Safety not Guaranteed

Steps to reduce the risk of infectious disease spread in hospitals

By Christopher Roberts

Healthcare organizations face growing challenges related to infectious disease control. Although adherence to best practices — frequent hand washing, disinfection of surfaces and the use of personal protective equipment — are regarded as the leading weapons against infectious disease spread and hospital-acquired infections, the built environment, including its heating, ventilation and air conditioning (HVAC) systems, also play an important role. What’s more, strides in the development of smart building operation management platforms that easily and cost-effectively integrate with a facility’s existing systems can give healthcare providers a powerful tool with which to enhance the effectiveness of their overall infection control programs.

AIR CHANGE RATES

Human exposure to pathogens is influenced by the ways in which buildings exchange air with their surrounding environment. These exchanges can occur through a variety of means, including natural ventilation like the opening of windows and mechanical ventilation or HVAC systems.

According to the American Society for Healthcare Engineering (ASHE), the complex interplay of variables that influence the relationship between air changes per hour in a ventilation system and infection transmission make it difficult to determine ventilation’s direct effect on disease spread. But evidence from studies of natural ventilation and controlled indoor ventilation suggest that air changes per hour do play a part in controlling the spread of infectious disease.

The role of ventilation in reducing airborne infections drew heightened attention following the 2003 SARS outbreak. This resulted in a doubling of the recommended minimum ventilation rate for airborne infection isolation rooms (AIIRs) to 12 from six changes per hour. In comparison, one air change per hour is recommended for commercial buildings. Despite the many variables involved, a more frequent rate of air change in a hospital room is accepted as a useful strategy for reducing the risk of infectious disease because it can help remove or dilute virus or bacteria-laden droplets from the air.

VENTILATION AND ENERGY GOALS

Integrated platforms that facilitate the automated monitoring and control of building operations, including ventilation in clinical care spaces, are enabling hospital facility managers to ensure their systems are working correctly and achieving the specified ventilation rates. These platforms also allow systems to be adjusted as needed to enhance safety.

Healthcare organizations commonly focus on reducing energy usage by reducing airflow. However, efforts to reduce energy consumption should always carefully consider the impact of changes in airflow on the ventilation system’s role in reducing the spread of pathogenic microorganisms. In other words, energy saving and infection control are not separate silos. This means healthcare organizations should employ a systems approach to ensure these two functions of the built environment work hand in hand to optimize benefits in both aspects of hospital operations.

Comprehensive building operation management platforms that easily integrate with a facility’s existing electronic building management applications, including HVAC, are allowing facility management staff to access, control and monitor all building systems from a single interface.

These intelligent systems allow facilities to consider airflow rates and energy optimization. Their interoperability supports the more effective monitoring and maintenance of safe and comfortable ventilation that balances the health system’s infection control needs with its requirements to maintain a comfortable environment while conserving

energy and reducing associated costs. These platforms run intelligent algorithms against the system’s performance and provide reports and guidance that allow healthcare systems to address ventilation system-related performance issues.

AIR PRESSURE

ASHE standards and guidelines designate areas of healthcare facilities that should be positively or negatively pressurized in relation to their surrounding areas. Maintaining these air pressures throughout the building is a major component of effective infection control.

A positively pressurized area is designed to prevent the entry of pathogenic microorganisms and other contaminants into the space. These areas include operating rooms, delivery rooms, trauma rooms, the newborn intensive care unit and protective environment rooms, among others.

A negatively pressurized room is an environment of lower air pressure in relation to surrounding areas that allows air from surrounding areas to flow into but not out of the space. These areas include emergency room waiting rooms, radiology waiting rooms, toilet rooms, sterilizing laboratories, soiled workrooms or holding rooms and infectious isolation rooms.

The infectious isolation rooms are created for the purpose of isolating patients with infectious diseases or isolating areas where infectious agents may be present in order to protect others from infection. The negative pressure room stops the flow of potentially harmful particles to other areas of the facility by preventing the air inside from leaving the space.

