The New AIA Guidelines:
Their Impact on Pre-And Post-Op Infection Control
By Tim Cowan, AIA
The American Institute of Architects' (AIA) Academy of Architecture for Health has issued the 2001 edition of The Guidelines for Design and Construction of Hospital and Healthcare Facilities. This publication will have a significant impact on healthcare building design and construction and, in turn, on infection control policies and practices in hospitals and healthcare facilities throughout the nation.
Many state departments of health, or other authorities having jurisdiction over such matters, will soon implement the new AIA guidelines.
This article discusses some of the changes in the AIA guidelines that will impact your organization's infection control practices. There are changes that apply to routine infection control practices in the surgical suite and related spaces, as well as changes that apply to how your facility can maintain high standards even during construction and renovation projects. For an in-depth understanding of how the new guidelines will affect your organization, be sure to consult the guidelines themselves and talk with your facility planner and an architect who is familiar with the guidelines.
Is your facility working against you?
Healthcare workers (HCWs) continuously implement new infection control practices in the surgical suite. New technologies can actually enhance infection control and, as healthcare professionals, you are constantly striving for new and improved methods for preventing infection. For all of your efforts, does it sometimes feel as if your facility is working against you? Regardless of how "new" your space is, you could very likely identify changes and modifications to your facility that would enhance your infection control program.
Consider the following:
- Is your surgical suite's floor plan efficient? Does the layout of your surgical suite help prevent cross contamination, or are patients and staff moving back and forth between public corridors and clean areas? Do employees who have worked in pre-op, surgery, or PACU for more than two weeks still need a road map to navigate the confusing jumble of hallways and corridors?
- Are your patient holding areas adequately sized? Is there sufficient clearance around stretchers and lounge chairs, or do you sometimes feel as if you are playing "musical chairs?" Remember, closer quarters mean a higher probability of cross contamination.
- Are toilet facilities strategically and conveniently located for use by patients and staff? Are there separate facilities for patients, staff, and visitors? What about handwashing stations? Is there an appropriate number for the size of your unit? Are your handwashing stations in the bathroom facilities or nourishment centers, or are they separate facilities positioned at appropriate locations throughout the unit?
- Do your corridors look like storage rooms, and are former storage rooms now lounges, offices, or even procedure rooms?
Your answers to these questions can help you determine how your facility measures up to the new guidelines.
The new guidelines emphasize the importance of efficient, functional design; adequate space; dedicated toilet facilities for patients and staff; and adequate storage rooms. The underlying imperative, of course, is infection control.
Within the surgical suite, the guidelines specify the designation of three areas based on the activities that are performed in each: unrestricted, semi-restricted, and restricted. Unrestricted space is just that: this may be a centralized area for checking in patients or receiving materials, and street clothes may be worn. Semi-restricted space includes key areas adjacent to the surgical suite, such as storage rooms for sterile supplies, rooms for processing equipment for the ORs, and corridors leading to the restricted areas. Street clothing is off limits in this area: all personnel are required to wear surgical attire. Restricted space is what you would imagine: the ORs or procedure rooms and scrub areas. Standard surgical attire, including gowns, masks, and shoe coverings, is required in this space.
The new guidelines also apply to pre-operative holding and recovery areas. In facilities with two or more operating rooms the pre-op area is now required to accommodate patients on stretchers as well as ambulatory patients. This space now must be under "direct visual control of the nursing staff." Further, each patient area must be at least 80 sq. ft. and have a clearance of 4 feet on both sides and at the foot of each stretcher. In recovery, a step-down area is now required for outpatients, and minimum space requirements are dictated here as well.
The new guidelines introduce the term handwashing "stations." Previously identified as handwashing "facilities," the new term carries greater emphasis on ensuring that all components are included with a sink. The task force responsible for writing the new guidelines makes it clear that the waterless soaps and antiseptic lotions are not considered equivalent to soap and water since alcohol is readily inactivated by organic material or soil. New construction or major renovation will require a handwashing station in single-patient rooms in addition to the one in the toilet room. Waterless agents used for hand hygiene are treated as important supplements to sink use, and placement of alcohol-based cleanser/dispensers in various locations is encouraged.
Included throughout the guidelines are new requirements about adequate space for items that, in the past, tended to get pushed to the bottom of the list, or eliminated altogether. For example, each surgical suite must now have enough storage to keep the hallways free from equipment and supplies, and the guidelines go so far as to set the parameters at a minimum of 150 sq. ft., or 50 sq. ft. per OR, whichever is greater. (See guidelines Section 7.7.C10.)
The guidelines also establish new standards for hot water, ventilation, and finishes:
- Hot Water: The guidelines concerning hot water aim to reduce the growth of Legionella and other waterborne pathogens. The temperature in hospitals at the point of use is now a range between 105ºF.-120ºF. The higher temperature is a preventive tactic, although there is some risk of scalding without the use of mixing valves. While the appendix suggests several strategies for eradication if a problem is identified, elevating the hot water temperature to even higher temperatures (e.g., 140ºF) is still considered one of the easiest, though with an additional risk of scalding.
