Paths of resistant pathogens in hospitals: architecture, design interventions, transmission risks

Lead Research Organisation: University College London
Department Name: Bartlett Sch of Architecture

Abstract

'Paths of resistant pathogens' will map and visualise the paths that pathogens take through hospitals in order to model exposure and transmission risks. The project aims to minimise risks and prevent the spread of pathogens by making hand hygiene compliance easier through design interventions.
The emergence and spread of antimicrobial-resistance (AMR) is a growing concern to global health. An estimated 700,000 people already die every year of resistant infections. Improving infection prevention and control is one important strategy to combat AMR. However, traditional approaches have shown limited benefit. For instance, educating healthcare workers to achieve higher rates of hand hygiene compliance has proven short-lived and ineffective.
In this project we are building on existing design research, which has begun to shed light on the powerful role design can play in behaviour change, such as the location of sinks in increasing hand hygiene compliance.
We will take this tradition of design research one step further by asking who complies and who contributes most to the potential spread of pathogens. We will achieve this by focusing on the different types of agents populating the spaces around patients: doctors, nurses and other healthcare workers, but also frequently overlooked groups such as porters, cleaners, food service workers, medical students, volunteers, etc. We will carry out a detailed analysis of architectural layouts based on space syntax techniques, which map the potential to encounter other people arising from the geometry of the building. Spaces that by the nature of their strategic location in the wider hospital system attract more flow of traffic will carry higher risks of spreading pathogens. Depending on where agents go, what or whom they touch, whether and where they wash their hands, and whether they bring along mobile items (potentially shared with and touched by others), different transmission risks may emerge. We will create visualisations of the paths that pathogens may take, as well as estimate exposure patterns and risks for each agent path. Agent behaviours accruing the highest risks will become targets for design interventions.
To create appropriate design interventions, we will use a participatory approach. We will invite the different agents populating wards as well as hospital stakeholders (such as hospital management and directors of infection control) to co-creation workshops, where we will present our findings on transmission risks and spatial practices of agents. Listening to their experiences and reflections, we will create - together with them - a brief for design interventions in order to make compliance easier and improve infection control. Design responses will build on the collected data and depend on the co-creation process, but generally we can see opportunities arising from architectural modifications of layouts, adapting the locations of certain functional programmes and improving compliance by installations or a designed piece of interactive furniture.
Leveraging the role of design to subtly nudge people to modify their behaviours, we envisage this project as a starting point of a wider conversation between design research and medical science.

Planned Impact

The non-academic beneficiaries of the project 'Paths of resistant pathogens' will be:

1 - The general public
A world in which antimicrobial drugs may not be effective due to antimicrobial resistance (AMR) is scary. Most people will have had antibiotics at some point in their lives and will be able to relate to the issue personally; therefore, we anticipate great interest from the general public. Emphasizing the role that design can play to contribute to better infection control is a simple and elegant solution that the general public will be able to appreciate, specifically in a context where medical research can often appear very complex and difficult for laypeople. Ultimately, by aiming to improve infection control in hospitals, we might in the long run contribute to a reduction in AMR transmissions.

2 - Staff members and patients in participating hospitals
Staff members in the participating hospitals will play an active role in our research. They will not just be research subjects to be observed, but will directly feed into co-creating design solutions together with the research team and will contribute their knowledge and experience. We will focus on all staff in hospitals, including those in servicing roles. Including everyone in the process will create a clear signal that everyone's behaviour matters in tackling AMR. In the same fashion, we will engage and empower patient organisations to contribute. Immediate benefits for staff and patients will be increased wellbeing and a sense of pride to contribute to finding solutions for an important problem, but also health related benefits through a potential reduction in infections and pathogen transmissions.

3 - Participating hospitals
Our project partners, UCLH and St George's will benefit by understanding how their hospital layout works for them. They will also gain insights into behaviours and practices of staff, for instance detailed data from observations of hand hygiene compliance, which normally is not gathered in this form (typically, hygiene compliance data is self-reported). Being able to understand discrepancies between observed and self-reported data will be invaluable to the hospitals in improving their infection control processes and practices.