INTRICACIES OF AN AIIR

An AIIR is a single-occupancy negative pressure room for patient care designed to prevent the circulation of airborne pathogens into public areas. The creation of these rooms in hospitals involves a specialized design of the facility’s HVAC system that maintains the flow of air into and out of the room to produce negative pressure in relation to the adjacent space.

The ventilation of an AIIR is designed to ensure a clean to less clean air pathway and prevent pathogenic particles from escaping into surrounding nursing workspaces and public areas. The air from the corridors flows into the patient room but the air from the AIIR is prevented from leaving. The exhaust from the AIIR should not be recirculated by the HVAC system; rather, it should be exhausted through dedicated ductwork and diluted through HEPA filters before it is released into the atmosphere.

Maintaining negative pressure in the AIIR is important to help ensure that airflow moves in the correct vector. Several cases of infection have been reported in instances of pressure reversal caused by door openings. It has been recommended that sliding doors with an airlock-like arrangement be used instead of hinged doors to reduce the potential of pressure reversal.

To ensure safety, the AIIR must be continuously monitored to prevent infection. The differential pressure from the contaminated area to the clean space is a key indicator that airflow is moving in the correct direction. This indicator must be monitored and recorded. If there are any issues in these areas, staff must be immediately alerted through local displays and/or notifications.

REAL-TIME ALERTS

Current integrated building operation systems can provide critical real-time alerts to facility managers and clinical staff when the integrity of an AIIR has been compromised and individuals outside the isolation room have been put at risk. By enabling staff to take precautionary measures in a timely fashion, these alerts can add another layer of protection against infectious disease

transmission that enhances the overall safety and reliability of an organization’s comprehensive infection control measures. These conditions should also be monitored and logged within the building’s operation system to provide records that the systems comply with current safety standards.

FLOW MANAGEMENT

Controlling and monitoring the flow of people, tools and supplies is a vital aspect of infection prevention and control. To do so effectively, it requires spaces that are designed with consideration for traffic flows that separate individuals based on the activities they perform. An access control system plays a key role in managing these carefully designed spaces and workflows by restricting movement into and maintaining the security of sterile locations, and recording details of traffic into and out of the various spaces.

LOCATION AWARENESS SYSTEMS

Integrated building operation platforms with location awareness systems as components of their security functionality are also making it possible for hospitals to monitor the movement of people and equipment. These include radio frequency identification (RFID) and real-time location systems (RTLS).

RFID identifies objects, locations and people through the remote use of radio waves. RTLS extends the benefits of RFID by facilitating the identification and tracking of objects and people in real-time with greater precision and granularity than RFID and other identification systems can provide.

RTLS offers an additional source of protection that allows facility management staff and safety and compliance teams to determine the exact trail of a healthcare worker or other individuals who have entered a room and where they travelled after leaving.

Insights regarding specific incidents and patterns of unauthorized access that are acquired through these enhanced capabilities can be used for the ongoing improvement of infection control processes and procedures.

RTLS can also be used as a safety-enhancing measure by notifying staff of the location of patients with known infections, allowing them to take the necessary precautions before entering these areas.

In addition to enhanced access control and monitoring, as well as environmental conditions monitoring, both RFID and RTLS have a wide range of applications across healthcare settings, including asset and equipment tracking, operating room management, emergency response, hand sanitization monitoring, infant protection, inventory management and loss prevention, among others.

RELATIVE TEMPERATURE AND HUMIDITY

Careful monitoring of temperature and humidity as part of a comprehensive infection control plan can help hospitals reduce the growth of viruses and bacteria and lower the risk of infectious disease transmission.

According to ASHE, despite a large number of scientific studies of the effect of temperature and humidity on the survival of disease-causing viruses and bacteria, the ideal temperature and humidity range for the optimal reduction of pathogenic organisms is not yet known.

