Are patients at risk from the hospital environment?

ICPs use rounds, committees to assess risk

With patient acuity on the rise and many hospitals trying to extend the life of aging facilities through renovations and expansions, the risk of infection posed by the health care environment is becoming an increasing concern for infection control professionals.

"I think that overall the patients in the hospitals are sicker and most of the hospitals are older," says Raymond Chin, MD, hospital epidemiologist at Sharp Memorial Hospital in San Diego. "In order to keep pace with medical technology, they have had to either retrofit, add, or renovate."

Health care delivery changes and consolidations also have led to renovations and new construction as hospitals combine and rework their clinical missions. Such construction can result in environmentally linked outbreaks, such as airborne Aspergillus infections in bone marrow transplant patients during renovation projects.1 "These [environmental concerns] have been borne out of outbreaks, where controls were not in place," says Chin, a member of the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee (HICPAC). Chin is one of the key HICPAC members working on new environmental infection control guidelines, which are expected to be completed in the coming year. (See related story, p. 10.)

In addition to construction projects, experts remind that the health care environment poses day-to-day risks that may go undetected without systems in place for routine review of the facility. While the significance of the role of the health care environment in the spread of infection has been debated for years, it is clear that some airborne (i.e., Aspergillus) and waterborne (i.e., legionella) patho gens pose an infection risk to patients. On the other hand, routine environmental culturing has been generally discouraged, and most ICPs have neither the time nor the resources to give inordinate attention to the health care environment.

"There are limited resources available to infection control, and those really need to go where the risk is greatest," says Andrew Streifel, MPH, REHS, hospital environment specialist at the University of Minnesota in Minneapolis. "I believe, for example, that maintaining the ventilation system is more important than making sure that you use a powerhouse disinfectant on the floor."

In general, ICPs should be aware that the more immunocompromised the patient population is, the greater the possible risk of an environmental role in infection with such pathogens as airborne fungi, notes Streifel, a frequent environmental consultant to hospitals and co-author of a recent review article.2 "I think that is the case," he notes. "As I dig in my compost pile, I might sneeze from it, but I don’t think it will create a problem for me. But if I had a white [cell] count of less than 100, it might become a real risk factor. So it’s really very important, from my point of view, that hospitals taking care of [immune-compromised] patients can verify that the environment is reasonably safe."

Insidious sources

Of course, infected and colonized patients and the health care workers that treat them can contaminate environmental surfaces and equipment with such nosocomial pathogens as vancomycin-resistant enterococci. In that regard, patient sources and the unwashed hands of health care workers are still likely to be the primary routes of transmission in hospitals. But less obvious environmental sources also can be present, he notes.

"The majority of the organisms that do infect our patients are from people, and it’s important to recognize that, but there are conditions where the environment becomes contaminated," says Streifel. "I’m [consulting] at a children’s hospital now where the janitor’s utensils have been implicated in the spread of opportunistic fungi."

Streifel tracked down the problem to water damage around a sink in the janitorial closet. Mold and fungi growth had resulted, contaminating mops, brooms and other cleaning utensils that workers took into patient rooms, he noted. Indeed, an increasingly common environmental problem in hospitals — and also a possible source of mold and airborne fungi — is water damage and degraded cabinet materials beneath sinks. Ironically, many of the sinks were added to ease compliance with the cardinal rule of infection control: hand washing.

"In some respects, infection control is responsible for this in an indirect sort of way," he says. "They insist that we have sinks everywhere. I think that’s very appropriate, but then administration and construction planning puts in very cheap biodegradable sinks — generally plastic laminate — and that stuff degrades." To solve such problems, hospitals should use molded sinks of ceramic, stainless steel, or plastic that are not subject to water damage, he recommends.

Ideally, ICPs should have systems in place that allow input into such matters from the outset, bringing any concerns to the fore before problems develop. For example, a multidisciplinary committee was formed at Children’s Hospital in Dallas to deal with ongoing environmental concerns, says Pat Metcalf, RN, infection control director at the hospital. A subcommittee of the infection control committee, the panel meets monthly with representation that includes members of infection control, engineering, administration, and facility services.

Implications a construction person won’t see

"There are so many issues in the hospital, and just having this committee helps us all be aware of what is going on," she says. For example, having the committee in place enabled early review and discussion of a planned indoor fountain in a hospital atrium area. Fountains and whirlpools have been shown to be a source of aerosolized legionella or other waterborne pathogens, which can cause pneumonia and other serious infections in immunocompromised people who inhale them. To prevent such an occurrence, Metcalf ensured that infection control concerns such as routine disinfection of the water and maintenance of the fountain were addressed before the project went forward.

"[For example,] how long will it be before there is considerable microbial growth in the fountain and we need to think about draining the water?" she asks. "There were just a lot of implications that a construction person isn’t going to think about."

In addition to a standing committee, another approach to address ongoing general environment issues is to use a rounds concept like that devised by Mary B. Jones, RN, CIC, coordinator of infection control at Pinnacle Health System in Harrisburg, PA. The project was borne out of a collaboration between the committees for infection control, environment of care, and nursing performance improvement, she explains. The result was an infection control environmental rounds program that involves a walk-through inspection and use of a checklist form. The rounds are used to assess and measure compliance with such criteria as general unit appearance and infection precautions. The program is essentially an ongoing form of risk assessment, she notes.

"It gives us a mechanism in which inspection, evaluation, and correction of environmental issues can be uniformly addressed," Jones says. "We are a very common visible entity. When I first started in infection control, a very wise individual — my first boss — said there is not one area in the health facility in which you don’t belong. Of course, with courtesy. But I have that attitude as I go around and do the infection control environmental rounds. We’re not perceived as police, but rather part of the team."

To emphasize that aspect, ICPs conduct the survey every other quarter, and clinical units are asked to do their own self-assessments in the alternating quarters. An area that was identified early as a potential problem was rolling stock like wheelchairs and IV poles. No department had taken "ownership" for the cleaning and maintenance of the equipment, so protocols were put in place assigning those responsibilities. While the program enables some monitoring of basic infection control measures and environmental issues (i.e., hand washing, accumulating dust), it also creates a mechanism for raising concerns about more "silent" issues such as air flow.

For example, Jones has established reporting mechanisms that call for hospital technical services to routinely ensure that air flow in negative-pressure rooms (i.e., for tuberculosis isolation) is vented to the outside and does not recirculate. Conversely, positive air pressure is maintained in operating rooms to ensure that air flows out and away from vulnerable surgical patients. "We were able to have that regular monitoring initiated specifically because of the infection control rounds," she says. "We were finding that it appeared to be appropriate, but we wanted to make sure that it was well-documented."

In addition, having the rounds program in place proved important as extensive renovations began at the four-hospital system, she notes. "Because of the visibility we had with the infection control environmental rounds, we were able to easily slide into the construction environmental rounds’ without any issue whatsoever," Jones says. "We made certain that there was negative [air] pressure in the construction areas and that the barriers were in place prior to construction. If there were difficulties, we made sure they were corrected immediately and the work was halted until they were corrected."

References

1. Carter CD, Barr BA. Infection control issues in construction and renovation. Infect Control Hosp Epidemiol 1997; 18:587-596.

2. Vesley D, Streifel AJ. "Environmental Services." In: Mayhall, ed. Hospital Epidemiology and Infection Control. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 1999, pp. 1,047-1,053.