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Renovation or construction that happens in preexisting spaces or occupied areas have very different sets of challenges than the building of new facilities.

Breaking the Chain: How to Better Contain Infection Risk During Hospital Construction

's) Editorial Board members—a diverse group of professionals dedicated to advancing infection prevention and control practices. This series highlights each member's unique expertise and contributions to the field.

From groundbreaking research to innovative strategies, these experts are at the forefront of enhancing health care safety. Join us as we learn their insights, experiences, and visions for the future, providing valuable knowledge and inspiration to elevate infection control protocols.

In this installment, we hear from Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC, senior infection control officer, MSc, BSN, TQM, CIC, CPHQ, FAPIC. 

Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC, is an accomplished nursing professional with a diverse educational background and vast experience in infection control. She obtained a bachelor of nursing degree from Sharjah University in 2011 and a master of health care administration from the Royal College of Surgeon Ireland in 2013.

Tabrikah has furthered her expertise by obtaining certification as a CIC in 2018 and a CPHQ in 2021. She is also the founder of the IPQ Academy, where she imparts her knowledge and experience to other health care professionals. As the cofounder, head of the scientific committee, and infection control expert at the 

Middle East North Africa Federation for Hospital Sterilization Sciences

 (MENA FHSS), she has significantly contributed to the healthcare sector.

Emirates Infection Prevention and Sterilization Society

 (EIPSS), a nonprofit organization dedicated to advancing knowledge in infection prevention and sterilization practices in the United Arab Emirates. EIPSS operates under the 

Currently, Tabrikah serves as a senior infection control officer in 

, where she applies her skills and knowledge to ensure the safety of patients and healthcare workers. She is also a member of the 2023 editorial advisory board for 

, a testament to her reputation as an expert in infection control.

Tabrikah's contributions to infection control have been recognized through several awards, including the 

IP Idol from Certification Board of Infection Control and Epidemiology, Inc

 by Saudi Society for Infection Prevention and Control in 2023. She is also an international speaker at various conferences and conducts workshops.

Tabrikah sees these topics as trending right now:

These programs aim to optimize the use of antibiotics to combat antibiotic resistance. They involve the proper selection, dosage, and duration of antibiotic treatment to minimize resistance and adverse effects.

: Real-time data and advanced analytics track infection trends and outbreaks within healthcare facilities, allowing quicker and more effective responses.

Artificial intelligence and machine learning

: These technologies are applied to predict outbreaks and optimize infection control strategies.

Personal Protective Equipment (PPE) Innovation

: PPE is continually being innovated, with improvements in comfort, durability, and protection levels. Reusable PPE is also being developed to address supply chain issues and sustainability concerns.

Infection Control in Nonhospital Settings

: Infection prevention in long-term care facilities has become a major focus, particularly due to residents' vulnerability to infections like COVID-19 and influenza.

: There’s increased attention to infection prevention in schools, workplaces, and other community settings.

: Online platforms for infection prevention training have expanded, making education more accessible and scalable.

: There’s a growing emphasis on interprofessional education and collaboration in infection prevention, recognizing that effective infection control requires teamwork across various healthcare disciplines.

: Educating patients and their families on infection prevention practices, such as hand hygiene and recognizing signs of infection, is becoming more prevalent.

: There is a trend towards involving patients in their care, including infection prevention measures, to improve outcomes.

: There is an increasing focus on sustainable practices in infection prevention, such as reducing single-use plastics and developing environmentally friendly disinfectants.

Infection Prevention in Nonhospital Settings:

There is a growing focus on infection prevention in long-term care facilities, outpatient clinics, and community settings. Tailored infection control measures are being developed for these environments.

Telehealth services have expanded significantly, reducing the need for in-person visits and thereby lowering the risk of infection transmission. Remote monitoring of patients helps in managing infections and chronic conditions more effectively.

could focus on a range of timely and impactful topics. Here are her suggestions:

1. Emerging Infectious Diseases and Global Threats

 Coverage of the latest research and developments regarding new viruses or bacteria, particularly those with pandemic potential.

 Updates on global efforts to prevent and control infectious diseases, including responses to outbreaks and lessons learned from recent events.

 New technologies, treatments, and policies to mitigate the rise of drug-resistant infections.