However, new recommendations in the wake of the COVID-19 pandemic based on recent findings call for maintaining indoor humidity levels at 40 to 60 per cent to decrease exposure to infectious particles and reduce viral illness transmission.

INTERNET OF THINGS SENSORS

Advances in HVAC design technology and building monitoring systems, including the development of Internet of things (IoT) sensors, have enhanced monitoring of conditions at the room level. The systems allow for better control of temperature and relative humidity in specific spaces, separately from other areas of the building.

IoT sensors are also enabling room-level temperature and humidity monitoring of critical areas throughout the hospital. Smart building operations management systems can yield detailed analytics for use by facility managers and infection control teams to pinpoint spaces in which environmental conditions could potentially impact the growth of bacteria (high humidity) and viruses (low humidity).

SUITABLE FILTRATION AND CLEAN STATUS

Because the particle size of airborne viruses and bacteria is exceedingly small, ventilation, while essential, is insufficient by itself to guard against the movement of pathogens from one area of the hospital to another.

According to ASHE, acceptable indoor air quality can be achieved with proper ventilation in combination with filtration of recirculated and fresh air, mechanical arrestance media like HEPA filtration and ultraviolet germicidal irradiation in targeted applications.

HEPA filters are at least 99.97 per cent efficient in removing particles of 0.3 micrometres, becoming even more capable in removing both larger and smaller particles, according to a recent report.

Because of this, even when exhaust from an AIIR and other negative pressure spaces is moved directly to the outdoor environment where pathogens are diluted in the atmosphere, air filtration must be used in conjunction with ventilation to help control the spread of viruses, bacteria and other potentially harmful microbes.

In addition, according to ASHE, although HEPA filtration is an effective strategy, it must be used in combination with tightly sealed rooms, higher air change rates, positive pressure (airflow out of the room) and other control measures.

IMPROVED SAFETY AND PRODUCTIVITY

When HEPA filters are used, the facilities team should ensure they are changed as needed based on dirty status. Sensors integrated with a smart building operation management system that monitor pressure drop across the filters can deliver notifications to facility personnel when filters need replacing. Incorporating this aspect of safety and maintenance into smart operations can help maximize staff productivity while reducing unnecessary exposure among employees to potentially harmful microbes. The American Society of Heating, Refrigerating and AirConditioning Engineers (ASHRAE) provides safety guidance for facility personnel who perform these tasks.

RESILIENT POWER SUPPLIES

Ventilation, air filtration and the other environmental controls that work together as key components of a comprehensive infection control strategy are only as effective as the reliability of the power source that makes it possible for them to run.

According to U.S. Centers for Disease Control and Prevention guidelines, healthcare providers should develop a contingency plan for backup capacity in the event of a general power failure; deploy infection con-

trol procedures to protect occupants until power and systems functions are restored; and provide backup emergency power and air handling and pressurization systems to maintain filtration, constant air changes per hour, and pressure differentials in protective environment rooms, AIIRs, operating rooms and other critical care areas.

DIGITIZED SYSTEMS DELIVER ASSURANCE

The digitization of electrical distribution represents a major step forward in the management of complex power systems. Healthcare providers now have access to IoT-enabled platforms that can completely digitize their medium and low-voltage electrical distribution systems. These platforms, which can be cost-effectively integrated with a facility’s existing systems, offer analytics capabilities that can deliver actionable insights to facility management teams either at the desktop or on mobile devices to ensure critical systems, including HVAC and related components, continue running in the event of a power failure.

The analytics and insights available through these digitized systems can also be employed by facility managers to provide early warnings of risks; faster recovery when problems occur; data regarding opportunities for time and cost-savings; streamlined maintenance opportunities; and enhanced equipment performance and life span.

It is also critical for health systems to build redundancy into their infrastructure by design. Having the correct backup systems for power, fans and other components will ensure operation in the event of a power failure.

