Q&A: Design Hospitals to Best Fight Infections Like COVID-19

Workplaces will change because of COVID-19, no doubt about that. The workplaces for infection preventionists and other healthcare professionals-hospitals-are also going to be designed differently, according to Jeffrey Rose, the global technology manager at DuPont. An organic chemist by training, Rose leads the research and development team for DuPont’s Corian division, which focuses on creating new products. Rose recently spoke to Infection Control Today^®about how the COVID-19 pandemic might influence the design of the hospital of the future. 

Infection Control Today^®: What are some of the challenges in environmental cleaning?

Jeffrey Rose: Whether you’re in a pandemic or outside of one, it’s really a crucial step and regimen to have really in any commercial sector. So healthcare, of course, fundamentally, but also other commercial segments-hospitality, retail, civic spaces and so forth. It’s well known that one key mechanism of disease spread is from person to person and that could be from direct contact or through aerosolized microbes. But interacting with common touchpoints is another mechanism by which most diseases can readily spread. And while this is a novel coronavirus, there’s research that already has come out showing that this is in fact a mechanism with this novel coronavirus. Alongside proper engineering controls like HVAC design, and really good hand hygiene programs, particularly in healthcare, cleaning and disinfecting environmental services is really pivotal.

ICT^®: Do older hospital buildings present more challenges when it comes to cleaning and disinfecting? 

Rose: Older hospitals haven’t had the chance to embrace newer designs and materials that facilitate proper cleaning. They probably found themselves challenged to do it as readily as a newer facility. There’s really a lot emerging in terms of hospital design. We’re already seeing trends from architects and designers of how the next healthcare facilities will be designed. There are a few considerations. First of all, aesthetics still remains really important. That’s something to put, first and foremost. It seems like it’s just “Oh, it’s how things look. It’s not important in terms of function.” But it’s still really important. You need these welcoming healing hospital environments. We are seeing that people still care about how the hospital feels and looks and it’s going to be even more important that you have a warm, inviting feel. Beyond that-material selection, the role of nonporous hard surfaces. That’s going to be extremely important. Surfaces that do not have porosity do not have places for microbes to exist, and sometimes proliferate. But beyond that, not having materials with rubbery or laminated edges that are covering up a more core substrate. These are really key fundamental material properties. We see architects and designers appreciating that and going toward more and more of those materials. You have to really avoid areas that are going to collect debris and microbes. That could be the rim around a sink, it could be a grout line, it could be a silicone joining material. There are all these features that you may or may not find in a given healthcare facility that are really traps for dirt microbes. They also make it very difficult to clean and disinfect when you have these design features. Focus on smooth curved surfaces, instead of 90-degree angles. You have fully integrated and under-mounted sinks instead of a traditional one that goes over the top of the counter. You avoid silicone where you can, things like that that all contributes to facilities that are one hard to trap these dirt microbes. But make it really easy to clean and disinfect.

ICT^®: Is there any hospital system that really does an exemplary job at infection prevention?

Rose: There are certainly a number of leaders in not only healthcare, but architects and design space that you know, help inform how a hospital should be designed. I think one that I’ll cite is Kaiser Permanente. It’s one of the largest integrated health care firms in the country. And I bring them up because they very publicly have taken great pride in their record on healthcare-acquired infections. But also the fact that they have really rigorous cleaning protocols, hand hygiene and all these fundamental things that build up to a really good infection prevention program. And they very famously, in 2015, put out a list of antimicrobials that they would not allow to be in the materials that went into their facility. They stand out in my mind. They have a very good record of disease prevention. But they’re also in some ways leading the way for what should be really a pause or concern around materials with embedded antimicrobials.

ICT^®: When COVID-19 struck, one of the first things the CDC and WHO said was that the established protocols for disinfecting surfaces against pathogens should work against the novel coronavirus. Still true?

Rose: I think it’s still the case. Again, there are so many difficulties associated with this. And that’s not to say that it’s not a difficult disease to manage. Obviously, it is. But as far as viruses and bacteria go, it’s considered a relatively easy virus to eradicate, because of the structure of the virus. So again, that’s not to say that this shouldn't be a big problem. There are tons of reasons why it’s spreading the way it is. But so because of that, really, a lot of the disinfectants and sterilants already on the market are highly effective in eradicating this. It’s just the means of applying them include having the right substrate that can actually withstand in some cases a harsh sterilant or disinfectant to completely eradicate the microbe. The EPA has a database that basically lists all of the registered disinfectants against various microbes and diseases and they came out with List Nin early March and said, “Hey, here’s the list of disinfectants that are effective against this novel coronavirus.” The EPA was way ahead and in putting that out and providing that guidance. Really, with any disinfecting material, you can refer to the EPA registration number, tie that back to this database and reaffirm that, “Yep, the EPA says this will work well on the disease.” 

ICT^®: Do you think that COVID-19 will make hospitals rethink how EVS teams are trained?

Rose: I think COVID-19 is going to make hospitals really double-down on their infection control measures, their staff around that, their procedures. I think it’s going to really highlight it as more important than ever that a really well-maintained infection control program and health care facility is key. We do interact with hospitals directly; and, certainly, with architects and designers. Again, our focus is really around helping guide material selection. Nonporous is really the truly the way to go. These are the services that all these disinfectants work well on. And around, again, the design features. How do you design a healthcare setting that is first of all very functional and, again, doesn’t have any of these areas where it can trap microbes not easy to clean. All of that plus, again, just the aesthetic beauty and just a warmth not only for the patients to provide that environment but even the healthcare workers that have to live it every day for often very long shifts. That’s our main interaction-trying to solve problems in material selection and design.

ICT^®: Are these nonporous materials relatively new inventions?

