EPA BASE study suggests HVAC plays a role in Sick Building Syndrome

A newly released analysis of the US EPA BASE study shows that improperly maintained HVAC systems may cause symptoms associated with Sick Building Syndrome (SBS). The study's authors (representing Lawrence Berkeley, Harvard University, Helsinki University and the US EPA) assessed data collected from 97 representative US office buildings that use air conditioning.
The findings that interested us most dealt with SBS symptoms that may be attributed to moisture with the HVAC systems. From the study's abstract (text emphasis added by me):

"Humidification systems with poor condition/maintenance were associated with significantly increased upper respiratory symptoms, eye symptoms, fatigue/difficulty concentrating, and skin symptoms, with OR = 1.5, 1.5, 1.7, and 1.6. Less frequent cleaning of cooling coils and drain pans was associated with significantly increased eye symptoms and headache, with OR = 1.7 and 1.6. Symptoms may be due to microbial exposures from poorly maintained ventilation systems and to greater levels of vehicular pollutants at air intakes nearer the ground level. Replication and explanation of these findings is needed."

Also from the study's Discussion section:

"These findings support current beliefs that moisture-related HVAC components such as cooling coils and humidification systems, when poorly maintained, may be sources of contaminants that cause adverse health effects in occupants, even if we cannot yet identify or measure the causal exposures."

Limitations
The authors caution that these findings need replication before suggestions or guidelines are advocated. While researchers were able to quantify the risks associated with poorly maintained humidification systems, they were unable to "...identify important (symptom) benefits from well-maintained humidification systems."

The study's findings are important because they demonstrate and elevate the need for Ultraviolet Germicidal Irradiation (UVGI) in all air conditioned buildings. Our experience has shown that if you have dirty or inefficient cooling coils, your HVAC is likely a reservoir for microorganisms. These microorganisms can cause symptoms associated with SBS, in hospitals these pathogens can promote Hospital Acquired Infections (HAI).

This study is a small but important piece in the puzzle that surrounds Indoor Air Quality. Its importance lies in the fact that yet another credible group of scientists have found evidence that HVAC systems can be linked to airborne pathogens that cause health problems.

Physicians respond to changes in HAI reimbursement

Former NY Lt. Governor Betsy McCaughey wages her crusade against HAI in the media. You will frequently find her opinions on television, in newspapers and on-line. A recent example is this Wall Street Journal opinion piece from August 14:

"We have the knowledge to prevent infections. What has been lacking is the will. A recent survey from the patient-safety organization Leapfrog found that 87% of hospitals fail to consistently practice infection prevention measures. Insurance companies that sell liability coverage to hospitals could change that by offering lower premiums to hospitals that rigorously follow infection-prevention protocols.

To be sure, lawsuits are not the best way to improve patient care. Many verdicts are unjustified, and few truly injured patients find a lawyer to take their case. Still, the coming wave of lawsuits, as well as financial incentives from Medicare and insurers, will fight complacency about hospital hygiene."

Physicians are responding to the article, maintaining that HAI rates must be reduced--while maintaining that not all HAI can be prevented:

"Regarding Betsy McCaughey's "Hospital Infections: Preventable and Unacceptable" (op-ed, Aug. 14): Strengthened measures to stimulate hospitals to prevent methicillin-resistant Staphylococcus aureus (MRSA) acquired in-house are certainly well-intentioned. The germs outsmarted everyone. What nobody predicted was the continuous evolution of new threats to patients and hospital personnel. I well recall our fervor, and idealism, in reporting prophylactic and control tactics to deal with sequential explosions of Legionnaires' disease, AIDS, intestinal infections as a side effect of antibiotic usage, drug-resistant tuberculosis, hepatitis B (followed by C), etc.

It is noble posturing for Medicare to proclaim it won't pay hospitals for treating infections acquired on the premises, but how does that policy stand up when the bacterium was heretofore unknown or not foreseen as a danger to patients or staff?

Leslie Norins, M.D., Ph.D.
Naples, Fla.

If such a standard is imposed, rational surgeons will try very hard to avoid patients most at risk. Such flight to the good-risk patient already occurs in states with aggressive cardiac surgical-reporting requirements. In addition, surgeons and hospital administrators will work even harder to game the system in their reporting, and will become even more incautious in their use of prophylactic antibiotics, further promoting the emergence of resistant strains of bacteria.

Aggressive harassment from insurance companies, government agencies, hospital administrators and ignorant non-medical persons is doubtless a major factor in the early burnout and decline of cardiac surgery as a "hot" specialty; residency slots, coveted a generation ago, now go begging, and fewer than half which are taken are filled by American graduates.

Ronald M. Becker, M.D.
Sacramento, Calif.

A deep and serious breast bone infection following open-heart operations currently occurs in approximately 1% of patients. Patients who are obese and diabetic are at a substantially higher risk for such an infection. The proportion of individuals in the U.S. who are obese or diabetic (or commonly both) is increasing in epidemic proportions, as is the number of such patients who require open-heart surgery or other invasive procedures to treat their heart conditions. Many patients who enter hospitals for treatment are already colonized by MRSA, further increasing their risk of infection. The combined threat of no reimbursement and a lawsuit will result in a refusal by physicians and hospitals to perform invasive procedures in many of these high-risk patients. This scenario will also play out for patients who require major orthopedic procedures, such as joint replacement. It is totally unrealistic to assume that these complex procedures can be performed with zero risk of infection.

Nicholas Kouchoukos, M.D.
Michael C. Murphy, M.D.
St. Louis, Mo.
Dr. Kouchoukos is a past president of the Society of Thoracic Surgeons.

We live in a sea of bacteria. We have 10 times more bacteria in our gastrointestinal tract then we have cells in our bodies. We cannot eliminate all of these bacteria from our body before surgery. We can be clean, but not sterile. Many years ago, a study demonstrated that at least 50% of "hospital-acquired" infections arose from bacteria that patients carried into the hospital with them."

Gary L. Simon, M.D., Ph.D.
Director, Division of Infectious Diseases
George Washington
University Medical Center
Washington

It is likely that the Medicare guidelines will be adjusted after they are used for awhile. I can see both sides of the story here. Perhaps the truth is that both sides are right and HAI will be significantly reduced, lives will be saved, costs will be cut.

A new study from a leader in airborne disease research indicates that Operating Room HEPA filtration is not a guarantee against nosocomial infection. Dr. Russel Olmstead led a team that looked at airborne contamination inside of the OR environment.

