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

'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.

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.