 Strategies for improving AMR monitoring in healthcare settings.

3. Infection Control in Special Populations

 Best practices for preventing infections in nursing homes and other long-term care settings.

 Specialized approaches to infection control in pediatric units.

4. Health Care-Associated Infections (HAIs)

 Latest strategies, protocols, and technologies for preventing HAIs, with a focus on surgical site infections, catheter-associated infections, and ventilator-associated pneumonia.

 Case studies and lessons learned from recent HAI outbreaks.

5. Environmental Hygiene and Disinfection

 New products, technologies, and practices in environmental cleaning and disinfection.

Role of air quality in infection control:

 Research on the impact of ventilation and air purification in preventing the spread of infections.

 Strategies for healthcare professionals to address vaccine hesitancy and counter misinformation.

 Updates on new vaccines and vaccine delivery methods.

7. Technology and Digital Health in Infection Control

AI and machine learning in infection prevention:

 How artificial intelligence predicts and prevents outbreaks in healthcare settings.

 The role of telehealth in infection control, especially in managing patients with infectious diseases remotely.

 How the pandemic has changed infection control practices permanently.

 Future-proofing infection control protocols.

9. Infection Control in Nonhospital Settings

Infection prevention in outpatient clinics:

 Best practices for clinics, dental offices, and other non-hospital healthcare settings.

 Strategies for preventing infections in schools and workplaces, especially with the increasing focus on respiratory illnesses.

Continuing education for healthcare workers:

 New programs, tools, and certifications in infection prevention.

 How to involve patients and their families in infection prevention efforts.

Meet the experts shaping infection prevention: Infection Control Today's Editorial Board members share insights, experiences, and cutting-edge strategies to enhance health care safety and quality. Meet Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC.

Meet Infection Control Today's Editorial Board Member: Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC

Because instrument sterilization is a key operational need for every health care facility--regardless of size--offering surgical or other invasive procedures, the location of that sterilization process is completed is important for an infection preventionist and an operations manager to be involved in sterilization operations. The process, the operations manager, the infection preventionist, and, most importantly, the patient will benefit from the collaboration of infection preventionists and operations managers and their learning about the benefits of integrating operating models.

Several different operating models are available for operating models, including 1 hospital site central processing department (CPD) and 1 ambulatory facility CPD. Jenny Hayes, MSN, RN, CIC, CAIP, CASSPT, and the infection preventionists RN, Clinical IV at the Hospital of the University of Pennsylvania in Philadelphia, Pennsylvania, spoke about this topic in her presentation at the 

Association for Professionals in Infection Control and Epidemiology (APIC) 2022 Annual Conference

, held June 13-15, 2022, in Indianapolis, Indiana. Hayes’ presentation titled, “Moving Sterilization Off-Site,” discussed the challenges and role of infection prevention in both design and operations sterilization operations.

) at the conference and stated what she hoped both APIC attendees and 

 readers learn from her presentation. “The integrated operations models serve as an interface to a single entity model in a horizontally-integrated health care system. Infection preventions serves in policy development and compliance to include the additional measures of instrument handling and transport offsite.”

Hayes does caution, though, that off-site sterilization cannot be the sole sterilization for any sized facility. “This does not eliminate on-site sterilization as that will always be need in case of inclement weather, delays, and emergencies. High level disinfection of endoscopes should also remain onsite due to the required 1- to 2-hour timeframe from scope-use to full decontamination of the endoscope.”

The infection preventionist’s role extends far beyond simply surveillance activities and into  an integrated member of design and operations.


IPs Should Serve in Off-Site Sterilization Policy Development/Compliance 

Realism is what 3-D glasses aim to give theatergoers through polarized lenses, digital projectors, and IMAX 3-D camera systems for an immersive experience that imitates real life.

A 3-D approach to environmental cleaning aims to give Infection prevention and control (IPC) and environmental services (EVS) a realistic view of indoor spaces that includes not only surfaces (2-D) but the air above surfaces (3-D) because a) we often deal with immune-compromised persons; b) infectious exposure can occur through both airborne and surface routes, and c) infectious exposure is most often a 3-dimensional and immersive rather than a 2-dimensional process.
Respiratory infections are a major part of health care-associated infections (HAIs), as between 23 to 63% of all HAIs are respiratory infections.