Pilot study reinforces use of portable anteroom HEPA filtration

To prevent perioperative transmission of airborne microorganisms

Washington, DC, May 6, 2008 – Amidst an increase in new tuberculosis cases, researchers have begun investigating the effectiveness of new operating room filtration systems designed to protect staff and patients. According to pilot study findings published in the May issue of the American Journal of Infection Control, a supplemental portable anteroom high-efficiency particulate air (PAS- HEPA) filter unit placed outside operating room suites may prevent secondary transmission of airborne microorganisms like Mycobacterium tuberculosis (M. tuberculosis).

“The rate of decline in newly reported tuberculosis cases in the U.S. has slowed,” said lead study investigator Russell N. Olmsted, MPH, CIC, epidemiologist from Saint Joseph Mercy Hospital in Ann Arbor, MI. “This, coupled with the worldwide emergence of even more drug-resistant tuberculosis, reinforces the need for renewed vigilance and surveillance from healthcare professionals. In particular, study results reinforce the need for measures to optimize air particle removal.”

Olmsted and colleagues compared the efficiency of freestanding HEPA filtration units to a new portable anteroom system (PAS)-HEPA combination unit in removing harmful airborne infectious pathogens. Freestanding HEPA units were evaluated in the operating room, while the PAS-HEPA unit was placed outside over the main operating room door. Both smoke plume and non-infectious particles similar in size to M. tuberculosis were used to mimic movement of airborne pathogens within highly pressured environments.

“We observed interruption of normal patterns of airflow with freestanding HEPA units placed inside the operating room,” said Olmsted, adding that instead of being captured by the air-filtration system, smoke plume traveled upward from the operating room table and into the breathing zone of personnel who might be present during a typical surgical procedure.

“This suggests an increased potential for occupational exposure to airborne microorganisms as well as an unwanted introduction of contaminants into the patient’s open surgical site,” he explained.

In contrast, deployment of the PAS-HEPA combination unit pulled the smoke downward, away from the operating room table and toward the floor and main door. The second phase of the study (which involved simulated microscopic particles) mirrored these observations; within 20 minutes, over 94% of submicron particles were cleared from the operating room.

“The results of Mr. Olmsted’s study reinforce the Centers for Disease Control and Prevention (CDC) 2003 guidelines for environmental infection control as well as 2005 guidelines for preventing the transmission of M. tuberculosis in healthcare settings,” said Janet E. Frain, RN, CIC, CPHQ, CPHRM, APIC 2008 President and Director, Integrated Services, Sutter Medical Center in Sacramento, CA. “These findings should be considered for integration into an overall infection prevention and control program to help ensure both patient and healthcare personnel safety.”

These findings substantiate results we've discovered in our testing of Operating Rooms. Recently we found microbial contamination (including fungi) immediately downstream from HEPA filtration units installed in ORs. The contamination was found one week after the filters were certified for efficiency compliance.
Filters are great for trapping microorganisms, but they do not 'kill'. Eventually filters can become colonized and act as a breeding ground for pathogens. Thinking that you have 100% protection because you have HEPA filtration is a false sense of security.
We suggest a balance between UV and filtration to provide a better strategy for reducing environmental pathogens in critical care areas of your hospital. E-mail us to find out more about a recent study in which VIGILAIR provided better protection than laminar flow for operating suites in a large urban hospital.

Hospitals struck by new killer bug | Metro.co.uk

UK Newspaper continue to examine (and exploit) news on infectious disease. The latest cause for concern is Stenotrophomonas, nick-named 'Steno' for popular consumption.

Hospitals struck by new killer bug | Metro.co.uk

Tuesday, May 6, 2008

A new hospital superbug resistant to all antibiotics could be killing hundreds of patients, experts have warned.

The infection, known as 'Steno', is on the increase and could be harder to tackle than MRSA and C.difficile.

The bug spreads almost exclusively in hospitals through wet areas such as taps and shower heads, and is thought to kill a third of the people it infects after entering the bloodstream.

Chemotherapy patients, including children, are among those most in danger, because the infection spreads through ventilation tubes and catheters.

There are about 1,000 reports of Steno blood poisoning in Britain each year, according to today's study by the Wellcome Trust Sanger Institute, near Cambridge.

Research leader Dr Matthew Avison said: 'This is the latest in an ever-increasing list of antibiotic-resistant hospital superbugs.

'The degree of resistance it shows is very worrying. Strains are now emerging that are resistant to all available antibiotics.'

MRSA is thought to have caused 1,652 deaths in 2006, up from 51 in 1993. Clostridium difficile was mentioned on 6,480 death certificates in 2006, a 72 per cent rise on 2005.

Steno sticks to catheters or medical tubes and grows into a so-called 'biofilm'. When the catheter is next flushed, the bug enters the patient's bloodstream and can cause septicaemia, especially if their immune system has already been weakened.

The onus is on both patients and healthcare professionals to do more to keep equipment clean, Dr Avison told the Genome Biology journal.

Stenotrophomonas is another pathogen that we've isolated from the hospital environment. In our study, we were able to culture Stenotrophomonas from surfaces in the Heating Ventilation and Air Conditioning (HVAC), surfaces in NICU as well as in the tracheal aspirates of the patients. As mentioned in the article, this bug likes water--and that is where we found it, in the water of the HVAC drain pan.

As we look to decrease Hospital Acquired Infections (HAI), we should consider all the reservoirs for pathogens. Neutralizing the source of an infectious agent is the key to long term success in infection prevention. Is the Stenotrophomonas in the HVAC water making its way into the care areas? It's hard to say and expensive to prove.

So, we focus a lot of attention on 'end of the pipe' solutions such as hand washing. This is a good thing. But at the same time we should eradicate the factories where pathogens are generated and distributed within a health care facility. Our research has shown that one such factory is the HVAC system. We've also shown that VIGILAIR® can eliminate this reservoir as a potential source.

The war on hospital acquired infections, fighting on two fronts

Ok, so it's an old analogy, but it works. Imagine being at war. You're a general tasked with disrupting the enemy's supply chain. The enemy has trains, boats and trucks that carry supplies, but it also has factories where supplies are built and depots, camps and ports where large quantities of supplies are stored.

What is your bombing strategy? Do you hit the individual vessels of supplies, or do you attack where the supplies are produced and stored?

The answer is you bomb both.