WATER SUPPLIES

Water safety in healthcare facilities is often underappreciated until an infection occurs. However, a large number of pathogens can be spread through a healthcare facility’s central pipes, cooling systems or points of use (drinking fountains and sinks). For this reason, the safety of the healthcare facility’s water supplies should be part of a comprehensive infection control strategy.

Both ASHE and ASHRAE have published guidelines recommending that healthcare facilities prospectively develop and follow a comprehensive water management program that includes a risk assessment of all water treatment systems and water use points

t The purpose of an infectious isolation room is to isolate patients with infectious diseases or isolate areas where infectious agents may be present in order to protect others from infection. The negative pressure room stops the flow of potentially harmful particles to other areas of the healthcare facility by preventing the air inside from leaving the space.

that present a potential hazard, as well as control strategies to mitigate any problems.

Monitoring of temperature and water throughput or flow are particularly important in the prevention of legionella. Stagnant water in pipes, cooling towers or air handling units can become a reservoir for legionella, which can be aerosolized. The building operation system should monitor temperature and water flow of piping systems and facilitate the automatic flushing of pipes. These preventive efforts should be recorded to demonstrate compliance with infection control regulations. Considerations related to the efficient and effective operation of a facility’s HVAC systems should be a part of every healthcare organization’s larger infection control strategy.

KEY CONSIDERATIONS

Hospital leaders, facility managers and infectious disease specialists should work together to ensure these environmental factors are given the emphasis they deserve as part of their organization’s overall efforts to reduce infectious disease risk and HAIs among patients, staff and visitors.

Key considerations that warrant close attention include the maintenance of air change rates throughout the facility; maintenance of the correct air pressures for safety in different departments; protocols to manage the flow of people, equipment and supplies; adjusting and monitoring temperature and relative humidity in keeping with current findings; air filtration and removal; ensuring the safety of resilient power supplies; and maintaining and monitoring water supplies. The monitoring, recording and logging of these conditions is also a critical part of the system to ensure safety and adherence to compliance standards.

Healthcare organizations that tap the insights, efficiencies and safety monitoring enhancements available to them through today’s smart building operation management platforms will be best prepared to meet the growing challenges they face with infectious disease prevention and management.

As the global solution architect for Schneider Electric’s healthcare segment, Christopher Roberts is responsible for design, development and support of intelligent healthcare infrastructure solutions. He leads a team of technical experts and works with external partners to develop integrated architectures that have improved the environment of care and the operating efficiency for healthcare facilities around the world.

This article is the abridged version of the white paper, Seven Steps to Reduce the Risk of Infectious Disease in Hospitals. To read the white paper in its entirety, visit https://it-resource.schneider-electric.com/white-papers.

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All about the Chemistry

Why active ingredients matter in disinfectant products

Active ingredients, such as bleach or quaternary ammonium chlorides, are what give cleaning and disinfectant products their strength against bacteria and viruses.1,2 And the science matters! Each class of active ingredient works in its own way. For example, quaternary ammonium chlorides poke holes in bacterial membranes, and chlorine-releasing compounds, like bleach, disintegrate membranes. Most active ingredients will degrade proteins, thereby killing pathogens.2

Ingredients do not reflect full potential on their own. They need helpers.

The peroxygen class of disinfectants, which includes hydrogen peroxide, can be a very effective disinfectant but the amount of hydrogen peroxide in the formula is not the key driver here. You might be surprised to hear that a 3% hydrogen peroxide solution you get at the pharmacy will not be as good at killing microbes as a disinfectant product containing less than 1% hydrogen peroxide.2 This is because in the 1% hydrogen peroxide disinfectant, it is mixed into an effective formulation. In the presence of the right buffer, hydrogen peroxide can become a much better oxidizer, which will make it more effective at killing microscopic pathogens. Similarly, chlorine-releasing compounds like bleach, or sodium hypochlorite, will be better at killing microbes at different pH conditions. At low pH, sodium hypochlorite converts to its acidic counterpart, hypochlorous acid. Though hypochlorous acid is a much stronger antimicrobial, it is available only at low pH. A product containing bleach can be formulated to have a lower pH in order to increase the antimicrobial efficacy. Again, with cleaners and disinfectants, it’s all about the chemistry.2