4 - Public Health England
Our collaborative partner Public Health England will benefit from the project through capacity building in the field of the built environment and its role in infection control. Collaborating with the Bartlett School of Architecture will raise PHE's profile and lead to peer-reviewed publications and future joint grant applications.

5 - The NHS
We anticipate our findings to be transferable to other NHS hospitals. While our design interventions will be planned for local settings, results on transmission risks of agent practices will transcend the local context, since we will be able to compare findings across the two different hospital sites. The NHS will benefit from an increased understanding of how work processes together with hospital layout influence transmission risks. This knowledge could be used as guidelines for subtle modifications of spatial arrangements in wards, reorganisation of practices and future hospital planning recommendations.

6 - Architects and hospital planners
Hospital design is a complex task due to many different requirements to be united in a single architectural layout (medical practices, needs of patients and visitors, accommodation of specialised equipment, complex flow of clean and contaminated materials, etc.). Architects and hospital planners will benefit from insights into which design decisions have an impact on transmission risks. Our results can feed directly into the emerging practice of evidence-based design.
 
Title Design For Change Exhibition 2019 
Description We exhibited a costume, which was designed as part of our project. It resembled a superbug, but had tentacles that ended in plastic hands to highlight the relationship between the spread of pathogens and human touch as a potential transmission route. The costume was worn by a researcher as part of our co-design workshops held in both participating wards. We also exhibited brochures distributed to professional practitioners in the same co-design workshops. 
Type Of Art Artistic/Creative Exhibition 
Year Produced 2019 
Impact Our project received considerable publicity by being included in this exhibition. The London Design Fair is a major annual trade fair attracting over 29,000 visitors including retail buyers, interior designers, architects and specifiers. We were featured in the exhibition catalogue (see book chapter publications) and also in two videos, made by the AHRC: https://www.designresearchforchange.co.uk/design-research-for-change-showcase-2019-film/ https://video.twimg.com/ext_tw_video/1212799727378534400/pu/vid/1280x720/w5KKRHBhsTcRe-Y7.mp4?tag=10 
URL https://www.designresearchforchange.co.uk/design-research-for-change-showcase-2019-at-london-design-...
 
Description In this project we investigated different agent groups in hospital wards (doctors, nurses, cleaners, caterers, porters, physios, healthcare assistants, visitors, etc.) and observed their contact as well as hygiene behaviours (surface contact, person to person contact, hand hygiene events). This was done in order to find out which group contributed most to the potential spread of resistant pathogens, and in effect which design-led interventions might help best to tackle antimicrobial resistance (AMR). We also asked whether agents adapted their behaviours when leaving a bed with a patient colonised by an AMR pathogen. Two different NHS hospitals in London participated: hospital A was a relatively new built hospital, while hospital B dated back to the 1970s.
We developed a novel way of researching hectic schedules of agents in high resolution and real time.
Findings highlighted that the two hospitals differed significantly. In hospital A most person contacts before the first observed hand hygiene event (40%) originated from healthcare assistants, while in hospital B nurses were responsible for the majority of person contacts (28%). Agents also altered their behaviour when leaving critical patient areas, since healthcare assistants in hospital A predominantly engaged in hand hygiene after seeing AMR patients. Instead caterers were responsible for 43% of all person contacts before performing hand hygiene when leaving an AMR area, followed by doctors (37%). In contrast, in hospital B doctors were as prone as nurses to engage in person to person contact (both 18%) before the first hand hygiene event and after having seen an AMR patient. Cleaners were the third agent group with high person to person contacts (16%).
This means spreading risks were shared quite widely among different agents and also involved under researched groups such as cleaners and caterers. Different agent groups also showed different degrees of awareness around the potential spread of pathogens, and spatial practices differ across hospital sites.
In addition, we found relevant differences in surface contacts. The most touched surface in hospital A was the keypad to the clean utility room (which is where medication supplies were kept), whereas in hospital B the clean utility room was mostly accessed through a second door passing by the nursing station, therefore leaving the key pad secured door more or less untouched. Instead the door to a side room accommodating an AMR patient was the most touched surface, therefore potentially causing spreading risks.
We took these findings back into the wards through co-design interventions, where we distributed results with a researcher dressed in a superbug costume. We engaged in communication with different agent groups around their behaviours, soliciting their advice and activating their problem-solving capacities but also giving often underrepresented but crucial groups such as caterers and cleaners a voice.
This research has opened up relevant new research questions around interventions (for example how best to access utility rooms), but also in how to engage user groups in problem-solving. Future research could also involve microbiologists in taking swabs to assess the relationship between potential and actual spreading risks.
Exploitation Route Our outcomes might be taken forward by different stakeholders. Firstly, architects and other planners in the construction industry might consider the generated evidence in their decisions on planning healthcare facilities. One major company in the construction and engineering sector, Mott MacDonald, have already taken an interest in our findings. Secondly, insights will be relevant to clinicians, infection control nurses and others aiming to prevent the spread of pathogens. Our engagement approach as well as our findings on different awareness levels for different groups will be useful to create impactful interventions. On a practical level, a touch free access to clean utility rooms (via RFID for instance) could be implemented. Finally, the NHS, Public Health England and the Department of Health could take outcomes forward, for instance to shape policies on training, awareness and involvement of all agent groups.
Sectors Construction,Healthcare,Government, Democracy and Justice