- Ventilation: Total air exchanges per hour have been increased for many spaces, (e.g., patient rooms), though the number of air exchanges in the OR remains the same. However, achieving a measurable pressure differential in the OR will require that the room be virtually airtight. Due diligence must be paid during construction to make sure all wall penetrations are sealed (especially above ceilings) and that doors have proper gasketing.
- Ceilings and Finishes: The new guidelines more clearly define the types of ceilings that are appropriate for certain spaces. For ORs and other restricted areas, ceilings must be "monolithic" and capable of withstanding aggressive cleaning techniques, including chemicals. Lay-in ceilings are permitted in semi-restricted areas, but must be secured by clips to eliminate the possibility of dust and other particles from entering the room. All ceilings must be easily cleaned, and any ceiling with textured surfaces should be ruled out. Your architect and designer can help you select the most appropriate ceiling type for each space.
From an infection control standpoint, keep in mind that wallcoverings and painted surfaces must be easily cleaned, "scrubbable" surfaces. Make sure that your carpet selections are appropriate for the area, and easily cleaned to minimize stains and odors.
Construction and Renovation: New Challenges for Infection Control
In addition to increased floor cleaning, a "walk-off mat" placed at entrances to the construction area can help reduce tracking of debris to patient areas. Similar to a giant pad of Post-It™ Notes, the pad is placed adhesive side up. Periodically a spent sheet is removed, exposing a clean adhesive surface.
By now you are probably considering all of the improvements that could be made to your facility to enhance infection control. Before construction begins, a great deal of planning must be completed. Even after the project is ready to commence, you must first endure inconvenience, dust, dirt, and other hazardous conditions before you can benefit from the long-term gains the project was designed to provide. Planning minimizes the impact of construction-related problems, and an infection control risk assessment can help. One important change in the AIA guidelines is the addition of an expanded "planning and design" section. (See guidelines Section 5.1.) Although many healthcare facilities have been preparing infection control risk-assessment documentation in connection with construction and renovation projects for some time, the current edition of the guidelines makes completing an infection control risk assessment (ICRA) a requirement.
The AIA guidelines state that completing the ICRA should be the result of a "consultative" process. If a construction or renovation program is in your future, you may want to review the guidelines with your colleagues in facilities planning. An architect can assist you in determining how the AIA guidelines will affect your project.
Although the guidelines do not specify a particular ICRA tool or instrument, there are several excellent sources of information and tools available to you. These include matrices that classify construction projects by type and activities; descriptions of required infection control precautions by class, both during construction and upon completion of your project; and even paper forms that ask for the signatures of contractors and subcontractors as a way of building project awareness.
The ICRA should be comprehensive in scope, dealing with such issues as patient relocation, barriers that limit airborne contaminants, and air handling and water systems that limit airborne and waterborne pathogens. These take on added significance because the AIA guidelines now require the phasing of construction and renovation projects to minimize patient and staff exposure to potential contamination. If you have ever been through a construction project, you already know how challenging phasing can be. You should anticipate the potential impact of this phasing early in the planning stage since it may affect the duration of your project and your budget.
Your ICRA will be specific to your project and will undoubtedly address a wide range of issues. Work closely with your facilities planner, architect, and contractor to ensure that everyone involved understands their role in infection control.
For example, during the design phase of the project your architect and facility manager should plan for the placement of barriers to isolate specific areas during construction. Your contractor, in turn, will be responsible for actually erecting the barriers. A wide range of materials can be used, including everything from fire-rated plastic to temporary walls with doors that are sealed. In addition, because dirt, dust, and debris carried out on the workers' shoes is always a concern, talk with your architect about specifying a "walk off mat" at the openings of the barriers. This is similar to a giant pad of Post-It™ Notes placed adhesive side up. As personnel enter or leave the construction area and walk across the mat the sticky surface collects debris clinging to the bottoms of their shoes. Periodically a spent sheet is removed, exposing a clean adhesive surface. An alternative is ensuring increased floor cleaning around the traffic area to reduce the tracking of debris to patient care areas.
The ICRA will definitely require cooperation and teamwork. The ICRA is an excellent way to build awareness about the importance of infection control and create a sense of responsibility among everyone involved. The plan itself will help you identify action items that need to be addressed.
AIA Guidelines: Helping You Plan for the Future
The AIA Guidelines offer an excellent source of information for staff members responsible for infection control. Whether or not you envision a construction or renovation project to be a part of your future, the guidelines provide a "heads-up" about the issues that directly impact infection control. They also provide a forecasting tool for the issues that authorities having jurisdiction may be emphasizing in future approval and accreditation inspections. Finally, the guidelines provide some insight into helpful tools that you can use to help maximize your efforts to keep your patients, staff, and visitors safe.
Author's note: Special thanks to Judene Bartley, MS MPH, CIS, vice president of Epidemiology Consulting Services in Beverly Hill, Mich. for her valuable assistance in providing input for this article. Bartley was recently elected to the AIA Revision Guidelines steering committee and has served as a task force member since 1992.
Tim Cowan, AIA, is a senior associate with Burt Hill Kosar Rittelmann Associates, an architecture and design firm with offices in Pittsburgh, Butler, and Philadelphia, Pa.; Washington, D.C.; Boston, Mass.; and Cleveland, Ohio.