Disinfecting products providing efficacy and more…

During the process of developing a product formulation, it is possible to change performance criteria to create different products with the same active ingredient. Besides the ability to kill microbes, formula variants can create products with a wide variety of product attributes. Disinfectants can cover some or all of these attributes: • Effective at killing pathogens • Effective at cleaning dirt, grease, and grime • Without an offensive or harsh odour, ideally pleasant smelling to improve the aesthetic of hard surfaces after they have been cleaned • Safe to use on many different types of hard surfaces and leave minimal or no residue • Safe to use around children and pets, when used as directed • Shelf stable at room temperature so that we can use them week after week without losing efficacy A superior product formulation can accomplish many or all of these objectives. Fragrances are added to improve the aesthetics, surfactants and detergents break up dirt and grease and aid in spot cleaning, and additives may improve product stability and provide greater surface compatibility.

Appreciate your formulations

In addition to the results expected from disinfectants, the formats that they are commercially available in are equally important.2 For example, formulations that are approved for use by Health Canada through trigger sprays may not be suitable and thus not approved for use through an electrostatic sprayer device. Due to the COVID-19 pandemic and the increase in cleaning and disinfection of public spaces (to reduce the risk of exposure to SARS-CoV-2, the virus that causes COVID-19) there has been increased interest in electrostatic spray disinfectants, which can be used to disinfect large indoor spaces. Electrostatic sprayers work by charging the antimicrobial liquid as it passes through a nozzle. The positively charged antimicrobial droplets are attracted to negatively charged environmental surfaces allowing for improved coverage on hard, non-porous environmental surfaces.3,4 As a result, not just any disinfectant solution can be used in electrostatic spray devices. Check the label – it will tell you if your product is approved for use with an electrostatic sprayer device. These products need to have the Health Canada review and approval for use with an electrostatic sprayer (ES). To check whether a product has the ES designation, visit Health Canada’s COVID-19 database at https://www.canada.ca/en/healthcanada/services/drugs-health-products/disinfectants/ covid-19/list.html. If your product has “Electrostatic Spray” in the “Product form” column, it’s approved for use by Health Canada with an electrostatic sprayer.5 Finally, always be sure to follow the directions for use on the product label. Using products correctly as directed will help to ensure safety and efficacy, and that you get the most out of each carefully formulated disinfectant.

Learn about the functions of some common ingredients

Take a look at the label of the cleaning and disinfecting products you are currently using. Do you know what the ingredients add to the product formulation? When you are considering a product, notice all the components that work together for the final product from microbe-killing to aesthetics. The chemistry matters!

CloroxPro® has developed disinfecting-sanitizing products that are registered at Health Canada to help meet the needs of your facility.

Learn more at CloroxPro.ca

References: 1. What’s the difference between products that disinfect, sanitize, and clean surfaces? https://www.epa.gov/coronavirus/whats-difference-between-products-disinfect-sanitize-and-clean-surfaces. Accessed July 5, 2021. 2. Hochberg K. What’s In Your Disinfectant and Why It Matters. https://www.cloroxpro.com/blog/whats-in-your-disinfectant-and-why-it-matters/. Accessed July 5, 2021. 3. Velez K. Electrostatic technology: A new method for surface disinfection. CloroxPro Canada, December 7, 2020. 4. Velez K. Evaluating Electrostatic Sprayers for Surface Disinfection. CloroxPro Canada. 2020. 5. Government of Canada. Hard-surface disinfectants and hand sanitizers (COVID-19): List of disinfectants with evidence for use against COVID-19. https://www.canada.ca/en/health-canada/services/drugs-health-products/disinfectants/ covid-19/list.html. Accessed November 15, 2021. © 2022 The Clorox Company