“If the pathogen has some part of its life cycle in the respiratory tract, it is more likely to be present in aerosols generated and projected into the surrounding air by breathing, talking, coughing, sneezing and singing,” notes researchers in the 2006 report, “Factors involved in the aerosol transmission of infection and control of ventilation in health care premises.”

In 2024, the World Health Organization suggested the umbrella term infectious respiratory particles (IRPs) to simplify and include aerosols (tiny particles), droplets (larger particles), and other airborne infectious particles in a single metric.

While our ability to assess the quality of 2-D surface cleaning using simple, science-based tools is fairly well understood (see Sidebar, “Seeing in 2-D”), seeing airborne matter such as IRPs is not; hence, this article focuses on the third dimension of cleaning—air monitoring and purification.

As the medical model teaches us, diagnosis precedes treatment, so diagnosing indoor air should precede treating or purifying it, and this involves understanding how IRPs behave indoors.

One way to visualize the movement of IRPs indoors is to use 3-D modeling. 3-D modeling can help simulate the behavior of particles in different scenarios, such as inpatient rooms, waiting areas, restrooms, or hallways. By using 3-D modeling, we see how factors such as the distance, duration, and direction of exposure; the size, shape, and density of the particles; the airflow, temperature, and humidity in the space; and ventilation and filtration of the indoor air, can potentially affect the risk of infection.

Generally, smaller and lighter particles stay suspended in the air for more extended periods than larger and heavier ones, which tend to settle on surfaces more quickly. Some studies estimate that the average time for bacteria and viruses to stay airborne is about 1 to 2 hours, though this varies widely depending on conditions and types of microbes. For example, some research has shown that the coronavirus that causes COVID-19 can remain viable as an IRP for up to 3 hours, while other studies suggest that it can persist for less than an hour. (See sidebar, “IRP Dynamics”)

In addition to 3-D modeling, active air monitoring technology enables “seeing” invisible airborne particles down to .1 micron (eg, the COVID-19 virus is ~.1 micron in size)—plus detecting Total VOCs (TVOC), carbon dioxide (CO

), temperature, and humidity—and when coordinated with real-time air purification, enables a 3-D approach to facility cleaning.

The best strategy for combining indoor air quality (IAQ) monitoring and purification in health care facilities depends on the type, level, and source of the indoor environmental contaminants, as well as the specific needs and characteristics of the people in the facility. However, some general principles and guidelines are:

Continuous air monitoring is key to identifying and quantifying indoor air pollutants, helping assess health effects, and evaluating the effectiveness of air purification measures in real time. For example, units may have internal fans that actively sample the air and upload the data wirelessly to a building management system or cloud-based software every several seconds.

Continuous monitoring is important as it shows trends such as particle levels during vacuuming or cleaning processes, VOC levels during medical procedures, disinfection or other activities, and or CO2 levels, which serve as a proxy for other pollutants.

Air monitors should be accredited by an independent source such as RESET (Regenerative Ecological, Social, and Economic Targets), which specifies requirements to help ensure the quality, timeliness, and accuracy of data—such as levels of fine particles 2.5 microns (PM 2.5) and smaller, TVOCs, CO2, Temperature, and Humidity—and enables periodic calibration and audits of monitor performance. RESET is recognized by the International WELL Building Institute (IWBI) and the LEED IAQ innovation credit.

Air monitors with customizable sensors enable flexibility in detecting particular airborne contaminants and should offer data security features to control access to sensitive information.

Air purification can be achieved by various means, such as ventilation, filtration, UV-C, adsorption, and more. The choice and combination of the air purification methods should be based on the specific characteristics of the indoor air pollutants, such as their size, concentration, chemical composition, and biological activity, as well as the availability, cost, efficiency, and safety of the methods. For example, EPA states that “in order for an air cleaner to be effective in removing viruses from the air, it must be able to remove small airborne particles (in the size range of 0.1-1 um).”

Air purifiers in healthcare spaces should incorporate technologies associated with log reduction, such as a 4-log (99.99%) to 6-log (99.9999%) microbial log reduction.

Air monitoring and purification should be integrated and coordinated with surface cleaning protocols as part of a comprehensive, holistic, 3-D approach to indoor environmental quality management in health care facilities.