Rose: Not necessarily. It’s just a renewed focus. Even if you go to the EPA website, it talks about sterilization, disinfectants. It’s all with the caveat of this is for a nonporous surface. So, I wouldn’t say they’re new. It’s just a matter of choice and understanding their importance. And while the surface of it could be nonporous, many things are. It can be a structure where it’s supported by a particle board that has a rubbery wrap around it. You can kind of picture what I’m talking about. So brand new, it may be nonporous, but as that rubbery edge comes off, or if a laminated face tends to delaminate or chip off, you’re now exposing a porous surface, which can be a real problem. I’d say that it’s not a huge revolution. It’s really just pointing people to nonporous surfaces that give all this design flexibility and on top of if you can have something that looks really nice and creates a nice environment that’s even better.

ICT^®: Does design flexibility depend on the materials that are used?

Rose: Yes, absolutely. Our basis is providing materials that really meet these criteria and a really important one is that they’re easy to work with. They’re easy for fabricators, for example, to transform a flat product into a full installation with all these features that I talked about with total backsplashes, and integrated sinks. And total seamless installs that are really just ideal for not only healthcare but really any commercial segment. And I think other commercial segments are really going to look toward what’s going on in healthcare and focus more on design for really good ease of cleanability.

ICT^®: Do you mean also the layout of the hospital or is that another issue? 

Rose: We’re very interested in how that's evolving. And it certainly is. We see trends and concepts already coming out around how hospital design in a broader sense, like layout, like you said it’s going to change. I think the desire to break apart some of the functionality of the hospital and spread it out into other facilities-like oncology centers or ambulatory surgery centers-to reduce the large population at one building, is going to continue to grow. And in addition, if you design them correctly, you can use those facilities for surge capacity. If you have another pandemic, you have all these isolated facilities that are serving their role day in day out, but they could serve for overflow facilities in case of a pandemic. At the highest level, you’re going to see it spread out. In terms of a traditional hospital, certainly designed configurations around social distancing. It’s not just going to be something we’re talking about this year. It’s going to be reality going forward. Designing facilities where you have people sitting further apart, you have smaller waiting areas, perhaps, instead of a big, large emergency room waiting area where everyone’s sitting side by side. That’s kind of a terrifying sight right now. It’s going to be breaking that apart. At the same time increasing the capacity of emergency rooms. That’s going to be important, too. Flexibility is another element. Being able to transform an operating theater, for example, into a different setting where it’s for triage or treatment during the pandemic. There’s a lot we’re already seeing of how it’s really going to shift the overall layout and design of healthcare facilities.

ICT^®: What will be the place of negative pressure rooms in the new hospital after COVID-19? 

Rose: HVAC design and controlling air pressures is extremely important. It’s a key measure, again, not just in healthcare, but other commercial spaces. If you have poor ventilation in a space, that’s a big problem for disease control. It's going to on the forefront of architects’ minds going forward. But regarding these negative pressure rooms, we see trends where they’re almost like modules or pods that would be not necessarily inside the hospital but just adjacent to it and can be used for surge capacity during pandemics. Would those be built right off and ready to go? Perhaps. Or would there just be a lot of work to have something where you can quickly set these up in a less maybe chaotic way than had happened this time? But the concept is having these negative pressure rooms. Even some have concepts we’ve seen have features where it almost completely isolates the patient from the healthcare provider. And again, they’re totally designed for this type of situation like with the pandemic. In addition, of course, they would be very easy to clean and disinfect. 

ICT^®: Will the ideas about how to redesign hospitals be applied to industries other than healthcare?

Rose: Yes, absolutely. For example, material selection and design features. That will certainly carry over from healthcare into other commercial segments. I mean, they’re really dealing at a different level, but with the same problems. If you have multiple people touching the same things in the same space, you need design to help prevent infection. Really close quarters; you should at least enable really effective cleaning and disinfection on demand to keep spaces clean. We see it already and we’ve seen it before. We said we see the carryover of these key design features, but I think it’s going to be stronger as every business owner, every person that manages a civic space-it’s going to be very much on that person’s mind. They’re going to want to put the best possible forward in their ongoing designs.

ICT^®: What should infection preventionists expect concerning new hospital designs and features?

Rose: Many, many companies are going to put forth offerings that they think are going to be the best to solve problems. But it’s really taking a very careful look at what’s out there. Working with other professionals to really keep up on the literature about what the architectural design community is talking about. It’s really being careful about selection. One thing I brought up before is the role of embedded antimicrobials. This is something that’s been around for decades. The concept is that you have a product that has some kind of antimicrobial agent inside the product that promises to actively kill microbes that come into contact with it. It sounds very promising. But the CDC about 15 years ago concluded that up to that point, there was really no evidence that proved that it actually helped human health. It didn’t benefit human populations. Even though in a lab, we could show that the antimicrobial has efficacy. And then even just three years ago, Perkins and Will Research put out a really good white paper that kind of reaffirmed the CDC’s guidance. Hey, look, now decades later, we still don’t see evidence that that these types of materials are actually an important part of an infection control strategy. And there are other deficits that are still kind of open items. Can these type of materials that are, again, just always sitting there and actively killing microbes, could they actually create antibacterial resistant microbes? Could they lead to complacency around cleaning and disinfection? “Hey, I’ve got surfaces that kills things that touch it. I guess they don’t really have to be cleaned anymore.” So that’s kind of an extreme, but that’s a concern as well. There’s a lot of noise around it. It’s pretty polarizing, but again, I brought up Kaiser Permanente because they took a pretty firm stand on, you know, not wanting to include these type of materials in their healthcare design.

This interview was edited for clarity and length.