And so it goes for infection control. Enforcing hand washing protocols is a good start. Hands are like the boats and trains; they're vessels that deliver supplies (infections). But if you only attack the supply carriers, some are likely to get through and new routes will open as soon as the old ones are closed.

That's why it is important to also attack the factories and staging places for supplies. For infection control, this means looking at the source of pathogens and the reservoirs in which they hide. Individually each of these tactics are good, but together, their strategic value is much greater.

I thought of this tired analogy after reading a study (1) that says previous contamination of a hospital care area is an excellent predictor of future infection. Here's an overview of the study from infectious disease dot com:

Patients may be at an increased risk for vancomycin-resistant enterococci in health care settings if they are treated in areas where contamination with vancomycin-resistant enterococci has previously occurred, according to the results of a new study, which were published in Clinical Infectious Diseases.

Prior room contamination is highly predictive of vancomycin-resistant enterococci (VRE) acquisition, according to the study’s researchers, who stressed that increased attention to environmental disinfection is warranted to help reduce the risk for VRE infection.

“Everyone on the health care team — from doctors, to nurses, to medical students, to technicians — needs to take personal responsibility for preventing infections,” Marci Drees, MD, from the Center for Outcomes Research at Christiana Care Health System in Newark, Del., and one of the study’s researchers, told Infectious Disease News. “I think for too long we’ve had the attitude that these infections ‘just happen’ and are bad luck, but we now know that many are preventable. Preventing infections comes down to the basics: universal handwashing, wearing gowns and gloves when appropriate and thorough environmental cleaning. It’s easy to cut a corner here and there when you’re busy taking care of patients, but that’s how these infections happen.”
(snip)
Three of the most significant factors associated with the risk for a VRE infection included sharing a room with a VRE-colonized patient, being treated in a room where a VRE-colonized patient had been treated within the past two weeks and being treated in a room with previous positive culture results.

To put a fine point on it, infection control professionals are fighting on several fronts. Hand washing is an important tactic. We should remember, however, that hands don't produce many pathogens--although they do a fine job of transporting them.


Where are the microorganism 'factories'? Among the places in a hospital where microorganisms are produced is the Heating Ventilation and Air Conditioning (HVAC) system. Our staff members have hundreds of data points taken from microbial swabbing of hospital HVAC surfaces. We find that the same microorganisms that cause infection are found thriving on cooling coils, drain pans and water inside hospital air handlers. Pathogens that are commonly cultured on hospital cooling coils include:

• Pseudomonas
• Acinetobacter
• Staphylococcus

VIGILAIR is like a carpet bomber for these pathogens. But unlike bombing, whose effects are transitory, VIGILAIR eliminates reservoirs for microbial growth and prevents them from returning.

Now, onward infection control soldier!



1. Drees M, Snydman DR, Schmid CH, et al. Prior environmental contamination increases the risk of acquisition of vancomycin-resistant enterococci. Clin Infect Dis. 2008;46:678-685.

Study: MRSA Screening Fails to Lower Infection Rates

A new study published in the Journal of the American Medical Association says that universal MRSA screening upon admission to a hospital may not lead to fewer MRSA infections. The study compared two sets of surgery patients who received services at a Swiss hospital.

One group of more than 10,000 patients were screened for MRSA prior to surgery. If they tested positive for MRSA they were isolated and treated with disinfectant and antibiotics. The control group was of similar size and was not screened. Results from the study show no significant differences in the infection rates between the two groups.

From the Chicago Tribune:

"This is what we've been saying all long," said Kathy Warye, chief executive officer of the Association for Professionals in Infection Control and Epidemiology, a group that opposes efforts to mandate MRSA testing.

While screening patients can be a valuable, it's not a "magic wand" and it's not always the best way to deploy a medical institution's resources, said Dr. Stephen Weber, director of infection control at the University of Chicago Hospitals

Critics of the report's findings say the study may've overlooked some pre-existing MRSA reservoirs:

"Dr. Barry Farr, a MRSA expert, noted the Swiss hospital didn't screen patients on medical wards, who probably served as a reservoir of MRSA infections within the institution and skewed the study's results.

About one-third of surgery patients at the Swiss hospital had surgery before measures could be taken to control potential MRSA infections; that may have contributed to the findings, said Dr. Karen Kaul, chair of molecular pathology at Evanston Northwestern Healthcare."

Responses from both sides (pro and con) augment a central argument in VIGILAIR's infection control (IC) strategy.

• We believe that IC is dynamic and multifaceted
• There is no one strategy to eliminate infection
• There are many reservoirs of infection including patients, healthcare workers and the environment
• A prudent IC policy attacks pathogen reservoirs on several fronts simultaneously; bundling strategies works best

So, Now What?

MRSA screening has resulted in significant benefit for other facilities, notably Scandinavian hospitals that have virtually eliminated nosocomial MRSA infection after implementing 100% screening upon admission. This new study is not enough justification for a wholesale discrediting of MRSA screening. It is, however, more evidence that IC is more like a web than a chain. Breaking one link of transmission rarely does the trick.

Why the Space Shuttle needs VIGILAIR®

Remember the Michael Crichton thriller 'The Andromeda Strain'? The story focuses on the efforts of scientists who investigate a deadly microbe from outer space that came to earth via a satellite that crashed in a small US town, killing all but two of the residents.

That's the first thing that came to mind when I read the abstract for a study published in the Proceedings of the National Academy of Sciences, entitled Space flight alters bacterial gene expression and virulence and reveals a role for global regulator Hfq. Researchers discovered that strains of Salmonella that were sent into outer space changed and became more virulent.

Here's a bit of the study's findings via Natural News, by reporter David Gutierrez:

"Researchers placed strains of Salmonella typhimurium, a common food-poisoning agent, into two separate containment canisters. One of the canisters was sent into outer space for 12 days, while the other remained in the Orbital Environmental Simulator at Kennedy Space Center. The environmental simulator remained in constant communication with the space shuttle, immediately replicating in real-time whatever temperature and humidity conditions were being experienced in the vessel. This allowed the two groups of bacteria to be exposed to identical conditions, except for the fact that one group was under microgravity conditions in outer space."

The Salmonella taken into space returned with changed expression of 167 different genes, a sign that microorganisms adapted to the zero gravity environment. Although the Andromeda Strain dealt with extraterrestrial bugs, and this study examines terrestrial bugs, imaginative people could find parallels.