ASHRAE Compliance, IAQP, Lower Costs—Have Your Cake and Eat It Too

ASHRAE 62.1’s Indoor Air Quality Procedure (IAQP) approves the use of peripheral air purifiers to meet its clean air equivalency requirements as an alternative to mandatory HVAC ventilation rates, such as 5 air changes per hour. This reduces the load placed on HVAC systems and the need to use costly high-MERV filters at the HVAC level, lowering resistance to airflow, fan/motor wear, energy, and overall costs.

, released in 2023, further validates the approach as it “establishes minimum requirements aimed at reducing the risk of disease transmission through exposure to infectious aerosols” and provides 

requirements for use of filtration and air cleaning … [eg, HEPA filters, UV, etc] for equivalent clean airflow rate target per occupant of pathogen-free airflow, reducing the risk of infection.”

To effectively use ASHRAE’s IAQP in health care, facility managers should integrate it with the sometimes more stringent air-change recommendations from ASHE, facility operations, and health care-focused groups. This involves:


•Conducting thorough risk assessments to identify and control potential sources of contamination.

•Ensuring that air quality targets align with health care-specific requirements, particularly in critical areas such as operating rooms and isolation units.

•Implementing robust monitoring and maintenance programs to verify that air quality remains within acceptable limits.

In-room or peripheral units equipped with MERV 19 or ULPA filtration and other technologies, such as UV-C, can do the heavy lifting regarding particle removal closer to the source and effectively reduce airborne pathogens.

WHO has recently updated its list of dangerous pathogens that could cause the next pandemic—consulting with some 200 scientists about 1,652 pathogenic species—finding the number has jumped to 30 vs about a dozen in 2017-2018—and many of these are airborne.


While we do not have 3-D glasses to assess our work in cleaning on and above surfaces, a 3-D approach to hygiene using surface and air monitoring and purification systems provides a solid path to realism in the health care theatre.

Al-Tawfiq JA, Pearlman A. HAI perspectives. 

Rong R, Lin L, Yang Y, et al. Trending prevalence of healthcare-associated infections in a tertiary hospital in China during the COVID-19 pandemic. 

 2023;23(1):41. doi:10.1186/s12879-022-07952-9

Wu YL, Yang XY, Pan MS, et al. An 8-year point-prevalence surveillance of healthcare-associated infections and antimicrobial use in a tertiary care teaching hospital in China. 

Tang JW, Li Y, Eames I, Chan PKS, Ridgway GL. Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises. 

World Health Organization. Global technical consultation report on proposed terminology for pathogens that transmit through the air. 18 April 2024. Page 9.

Environmental Protection Agency. Air Cleaners, HVAC Filters, and Coronavirus (COVID-19). 2024.

Zacharias N, Haag A, Brang-Lamprecht R, et al. Air filtration as a tool for the reduction of viral aerosols. 

 2021;772:145612. doi:10.1016/j.scitotenv.2021.145612

Guh A, Carling P. Options for evaluating environmental cleaning. 

Pathogens Prioritization: A Scientific Framework for Epidemic and Pandemic Research Preparedness.

  10. Toolkits for environmental cleaning evaluation. CDC. Accessed November   

https://www.cdc.gov/infection-control/media/pdfs/Toolkits-

Environmental-Cleaning-Evaluation-2010-P.pdf

A 3-D approach to infection control involves air and surface cleaning, leveraging monitoring, purification, and modeling technologies to reduce respiratory infection risks in health care environments.

The Role Of 3-Dimensional (3-D) Cleaning in Health Care

Outsourcing is often cited as a problem in ensuring health care facilities’ ability to provide quality environmental hygiene. However, it's becoming increasingly common in many regions.

If a health care facility lacks specialized in-house knowledge about environmental hygiene or the capacity to spend time finding, hiring, and training environmental service workers. In that case, outsourcing can address a significant need, especially considering the high turnover rate in environmental hygiene positions. The job is generally not a very attractive one; it’s physically demanding and requires long hours and repetitive movements around sick people and a variety of chemicals for relatively low pay.