URL https://video.twimg.com/ext_tw_video/1212799727378534400/pu/vid/1280x720/w5KKRHBhsTcRe-Y7.mp4?tag=10
 
Description In our fieldwork we collected data on the paths different people took through hospital wards in order to understand risks of pathogen spread as a function of ward design. We selected two different hospitals as sites of our fieldwork: UCLH NHS Trust in Camden / London and St Georges NHS Trust in Wandsworth / London. In the process, we engaged with the Directors of Infection Control in both NHS sites to understand their processes, protocols and policies. It turned out that both hospitals had slightly different ways to address infection control issues and we were able to put stakeholders from both sites in touch with each other to share best practices, for instance on a monitoring system regarding the presence of pathogens in patients. Healthcare workers and other agents (porters, cleaners, caterers) present in the two participating wards on the days we held our co-design workshops benefitted directly from learning about our results and engaging in conversation with us. An increased awareness of the potential spread of pathogens has a direct impact on their professional practices and the way they contribute to delivering best healthcare. In addition, we have found ways in which architectural decisions, for example how healthcare workers access the clean utility room make a difference to the amount of surface contacts. In one case the clean utility room was accessed directly, and the keypad was the most touched item. We have no record how often it was cleaned, but it did not seem to be on the radar of the infection control team. Providing touch free access (for example via RFID cards) would be an easy solution. An architectural solution presented itself in the second hospital we studied, where the clean utility room was accessible via the nursing station, providing natural supervision without the need for locking the room at all times. These insights are useful for designers and healthcare planners, and one construction and engineering company, Mott MacDonald have already expressed interest in our results to impact their design decisions in the future. This could lead to better design, but also better healthcare provision.
First Year Of Impact 2019
Sector Construction,Healthcare
Impact Types Societal,Economic,Policy & public services

 
Description Co-Design Workshop Marnham Ward, St Georges Hospital 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact We visited the ward, which was the location of our previous fieldwork and data collection, having mapped the paths of over 100 agents populating wards: doctors, nurses and other healthcare workers, but also frequently overlooked groups such as porters, cleaners, caterers, etc.
Whilst we conducted our spatial data collection discretely and in a hidden manner, one key intention of our design intervention was to create visibility directly on the ward. Therefore, a researcher dressed up as a 'superbug' and engaged professional practitioners on the ward in conversations around the spread of pathogens. This raised awareness of how behaviours, but also architectural decisions result in the potential spread of bugs.
Year(s) Of Engagement Activity 2019
 
Description Co-Design Workshop T9, UCLH 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact We visited the ward, which was the location of our previous fieldwork and data collection, having mapped the paths of over 100 agents populating wards: doctors, nurses and other healthcare workers, but also frequently overlooked groups such as porters, cleaners, caterers, etc.
Whilst we conducted our spatial data collection discretely and in a hidden manner, one key intention of our design intervention was to create visibility directly on the ward. Therefore, a researcher dressed up as a 'superbug' and engaged professional practitioners on the ward in conversations around the spread of pathogens. This raised awareness of how behaviours, but also architectural decisions result in the potential spread of bugs.
Year(s) Of Engagement Activity 2019