How does this relate to airborne infection? This research confirms that nature will always try to adapt to survive in its environment. Antibiotics have worked well for many years, but now nature has adapted yielding 'multidrug resistant organisms, AKA Super Bugs. VIGILAIR® inactivates viruses, bacteria and fungi by corrupting the genetic map that organisms need to reproduce.

So, NASA, call whenever you're ready, operators are standing by...

Killer in the NICU

From my adopted college town of Manchester, the sad story of a NICU death likely caused by airborne aspergillus:

"Baby ward hit by fatal infection

A Greater Manchester hospital has temporarily closed its neo-natal unit after a baby died and another suffered a potentially fatal infection. A premature baby developed an infection from aspergillus, a common airborne fungus, and died in December at Salford Royal Hospital. A second pre-term baby tested positive for skin aspergillus last week. The hospital said it had closed the ward as a precaution to establish any "common contributory factors". The aspergillus fungus is very common and can be found in homes and buildings everywhere, but can cause infections."

Many studies have shown that aspergillus is ubiquitous in the environment. Healthy people can be exposed to it without serious consequences. That is not true for immune compromised patients in ICU areas. So, what to do about it?

How about filtering the air? Hospitals already do that and yet aspergillus persists. How about letting in more fresh air? This strategy will introduce more and potentially different types of aspergillus into the hospital. What about cleaning the HVAC frequently to get rid of pathogens?

Studies have shown that traditional cleaning is not effective, as this report(1) from the ECMM shows:

"It appears that fungal spores are not necessarily removed by cleaning the fans. Even scratching and painting them, to eliminate rust and restore a smooth surface on which fungal spores cannot be retained, does not permit decontamination."

In fact, servicing the HVAC can exacerbate the problem(2):

"Our observations suggest that localized, short-term exposures resulting from disturbance of (aspergillus) reservoirs are comparable to or may even greatly exceed maximum expected routine exposures. Further, these reservoirs may be disturbed not just during construction or renovation, but even during routine maintenance activities (telecommunications cabling, HVAC filter replacement) that require access to ceiling spaces."

It is clear that the unique needs of ICU areas need unique solutions. That's where VIGILAIR® comes in. VIGILAIR® Systems combine filtration and the germicidal effect of UVC. Rather than just trapping aspergillus spores, VIGILAIR® is designed to provide enough UVC exposure (dose) to destroy aspergillus. UV technology disinfects HVAC surfaces and then keeps those areas clean by continuously radiating the reservoirs where microorganisms can thrive.

Once again, we need to be aware than Infection Control is an environmental issue. Diligent IC professionals must recognize and remove all reservoirs for pathogen growth within the hospital. Unfortunately, the HVAC system is frequently overlooked as a reservoir despite the fact that it houses the largest untreated water supply within a health care facility.

1. European Confederation of Medical Mycology Conference 1996. S. Heinemann, G. Van. houte, N. Nolard. Contamination of indoor environment and air conditioning.

2. European Confederation of Medical Mycology Conference 2008. Khan M, Gonsoulin T, Simpson S, Horner WE. Exposure levels of aspergillus fumigatus from various indoor reservoirs in health care facilities.

Echos in the media

It is encouraging to see response from the press over the recent report on hand washing and infection control. The argument that infection control is dynamic and environmental is being heard in the media, and from APIC! See the recent article from US News and World Reports:

Wringing Our Hands Over Infection Control

February 07, 2008 05:19 PM ET | Avery Comarow |
A number of thoughtful comments arrived concerning my January 23 hand-washing post, about a study showing that a much-increased rate of hand-washing is no guarantee that a hospital's infection rate will budge, let alone dive. A couple of correspondents (notably anesthesiologist-blogger Counting Sheep and hospital-CEO-blogger Paul Levy of "Running a Hospital") contributed thoughts that might prevent a few infections here and there.


The following came as a real letter, if also as an E-mail attachment, from Kathy Warye, another CEO. She runs the Association for Professionals in Infection Control and Epidemiology, whose obvious interest in this subject makes her note very welcome.


"Mr. Comarow makes a critical point that even the single most effective intervention (in this instance, hand hygiene) alone can't solve the problem of healthcare-associated infections. Certainly, even the best hand hygiene compliance only gets us so far.

Lessons learned from our 12,000 members who manage infection prevention programs in healthcare facilities around the world tell us that to reduce the risk of infection and protect people coming into hospitals means adopting a full range of strategies. The first step, from a facility-wide perspective, is conducting a proper risk assessment. Good infection prevention and control professionals don't just know their patients—they know their hospital, they know which areas are at high risk and where there may be hidden reservoirs of bacteria, be it the ER or the OR.


System-wide adoption of proper hand hygiene, contact precautions including use of gloves and gowns, and the "checklist" for device-related care that is receiving so much attention of late are among the tools known to be effective in preventing healthcare-associated infections."

Amen! The single largest source of untreated water in any hospital is its HVAC system. For Critical Care Units aerving the most immune compromised patients, we must eliminate the HVAC as a reservior for pathogens. While VIGILAIR is not a panacea, neither is washing hands. Our technology needs to complement other technologies and institutional efforts for infection control.

Hand washing just one part of infection control, medical experts say

An excellent common sense approach to the hype surrounding hand washing hygiene. This article is excerpted from the Grand Island Independent, a newspaper published in Nebraska:

"Widespread use of antibacterial hand gels has helped make it easier for healthcare workers to comply with hand hygiene policies, which is especially important during cold and flu season. The gels, which have been proven as effective at killing germs as soap and water, are also less drying to the skin an important quality for those who work in the medical field and may cleanse their hands up to 50 times per day. Recent studies and local experience have proven, however, that increasing compliance to hand-washing policies is not always enough to reduce the rates of hospital-acquired infections. A study published by the University of Nebraska Medical Center this month showed that while use of antibacterial hand gels in two UNMC adult intensive care units helped the units increase their hand-washing rate from 38 percent to 70 percent, there was no corresponding reduction in hospital-acquired infections. But a similar experiment at St. Francis Medical Center has had different results. At St. Francis, the use of hand sanitizer and the creation of a hand hygiene improvement committee has nearly doubled the rate of hand-washing policy compliance for the entire hospital, said Laura Mader, St. Francis infection control coordinator. The hospital's current 76 percent compliance rate is above the national average. It has also led to a decrease in St. Francis' incidence of hospital-acquired infections, Mader said. While UNMC and St. Francis had different results in similar experiments, officials from both facilities agree that hand washing, while highly important, is only one component of infection control. "There are many factors that influence the development of hospital-acquired infection," said Dr. Mark Rupp, professor of infectious diseases at UNMC. "It would be naive to think that a single, simple intervention would fix this problem." The lack of a correlation between increased hand hygiene and lower incidence of infections could be attributed to many factors, including UNMC's already low infection rate in the ICU."