The concept makes sense: specialized companies with the staff and knowledge to train them to your healthcare facility’s needs and specifications can provide a flexible and agile workforce at a cost generally lower than developing the same in-house workforce. Unfortunately, the services often delivered to health care facilities don’t correspond to the quality needed for those facilities to provide safe patient care.

We all know the outbreaks are expensive in terms of the monetary cost to a health care system, the human cost, the increased use of antibiotics, and the associated issues concerning antimicrobial resistance. Although there's still a lot of research to be done to quantify the full extent of the role of the health care environment, we are learning more and more about how a well-managed health care environment prevents disease transmission. One large-scale multicenter randomized controlled trial focusing on improvements in terminal room disinfection estimated that 10 to 30% of all MDROs are transmitted to people from the health care environment.

When health care facilities outsource their environmental services, they mainly do so because the in-house staff is more expensive to train and maintain. Outsourced contracts guarantee a steady supply of a workforce that has theoretically been trained to a “professional level” (although sometimes we are left wondering exactly what that means). The truth is that many external service providers can provide quality environmental hygiene services, so why are there often so many quality issues? The blame falls largely on the health care facilities themselves.

Health care environmental hygiene (HEH) programs are often victims of limited resources. They've been easy targets for hospitals to cut budgets without immediate fallout. Even if hospital outbreaks are expensive, hospitals tend not to calculate budgets for averted infections or reduced patient bed days.

There are 2 main reasons for this: Either hospital administrations still don’t appreciate the importance of environmental hygiene to infection prevention and control (IPC), or they are aware but simply don’t think that it is an issue in their facilities, even though every study that I am aware of which looks at how often or how well high touch points are cleaned and disinfected shows shockingly low adherence (there are more, but here are a few of the more recent ones).

I have visited more than 1 hospital where eadership told me that they either didn’t have any health care-associated infections (HAIs) or that there were so few that their current systems were more than sufficient. Having seen the inner workings of the HEH programs of the hospitals mentioned above, I can assure you that there was an extremely low likelihood that this was the case. However, until there is a widespread paradigm shift in how health care facilities view and approach environmental hygiene, it will be impossible to address the current challenges associated with outsourcing.

Although we don’t have much data on this, outsourcing seems to be mainly concentrated in high-income economies.4 It’s almost ironic that more straightforward HEH programs with fewer options can be better from a human factors point of view. An experience that left a lasting impression on me was a visit to a small rural hospital in Türkiye. The director showed me around and allowed me to observe how the rooms were cleaned and ask questions about how the HEH program was implemented.

What stayed with me wasn’t how the training was conducted or what products they were using; it was that the hospital director knew the EVS staff by name and asked the worker who showed me around how her children were and other personal information. When I asked him about it, he said that at the hospital, they were like a family and that they had been working together for well over a decade. This is a far cry from the environment we see in many far wealthier hospitals, where, ultimately, the bottom line trumps any other considerations.

An EVS workforce’s performance can only be as good if staff can be trained, motivated, and monitored. Health care facilities’ HEH and IPC departments must be the ones to decide on the products, processes, and microbiological standards that are implemented by the workforce, even if it’s outsourced. If facilities cannot measure quality (let alone ensure it!), then they cannot provide safe care to their patients.

At the very least, when HEH staff is outsourced, the hospital should employ someone who ensures that the workforce is adequately trained to the same standards as an internal workforce, in compliance with internal IPC recommendations, and given sufficient time and resources to do their jobs well.

This last item on the list is a big sticking point because it comes back to the issue of the constant cost-cutting in HEH. When hospitals are putting out tenders for external companies, they must evaluate the relationship between the price, quality of the workforce, relationship with current suppliers, quality and scope of the proposed service, etc. If over a third of a facility’s purchasing decision is based on the price of the outsourcing, price will always be the deciding factor, to the detriment of quality.

So, yes, currently, there are many issues with outsourcing, but there don’t necessarily have to be. If there is a single takeaway I can offer from this conversation, it is that you usually get what you pay for.

1. Xie A, Carayon P, Cox ED, et al. Improving daily patient room cleaning: an observational study using a human factors and systems engineering approach. 

Outsourcing environmental hygiene in health care facilities offers cost benefits but often compromises quality. Effective oversight, training, and standards are essential for ensuring patient safety.

Christopher Whiting

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