevention and control of infection during the operation phase. These systems may use risk assessments which consider the susceptibility of service users as well as any risks that both their environment and other users may pose to them.

It is recommended that the risk assessments, management and monitoring of the systems should be carried out by both the Healthcare personnel and by Facility management. Contractually, it is not usual to assign performance parameters to healthcare personnel such as doctors, nurses and administration personnel. However, performance parameters can be put on the facility management personnel to address AMR.

The Table below shows some requirements that could be required from the Facility Management Service staff.

Table 2: Recommendations (KPI) for Operations Phase

No Subject KPI

1 Maintenance frequency of Ventilation system components.

2 Maintenance frequency of HEPA filters.

Facility Management Company would be usually responsible to keep Air vents, grilles and other ventilation outlets unblocked and keep it free of dust, grit, soil, film, cobwebs, scuffs and any other marks. A schedule/frequency for cleaning or maintenance associated with the requirement should be introduced. This is typically carried out on a annual basis.

Filtration performance may affect Indoor Air Quality (IAQ) in several ways. Poorly maintained filters with inadequate seals and breaches in the filter media promote the passage of contaminants into occupied spaces. This seriously affects IAQ in critical areas where clean environments are needed. Severely occluded particulate filters increase the resistance of airflow through the filters, affecting air

3 Maintenance of alcohol-based hand rubs at point of care.

4 Using videos and posters to raise AMR awareness

supply rates. When filters are not changed according to the manufacturer’s instructions, the performance of the HVAC system is compromised.

HEPA filters are designed to filter 99.97 percent of particles with a diameter of 0.3 microns. When HEPA filters are not properly maintained and tested regularly in biological safety cabinets, there is risk of contamination of the product within the unit or release of airborne pathogens into the occupied environments. A schedule/frequency for cleaning or maintenance associated with the requirement should be introduced. This is typically carried out on semi-annual basis. The HEPA filter maintenance should be scheduled and not reactive.

Periodical control of the disinfection stations should be carried out by the Facility Management Staff and the responsibility of the refilling should be defined and monitored. The responsibility should be defined in the service agreement made with the Facility Management company.

Showing patients videos on hand hygiene at the time of their admission could dramatically increase patients asking hospital employees to wash their hands and hospital employees complying with their requests. This responsibility should be defined in the service agreement made with the Facility Management company.

Please see Figure 2.1.

5 Promoting hand hygiene in the workplace

Hand hygiene is one of the keys to reducing healthcare acquired infections. Banners and flyers on the walls of the hospitals to remind the importance of hand washing for the prevention of multi-drug resistant infections and also to improve awareness and understanding of antimicrobial resistance could be introduced. Also, within the scope of encouraging practices; sending warning messages via information systems, rewarding successful employees, organizing special events with the staff to discuss about hygiene materials used, the problems they have and to have their suggestions. This requirement should be defined in the service agreement made with the Facility Management company.

6 Periodical Hand Hygiene training programs

7 Compliance of employees with hand hygiene rules should be evaluated

8 Disinfection procedures should be defined

9 Maintenance procedures should be clearly defined for ventilation systems in the Operating rooms, and ICU’s.

The FM Company should be providing infection control related training sessions. Trainings such as Hand Hygiene should be given periodically and the details should be clearly defined in the service agreement made with the Facility Management company.

Evaluations could be carried out in accordance with the following requirements: a. Observations to cover all patient care areas over a one-year period (including selected polyclinics). b. Observations in intensive care units could be repeated every quarter. c. The result of the observations should be analysed on a quarterly period.

Some of the following requirements could be defined in the service agreement made with the Facility Management company: a. The Disinfection materials used should be selected from an AMR perspective b. Practitioners should be trained on the use of disinfectants. c. In areas where high-level disinfectants are used, appropriate ventilation conditions should be provided.

The following performance tests could be applied for the ventilation system to prevent infection spreading: a. HEPA filter compatibility (leak test) b. Air flow and air velocity measurement c. Pressure differences and air flow directions between sterile areas d. Measuring system effectiveness (re-cleaning) e. Particle measurement

The Above test could be included in the Facility management service companies’ scope of work defined in the service agreement.

10 Periodical Infection control trainings should be provided to the Facility management company staff

The following trainings should be provided to all personnel (Facility Management Company Staff. Not the Administrations staff e.g. doctors and nurses) for the prevention of infections and should be included in the Facility management service companies’ scope of work defined in the service agreement

i. Periodic cleaning of air conditioning and water tanks,

ii. Prevention of Legionella-induced pneumonia, iii. Maintenance and replacement of HEPA filters (prevention of airborne infections), iv. Proper disposal of filters. v. Training for hospital infections. vi. Prevention of vector-borne transmission, vii. Preparing and complying with disinfection program viii. Prevention of hospital infections, ix. Implementation of hospital cleaning procedure and Infection Control Committee approved risk level cleaning plans, x. Prevention of contamination, preservation xi. Cleaning of transport containers, xii. Annual health screening. xiii. Classification of dirty laundry in separate containers, xiv. Use of protective equipment, xv. Food hygiene and safety trainings for the kitchen staff before start of work, xvi. Periodic nasal and stool cultures xvii.Protection from biological risks and prevention of contamination xviii. Protection of health personnel and patient against biological risks and prevention of transmission in Imaging Service applications xix. Cleaning, disinfection applications, xx. Defining sterilization steps, xxi. Keeping records and periodically validating. xxii.Preventing the risks of transmission in Physical Therapy Services, xxiii. Changing the towels, pillows and covers used by the patients for each patient. xxiv. Completion of waste trainings by waste personnel, xxv. Control of periodic hepatitis markers, xxvi. Annual health screenings, xxvii. Monitoring of immunization xxviii. training for blood-borne diseases.