Infection Control professionals fight disease transmission on many fronts. While hand washing has drawn much attention, it is merely one weapon in the arsenal. We believe that a comprehensive approach to infection control should include air disinfection, especially in critical care units.

ASHRAE Meeting off to great start

It's cold here in New York City as the annual winter meeting ASHRAE lives up to its name. With so many forums to attend, where do you begin.
This morning we attended an excellent seminar titled, "Hazardous Biological Agents in Hospital Air: When the HVAC Plant exacerbates rather than mitigates against HAI". Dr. Bob Scheir of Steril-Aire led the discussion on why Health Care Facilities pose unique challenges to HVAC engineers. The seminar was well attended reflecting the increased interest in airborne transmission of disease.
Tim Keane, a consulting engineer to Health Care clients, talked about the importance of maintenance programs, and how simple measurements can indicate if your system is fouled by microorganisms.
William McCoy, PhD of the life sciences company Phigenics, focused on Legionella in the Health Care setting. Dr. McCoy enlightened us on the unique relationship between protozoa and legionella. He also said that while our understanding of this pathogen has increased, much more research needs to be done.
The afternoon was spent in a lively technical meeting (TC 9.6-the subcommittee on Infectious Diseases). A spirited discussion ensued, led by Mike Keen. While much ground was covered, the meeting also highlighted how much more science is needed. But the good news is that the engineering community is starting to accept the idea that HVAC can prevent/cause nosocomial infection. The seminar was a good mix of experienced members and many younger engineers who are interested in this emerging topic.
That's all for tonight!

Hand washing no panacea

I was delighted to hear the ABC song drifting from my bathroom last night.  It meant that my five year old son was following the instructions he learned in school to properly guage the amount of time he should wash his hands with soap and water.  Will he do this everytime? Probably not, but it is important to try.

The situation in my house is much like the situation in many healthcare facilities, according to an LA Tines article on the MRSA Watch blog site:

30 studies show hand washing neglect

Link: Beating the staph superbug - Los Angeles Times.

But, with a few exceptions, hospitals and public agencies have been slow to gear up against MRSA. More than 30 studies have shown, for example, that healthcare workers wash their hands about half as often as they're supposed to, even though washing before and after seeing each patient would drastically cut down on infection rates. Hospital surfaces and equipment aren't cleaned as often as they should be, and careless habits -- like touching potentially contaminated surfaces after hands have been washed but before touching the patient -- contribute to the spread. The first order of business should be to get a clear picture of MRSA. Where is it and how prevalent? An upcoming bill by state Sen. Elaine Alquist (D-Santa Clara) would make MRSA a reportable disease and require hospitals and nursing homes to report their infection rates. In Tennessee, which tracks MRSA, it quickly became the third most common reportable disease in the state, behind chlamydia and gonorrhea. A similar bill was vetoed in 2004 by Gov. Arnold Schwarzenegger, but the recent news from the CDC should make him rethink his position, despite the almost certain opposition of hospitals.

http://tahilla.typepad.com/mrsawatch/2008/01/30-studies-show.html

I bring this to your attention to demonstrate that infection control is dynamic.  There is no silver bullet.  Infection control requires multi-layers and some redundancies.  Our technology, VIGILAIR®, does not replace other sanitary efforts--it complements and enhances them.  Like hand washing, VIGILAIR® is not a cure all.  It is a prudent and effective way to reduce the airborne environmental pathogens within your facility.

Brits love a healthy debate...

From Britain's Telegraph, news on a new government program to reduce antibiotic prescriptions as a way to reduce the superbug cycle. I've included a snippet of the article. It is the responses to the article that are just as interesting. In response to this topic, readers blame doctors, politicians and patients for the problem. These comments show the complexity of the issue and the passion of those seeking a solution. My favorite response is listed below in which the writer tells people to stop being wimps, suck it up and go to the doctor's office less.

Stop giving antibiotics for colds, doctors told

By Rebecca Smith, Medical Editor
Last Updated: 12:09pm GMT 09/01/2008

Doctors are to be told to stop prescribing antibiotics for coughs, colds and sore throats because over-use of the drugs is fuelling the spread of killer hospital superbugs. Alan Johnson, the Health Secretary, says it is time to end the unnecessary use of penicillin and other commonly-prescribed pills, which cost the NHS £1.7 billion a year. Using antibiotics too liberally has led to bugs such as MRSA becoming resistant to treatment with the drugs. Most colds, coughs and flu are caused by viruses, which cannot be treated with antibiotics anyway, Mr Johnson points out. Announcing a £270 million campaign against superbugs, to be launched next month, he says it is vital that doctors adopt "less of a knee-jerk reaction to prescribing". The campaign, called Clean, Safe Care, will also include an extra £45 million for hospitals to spend on infection control nurses or antibiotic specialist pharmacists. All patients going into hospital will be screened for MRSA by 2009.

COMMENTS:

Antibiotics fight "bugs", not viruses, so the basic premise is absolutely correct. Do not give antibiotics merely for colds or flu. BUT post viral conditions such as chest infection, infected sinuses and catarrh (and real sore throats) DO need antibiotics and I hope this will not change under the new guidelines. Perhaps doctors could prescribe a placebo antibiotic to anyone insisting on antibiotics who merely has a viral infection.
Posted by graham wagner on January 9, 2008 9:59 AM

Antibiotics are not the cure for superbugs, cleanliness is - and the hospitals simply aren't clean enough in the UK. Accountability is needed, not money, run a hospital like a fast food joint. "Clean as you go" and it is all staff's responsibilty to clean up, not delegated to the lowest bidder.
Posted by Craig Douglas on January 9, 2008 9:55 AM

So what is Alan Johnson's next big idea? Now wash your hands? Make sure you're wearing your face-mask? Or is he going to go round every surgery and tell the doctors what medicine to prescribe? What a joke! The trouble is this joker is in charge of the health service! That is more frightening than any superbug.
Posted by Pinkie on January 9, 2008 9:27 AM

