Armitage Shanks Looking Deeper 15

Issue 15 | Spring 2024

consultancy to address anti-microbial resistance (AMR) and infection control management, as well as exploring novel antimicrobial therapeutics (medicines and treatments) and diagnostics. For the last 15 years the ERL has also been providing an environmental screening and surveillance service, developing considerable experience in investigating infection control outbreaks and “looking for the unusual.” How you design, build and test new hospitals is currently being widely discussed. However, there is not much of a focus on the patient environment, hospital building and environmental monitoring until there’s an IPC issue. "We have some guidelines such as ‘Health Building Notes (HBN)’ to guide the design of hospitals and wards and the Health Technical Memorandums (HTMs) to support how we test (air, surfaces and water) to monitor the patient environment. However, I don’t think we’ve got it right for existing buildings. There is little consultation with IPC in the early design stages for new hospitals." In clinical settings, when it comes to training and development, most of the clinical interest is in patient to patient transmission and the clinical side of microbiology, as opposed to the environmental microbiology aspect, i.e. the influence of air, water and surfaces. "There is an assumption that you can swab a surface or extract some air and a result comes out and it’s as easy as that...” There needs to be an understanding that the matrix being tested (air, surface, water) will determine what kind of test is used: for example, swabs shouldn’t be used for testing water samples. When sampling surfaces, the swab needs to be the correct one for the type of surface being tested and the target organism. A swab that works for E. coli may not work for MRSA or Clostridioides difficile. Looking at other considerations, for example, in water sampling: 100 mL samples are usually taken for routine water monitoring for Pseudomonas aeruginosa , however, monitoring of Legionella is more difficult. These require 1 litre samples, with a mass of 1 kg per bottle to be collected. Logistically these add up to a huge weight across the thousands of samples that might be generated from numerous outlets across many wards. While swabs are small, the size of Legionella samples makes for complex logistics around storage and transport — and this needs consideration in planning design. In the meantime, as NHS England’s New Hospitals Programme 1 is rolled out, a new standardised hospital design has been proposed, designated ’Hospital 2.0’: “ we have to consider what can be built now that will [both] cover enough of the

infrastructure [and allow us to] add new tech and new innovations and new ways of working with it.” How do the latest design trends to improve patients’ experiences impact on IPC?

Rooftop gardens

Mental health and mental wellbeing are increasingly, quite rightly, under discussion, particularly for long term patients who may feel trapped between their four walls. The idea ‘to bring the outdoors in’ in the form of rooftop gardens and other greenery is therefore very welcome, especially in cancer hospitals where patients can walk on grass, breathe the air, see the trees and sit amongst ‘nature’. However, this vegetation brings infection control risks with it: soil, compost and the plants themselves may harbour pathogenic microorganisms that can be particularly dangerous for immuno-compromised patients. This can pose a number of challenges.

Hospital roof garden, Erasmus Medical Centre, Rotterdam, The Netherlands. Credit: ID 119955427 © Frans Blok | Dreamstime.com

Alongside the plants, garden taps in rooftop gardens can also be problematic as they could become colonised with Pseudomonas. These outlets may be used by cleaners and porters to fill their buckets, potentially spreading contaminated water around the hospital. "I work with the hospital IPC, estates and microbiology teams to survey and test these areas to assure no risk or harm to patients ever occurs."

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