Photo 2.1: Polyclinic Room

The above Photo 2.1 shows a polyclinic room and it appears that a hand washbasin is present within the clinical area. This is appropriate rather than outside the room, for the prevention of multi-drug resistant infections because the Doctor is able to wash hands in the room in between patients and between undertaking procedures..

Source: Mott MacDonald

Photo 2.2: Surgery Preparation Area

Source:

The above Photo 2.2 shows a Surgery Preparation Area and it appears that hand washbasins are present and readily accessible when moving between bed spaces, which is appropriate for the prevention of multi-drug resistant infections.

Photo 2.3: Intensive Care Units (ICU)

Mott MacDonald

Source: Mott MacDonald

Photo 2.4 shows an Intensive Care Unit. Patients are nursed in individual rooms, with automatic doors, and hand washbasins are present in each room, which is appropriate for the prevention of multi-drug resistant infections. Additionally, the design means that despite the single rooms, patients can be easily observed and monitored by staff and the infection control measures do not hinder good clinical care. There is adequate space for patients and staff, and the area is uncluttered, which allows for easier cleaning.

2.4: Entrance of a Patient Ward

The above Photo 2.4 shows entrance of a patient ward. Although the doors are automatic, there is no sink or hand sanitisation station, which may discourage staff and visitors from decontaminating their hands on entering the ward, which can be a risk for the prevention of multi-drug resistant infections.

Photo

Source: Mott MacDonald

The above Photo 2.5 shows entrance of a patient room and it appears that a hand wash basin is present which is appropriate for the prevention of multi-drug resistant infections. The tap and soap dispenser are elbow operated, which reduces cross contamination.

Photo 2.5: Patient room

Source: Mott MacDonald

The above Photo 2.6 shows a nurse station and it appears that hand disinfection stations are not present which can be a risk for the prevention of multi-drug resistant infections.

Photo 2.6: Nurse Station

Source: Mott MacDonald

Figure 2.1: Posters to encourage hand washing

Source: Web

Figure

2.2: Typical Operating room HEPA Filter application

Source: Web Figure 2.3: ASHRAE 170- Table 6.1 Minumum Filter Efficiencies

Source: ASHRAE-170- to be used during defining design requirements.

Figure 2.4: ASHRAE 170- Table 7.1 Design Parameters

Source: ASHRAE-170- to be used during defining design requirements.

3 Conclusion and Recommendations

Healthcare facilities play a significant role in the development and spread of drug-resistant bacteria. Antimicrobial resistance (AMR) is an emerging global problem which will have significant impact on healthcare systems. It is estimated that many antimicrobials currently in use will be ineffective within the next decade, and it is widely acknowledged that the development pipeline for new antimicrobials will not be able to keep up with this need.

Healthcare associated infections (HAI) such as wound infections, urinary tract infections, pneumonias are frequently due to multi-drug resistant bacteria and are a major driver of antimicrobial use. Some of these infections will be difficult or even impossible to treat due to increasing resistance. Because of this, compliance with systems to prevent and monitor healthcare associated infections is now of paramount importance.

The global threat of AMR calls for the collaborative action for developing effective strategies in combating AMR. Increased collaboration between governments, non-governmental organizations, professional groups and international agencies appears to be very critical.

There are many recommendations made by professionals, researchers and academicians to prevent antimicrobial resistance in a healthcare setting. Most of these recommendations appears to be related to antibiotics use, surveillance, Incentives for the research and development of new drugs and vaccines. However, there are also recommendations which falls under the work scope of the engineers and facility management professionals. Examples of these recommendations are listed in Table 1 and Table 2. Table 1 details the actions that could be taken before the start of the construction phase and Table 2 details the actions that could be taken before or during the Operation phase.

Including AMR related requirements in the technical specification before the start of the construction of a hospital such as having hand wash basins in patient rooms, and in easily accessible locations at wards that make it easy for staff to wash their hands before moving between patients. Design measure which can enhance infection control such as adequate separation of patients (e.g. in single rooms), automatic doors to prevent contamination of handles, automatic or foot/elbow operated sinks, having adequate storage space for cleaning equipment could be included in the Technical Specification.

In general, the hospital management teams would be obliged to satisfy the official regulation requirements in relation to infection control. The FM company, responsible of support services, would generally be also required to satisfy the official procedures, regulations and requirements.

The FM Company would carry its work according to the scope of work outlined in the service agreement they have signed with the Hospital management. Therefore, consideration should be given to include AMR related KPI’s in the service agreement as well as the requirement to comply with the Clinical Infection Control policies. It appears to be difficult to amend any project agreement clause after the inception of a project for various reasons. Therefore, it is recommended that the performance parameters of an agreement should be reviewed before the signing and introduce appropriate KPI’s to the scope of service at an early stage. Ideally these KPI’s should be written in such way that it is clear, specific, frequencies defined, monitorable and linked to the service payments. We do however need to acknowledge that AMR is currently an evolving area were guidance and practices are liable to change and adapt over time.

In some projects, ESAP and ESMS documentation would be prepared and these documentations would be approved by the Lenders, Administration and therefore it would be part of the Facility Management Companies scope of work to monitor the activities against the requirements. Therefore, having AMR specific incentives in the ESAP and ESMS documents could make a significant difference.