The best solution for colds and viruses is to stop giving them to everyone else!
If people stayed at home and looked after themselves when they became ill there would be a lot less general illness in the community, rather than battling on and infecting all and sundry.
Surely we all know by now that antibiotics are not given out by GPs for colds - that has been common knowledge for decades - hence the barrage of cold 'cures' on the shelves.
Posted by Annie on January 9, 2008 9:25 AM

I am a GP and we know that we should not give antibiotics in the circumstances described; the patients do not always know this and it does not matter how many times we inform them they will keep coming back until they get them, in these circumstances another approach needs to be adopted and a debate needs to be taken on what this might be.
Posted by Jonathan Allcock on January 9, 2008 8:50 AM

Simple - don't go to your doctor - it's dangerous. I've been telling my patients this for years. The whole ludicrous thing is compounded by several factors: the great unwashed believe it's their god given right to be ill on a regular basis, a health service that is free at the point of delivery (if you offer free beer there's a queue that stretches round the corner and up the road), and a partially educated, disinterested and overpaid workforce.
Posted by Andrew Renaut, Associate Professor of Surgery, Brisbane on January 9, 2008 8:36 AM

The crux of the issue lies in the fact that many people are greedy and want immediate satisfaction. I have wrestled with people who demanded antibiotics for simple viral illnesses. The the patient wants to leave with something in his/her pocket and they are willing to go to any means to acquire it.
There are also legal implications that are caused by the system. If a patient complains of not receiving the desired medication or a rationalized "standard of care", the legal system automatically demonizes the medical practitioner.
I am all for placebo's in this instance.
Posted by James on January 9, 2008 7:51 AM

Yes suck it up. It is called illness. We are made of flesh and blood and mortal. It is normal for people to get sick off and on. You must endure illness sometime. If you find yourself going to the doc everytime you feel unwell then you likely are a mental case ie "nervous nelly". Anxiety /depression are a big reason why folks can't cope w/ minor illnesses. Quick being a wimp
Posted by ER doc on January 9, 2008 6:59 AM

Again the real cause of hospital infection is ignored. Unsustainable bed occupancy ratios, and out- sourcing of hospital cleaning. Blaming GPs is an irrelevant political ploy. Fight the real battle please.
Posted by John Powell on January 9, 2008 6:47 AM

Most experts talk around the Problem of Antibiotic Resistance. Your article headlines should say "ALL COLDS ARE VIRUSES, ANTIBIOTICS DO NOT KILL VIRUSES, THEREFORE YOU(DOCTORS) MUST NOT USE/ ANTIBIOTICS and start from there. Bacteria and viruses are as different as Gold and Lead. It is possible that a virus can make a person sick and that because of a compromised Immune System bacterial Infections can follow which can then require antibiotics to heal, It should also be pointed out that antibiotics tend to kill many neccessary bacterial species in the body and so lead to further problems-(example,life on the toilet) and Candida infections
Posted by declan mansfield on January 9, 2008 6:13 AM

Source: http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2008/01/09/nbiotic109.xml

H5N1 Beautiful and Deadly

New images of the H5N1 virus were released this week. The images are the work of science photographer Lennart Nilsson, who is well known for his imaging of human conception and development of the baby within the womb. These images were first printed in Swedish daily Dagens Nyeter. Nilsson originally asked the US government for H5N1 virus samples but was turned away. He was able to obtain the virus from the World Health Organization and used a scanning electron microscope to make the images. The virus is strangely beautiful in these images, seen as blue orbs attacking healthy pink cells. But keep in mind that it is deadly, as the samples came from a father and daughter in Hong Kong who died after being infected two years ago. I combined the images with a photo of Nilsson (credit Jacob Forsell) and a music bed by Silvermay.

HAI-an explanation

Looking for an excellent overview of Hospital Acquired Infections? Than look no further than this video clip from Dr. David Nash of Thomas Jefferson University. Dr. Nash is at the vanguard of medical educators who are examining health care and health care policies.
Dr. Nash is involved in Pennsylvania's aggressive Health Care Cost Containment Council. PHC4 is considered a model for the public reporting of information on hospital acquired infections.

Hospitals Battle MRSA: Why Infection Control Arsenals Need Many Weapons

If you read UK newspapers you get the impression that MRSA is public health enemy #1. Fortunately the public’s focus on MRSA has helped to raise awareness and resources to reduce infections caused by this bacterium.

An excellent study of technology designed to eradicate MRSA is found in a recent issue of the Journal of Hospital Infection. Researchers assessed the short and long term effects of cleaning a hospital ward with Hydrogen Peroxide Vapor (HPV). Due to its oxidative properties, hydrogen peroxide is effective at eliminating many types of bacteria.

During the five month study, researchers measured MRSA contamination for the three months prior, and four weeks after an ICU was cleaned using HPV. Scientists used a machine like this one to create the vapor that was released inside the sealed, nine bed ICU. Previous studies have noted that HPV is considered a ‘big gun’ in disinfection, affording significant reduction of bacteria when combined with surface cleaning.

In the months prior to the HPV treatment, MRSA was isolated from 11.2% of sample sites. In the hours immediately following the HPV, no MRSA was isolated from the environment. The HPV did its job, end of story. Not quite.

The researchers wanted to look for MRSA after the HPV treatment, when real patients populated the ward. In less than 24 hours, the MRSA was back in the ICU:

“Twenty-four hours after the readmission of patients, MRSA was isolated from five environmental sites. All of the strains were indistinguishable from the strain with which the patient in bed space 8 was colonized, but the environmental contamination was not confined within that bed space.”

Despite the effectiveness of the ‘big guns’ (HPV), MRSA returned. In fact, detected MRSA surpassed the pre-HPV levels (11.2% v. 16.3%). Use of HPV is a great idea, but it cannot be the Infection Control Practitioner’s only weapon. Disinfection is an ongoing battle fought everyday, in every ward. Vigilance and multi-faceted approaches are the keys to long term success.

VIGILAIR® can be an important part of that strategy. Deployed within the Hospital’s air handlers, VIGILAIR® constantly disinfects the air through a combination of ultraviolet germicidal irradiation (UVGI) and high efficiency filtration. The technology is more than infection control, it is infection prevention.

As we always say, there is no panacea in the fight against MRSA, H5N1 and HAI. There needs to be a cross-discipline, evidence based strategy to identify, and eradicate all pathogen reservoirs within a hospital. With changes looming on the reimbursement horizon, this strategy will keep patients and hospitals healthy.

A white paper on airborne pathogens is available here.

Original Study:

K.J. Hardy, et al. Rapid recontamination with MRSA of the environment of an intensive care unit after decontamination with hydrogen peroxide vapour. Journal of Hospital Infection (2007) 66, 360-368

Image:

Bioquell

UK University Leeds the way in Airborne Infection Research

Some of the most compelling and important research in airborne contamination control originates from a progressive university in the resilient city of Leeds. Known as a manufacturing center (or is it centre?), Leeds has managed to diversify itself, evolving into a hub for international banking and business services.

Researchers at the University of Leeds are proving that hospital design plays a major role in healthcare, specifically the growing problem of hospital acquired infections. Perhaps the key to their success is an understanding of the role that the indoor environment plays in disease transmission. According to Leeds professor Andrew Sleigh, “There is evidence that 10 to 20% of infections are spread through the air, but until now, their role in the infection chain has been largely overlooked, as doctors tend to emphasise the importance of washing hands and avoiding physical contact.” I guess being open to new ideas can lead to new discoveries.

Another key could be the University’s cross-disciplinary approach to learning. Leeds University prides itself on innovative study programs that give students creative options:

“Many of its research initiatives cross traditional subject boundaries and Leeds currently promotes projects through 58 inter-disciplinary centres and seven research schools.”

This approach is apparent in the Pathogen Control Engineering Research Group within Leeds’ School of Civil Engineering:

"Our multi-discipline approach brings together investigators from a variety of backgrounds including public health engineering , fluid mechanics , building services engineering and microbiology . This has produced a team with the all-round strengths required to undertake rigorous research in the field of aerobiology and indoor air quality.

Leeds’ advances demonstrate both the challenge and the promise of airborne infection research. Research in this field requires the talents and intelligence of participants from several disciplines. This approach was taken by scientists who reviewed research papers published between 1960 and 2005 on airborne disease transmission (1). More than 200 papers were assessed by a team of 15 experts in epidemiology, virology, environmental health and engineering. This study, and the work at Leeds, shows that greatest discoveries are found at the nexus of divergent technologies.

Recent Leeds Research

Although not entirely complete, Leeds researchers released some results from recent airborne pathogen testing. According to Professor Sleigh's research, infectious particles are distributed within hospital wards.

“Although diseases such as tuberculosis are widely accepted as being airborne, others may also be spread this way. Numerous bacteria-carrying particles - such as tiny flakes of human skin - can be widely dispersed into the air within hospital wards through routine activities, and potentially contribute to the risk of infection for patients.”

PhD students Abigail Hathway and Katherine Roberts used a laser counter to assess the particle concentration of hospital ward air. Their data indicate that normal staff operations such as making rounds, closing drapes and changing patient beds significantly affected concentrations of airborne particles.

These findings add important new insight to the role of the airborne route in infection transmission. This research will be used by the UK’s National Health Service to update guidelines for ventilation and infection control. According to Ms. Hathaway, more research will be done in the upcoming months, with an eye on possible publication in 2008.

Diverse curriculum, public-academic partnerships and accomplished professors are among the reasons why Leeds attracts more undergraduate applications than any other UK university. Plus, any school that Mark Knopfler attended has got to be way cool!

1. Li Y, et al. Role of ventilation in airborne transmission of infectious agents in the built environment—a multidisciplinary systematic review. Indoor Air 2007; 17: 2-18.

APIC’s MRSA Study: a good start

The Association for Professionals in Infections Control (APIC), has just released a comprehensive study that found MRSA rates may be much higher than earlier thought. Results showed that MRSA infection and/or colonization rates are at least 8 times greater than the results of previous studies. You can find the study on APIC’s web site here.

The study is significant because it surveyed a broader spectrum of hospitals and patients than any earlier study. So now that you know the prevalence of MRSA, what to do about it? APIC has some direction there as well. Health care workers can download the Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings. This resource is another good start, although it only devotes 2 pages to environmental transmission of MRSA. A quick check of the text finds 62 mentions of the word ‘contact’, as in ‘contact transmission’. There are zero mentions of the term ‘airborne’, as in ‘airborne transmission’.

Why the omission? Could it be that there is no science to back-up the assertion that MRSA is spread via the air? Perhaps these studies were overlooked:

Significance of Airborne Transmission of Methicillin-Resistant Staphylococcus aureus in an Otolaryngology–Head and Neck Surgery Unit¹
In this 2001 study, Japanese doctors attempted to measure if MRSA could be found in the air of a surgical hospital ward. The rooms of three patients who acquired MRSA after surgery were monitored with air samplers and surface swabbing.
Results:
MRSA was detected in all three rooms in the air and on surfaces. 20% of the MRSA particles were within the respirable range, of less than 4 µm.
From the study:

“Methicillin-resistant S aureus was recirculated among the patients, the air, and the inamimate environments, especially when there was movement in the rooms. Airborne MRSA may play a role in MRSA colonization in the nasal cavity or in respiratory tract MRSA infections. Measures should be taken to prevent the spread of airborne MRSA to control nosocomial MRSA infection in hospitals.”

Reduction in MRSA environmental contamination with a portable HEPA-filtration unit.²

In 2006 microbiology researchers in the UK wanted to know if filtering the air in a hospital would lead to a decrease in MRSA found on horizontal surfaces. Ward rooms housing “…heavy MRSA dispensers…” were supplied with portable HEPA filtration units.
Results:
95% of settle plates placed in the wards showed MRSA contamination. Plates were placed in a variety of locations, mostly along the perimeter of the room. When HEPA filtration was introduced, measurable MRSA decreased between 73%-95%. This study makes a direct link between air and the dispersion of viable MRSA.

From the study:

“Although this cannot replace standard infection control measures (e.g. isolation, hand hygiene, protective clothing and cleaning), it is likely to reduce cross-infection risks significantly and could provide a relatively cost effective method for enhancing MRSA control.”

The relationship between airborne colonization and nosocomial infections in the intensive care unit.³
In 2005 Turkish researchers used more than 900 data points to measure airborne pathogens and the colonization of those pathogens in hospital patients. The study tracked 179 patients and found that MRSA is definitely airborne.
Results:
Researchers proved that MRSA was airborne through the use of air samplers. The two most common airborne pathogens were MRSA and Acinetobacter baumannii. Furthermore, the study says there is a link between the concentration of these airborne pathogens and colonization in patients.
From the study:

“It can be concluded that, total number of airborne viable particles in the critical areas such as operating theatres and intensive care units, seems to be a significant risk factor for the development of nosocomial infections in immuno-compromised patients.”

An outbreak of Serratia marcescens infection in a special-care baby unit of a community hospital in United Arab Emirates: the importance of the air conditioner duct as a nosocomial reservoir.⁴

A deadly outbreak of S. marcescens vexed the staff members of a NICU located in the United Arab Emirates (UAE). In total 36 infants were infected, leading to the death of five babies. Concerned healthcare workers desperately worked to find the source of the outbreak.

Results:

Researchers determined that the reservoir of the deadly pathogen was the air conditioning system that fed the NICU. Despite many typical infection control interventions such as staff education, environmental cultures, isolation of colonized patients, compliance with aggressive infection control measures and recognition of the role of cross contamination the colonization of infants grew. When environmental sampling suggested that contamination was emanating from the air conditioning system, the hospital thoroughly sanitized the system. After this measure the 20 week outbreak ended.

From the study:

“…the growth of serratia from airflow samples suggested that the primary source of
this outbreak was the AC duct.”
“In conclusion, we have documented in this report the results of extensive surveillance and the importance of the AC duct site as a reservoir of nosocomial pathogens in the SCBU of a community hospital. The possibility of airborne transmission in nosocomial spread should not be underestimated.”

Although there is ample evidence that MRSA and other pathogens are transmitted via the air, most infection control measures focus on contact precautions. Data indicate that contact transmission predominates, so the emphasis on contact precautions is warranted.

It is reasonable, however, to also address other environmental contributors to infection. As we’ve learned recently in reducing VAP, a bundling approach yielded impressive infection rate reductions. Bundling recognizes that infection control is multifaceted and requires new thinking and new strategies. Bundling’s success proves that infection control is achieved through a system of evidence based measures.

Instead of thinking about infection control as breaking a single link in the ‘chain of transmission’, consider infection as a web with many avenues of opportunity. One of those avenues, the airborne route, deserves greater attention.

References

1. Significance of Airborne Transmission of Methicillin-Resistant Staphylococcus aureus in an Otolaryngology–Head and Neck Surgery Unit
Teruo Shiomori, MD, PhD; Hiroshi Miyamoto, MD, PhD; Kazumi Makishima, MD, PhD
Arch Otolaryngol Head Neck Surg. 2001;127:644-648.

2. Reduction in MRSA environmental contamination with a portable HEPA-filtration unit
TC Boswell; PC Fox
Journal of Hospital Infection 2006 May;63(1):47-54

3. The relationship between airborne colonization and nosocomial infections in the intensive care unit
G Dürmaz, et al
Mikrobiyol Bul. October 2005 (article in Turkish)

4. An outbreak of Serratia marcescens infection in a special-care baby unit of a community hospital in United Arab Emirates: the importance of the air conditioner duct as a nosocomial reservoir
S. A. Uduman, et al
Journal of Hospital Infection (2002) 52: 175±180

Taking the fight against hospital acquired MRSA into your own hands

Think of it as a ‘Do it Yourself’ kit for preventing hospital acquired infections (HAI). The kit is a collection of disinfecting wipes, hand rubs and other products designed to prevent patients from catching a bug while they’re in the hospital.

The “PatientPak’ is marketed in the UK for about $43. The web site for the product is long on promises short on specifics (www.patientpak.com). Consider this text from the company’s press release:

“The PatientPak Hand Sanitiser and Sanitising Wipes are the only products available that are tested and proven to kill and clean away MRSA and at least 99.999% of all bacteria, including dangerous viruses, Norovirus and Bird Flu. Combining a cleaning detergent and bacteria-killing disinfectant in one, harmful bacteria are killed in just 10 seconds. PatientPak’s Hand Sanitiser and Sanitising Wipes, the most extensively tested products on the market, are also the only MRSA-killing products that are hand safe with just 5% alcohol, meaning that food can be eaten after application with no need to re-wash hands.”

Maybe I’m reading this wrong, but the first sentence indicates that viruses are a subset of bacteria (see bold text). A quick scan of the web site reveals no corroborating case studies or published data on germicidal efficacy. If the products are indeed the most, “…extensively tested…” shouldn’t the test results be available?

I’d like to know how the sellers know that the products ‘kill’ bird flu? Was it tested against H5N1, or was it a surrogate? Or does it work against Influenza A, and therefore it is assumed to likely be effective against bird flu?

I’m also sceptical of the germicidal effects of a detergent that is used for 10 seconds. To the best of my knowledge, detergents do not ‘kill’ or deactivate microorganisms. Detergents help water remove and dilute contaminants. It is generally accepted that washing your hands with a detergent (soap) requires a good 20 seconds or so. I may be wrong, but since the company does not provide an explanation of their technology or other scientific studies, we are forced to use the information that we have.

On the positive side, I like the idea of empowering people to actively participate in their healthcare. Bringing the PatientPak to the hospital is not necessarily a sign that a hospital is not doing its job. To me it is an indication that HAIs are environmental issues requiring a broad-based strategy. While hospitals need to do more, I wouldn’t bet my life on it.

So, would I buy the PatientPak? No, not based upon what I know of the kit so far. I do not believe, however, that it will cause any harm. It might actually help. There’s a lot of sizzle in this product promotion, but not much science. It is always wise to remember that there are no panaceas for HAI.

A meeting of creative minds

I was privileged last week to attend the evidence based design and a passion for improving the environment of care in health facilities world wide. The Center is known for matching new design technology with progressive hospital administrators who are looking for innovative ways to improve patient care.
Environment Standards Committee (ESC) members volunteer their time to bring evidence based ‘best practices’ to such organizations such as the American Institute of Architects (AIA).
ESC members tend to be recognized leaders in architecture and design who are simultaneously extremely creative and pragmatic. They marry their expertise with a hunger for innovation to produce solutions that are aesthetically, environmentally and economically beneficial.
Following the meeting, we were given a tour of the building. Richard Smith was kind enough to show us the newly designed structure of 1305 York Avenue, a part of the Weill Cornell Medical College. Mr. Smith demonstrated how attention to design details have yielded a significantly better care experience for patients who receive ambulatory outpatient services here.
Many of the innovations stemmed from a patient survey that highlighted patient perceptions about care. Changes in design to floor plans and internal procedures have produced a streamlined admissions process that reduces waiting time, assures HIPPA privacy and eliminates paper records. It would be difficult to review all the innovations of this building, so I will share some images of the tour.

Center For Health Design