With specific requirements over a wide range of operations settings, communication amongst the entire building team will help deliver a safe and convenient environment for patients and staff.

To achieve these higher standards for healthcare facilities, a plumbing designer should meet with the facility staff after reviewing the architect's building plans to ensure the facility's requirements are met and piping sizes and locations are adequate. This critical step allows additional input from the end-users to make sure fixtures and working areas will fit properly while accommodating the medical staff's duties.

While this coordination of designs must take place for any type of built environment, designers of healthcare facilities have another role to fulfill: providing an atmosphere that will minimize cross-contamination of patients, i.e., nosocomial infection, which makes hand hygiene imperative.

Nosocomial Infection & Handwashing

This fact is stated today by the Centers of Disease Control and Prevention and is backed by more than a century of research that goes back to Joseph Lister's theory from the late 1800s that antiseptic conditions via handwashing reduce the number of infections in medical procedures.

That said, plumbing engineers have a tremendous responsibility and are in a unique position to affect the outcome of a patient's stay at a medical facility because the systems they design will either be user-friendly or considered cumbersome to everyday tasks.

While this may seem overstated, consider that the CDC identifies inaccessibility to sinks as the second most cited factor by healthcare workers for not following proper hand hygiene protocol.1

Plumbing system designers should see themselves as playing a significant role in producing an environment that aids in the healing of patients.

One of the most effective ways to reduce cross-contamination of patients via hands is the specification of sensor-operated plumbing fixtures that eliminate the need to touch potentially harmful surfaces including sinks, faucets, toilets, soap dispensers and hand dryers.

While designers may hesitate to present plans that call for plumbing system upgrades - touchless fixtures do cost more than manual units - investing in a comprehensive hygiene program is justifiable to healthcare administrators who are facing increasing scrutiny for healthcare-related infections. That's because nosocomial infections affect 2 million patients each year, cause an additional $4.5 billion in medical expenses and are the fourth-leading cause of mortality for Americans, according to the CDC. In fact, the yearly infection mortality is more than car accidents, fires and drowning combined.2

These startling facts show that plumbing system designers should take a proactive approach and market their services as the front-line defense in the combat against nosocomial infections.

Break The Chain

In other words, a person is admitted to the hospital and later develops an infection as a result of cross-contamination from a surface, which can include patient-to-surface contamination and hand-to-hand contact by visitors, medical personnel or any number of people involved in the care of a patient.

Approximately one-third of hospital-acquired infections are preventable with effective handwashing. In fact, transfer of a pathogen to a patient via the hands of healthcare workers is thought to be the most likely mechanism of exposure to patients.

What is even more frightening is how easily a person can "pick up" and then transfer bacteria that can develop into a nosocomial infection. Research attests that an ordinary event like flushing a toilet spreads a plume of mist throughout the restroom. These droplets can harbor Escherichia coli, as well as other coliforms, and remain airborne locally for at least 12 minutes.3

Once this mist settles onto surfaces in restrooms, the next link in the chain of infection can occur because pathological organisms, such as fecal coliform, transfer to skin from a laminate surface 40 percent of the time two hours after the contamination event. Clinical testing also shows that cross-contamination can occur even up to 24 hours after the event.4

It's also a proven fact that a person who touches a contaminated surface can pass on the germs and bacteria just as easily. Additional research on cross-contamination concludes that the bacterial transfer rates of hand-to-hard- surface are similar to the transfer rate of fingertips-to-lips.4 This is the final link in the chain - a portal of entry into a new host. Organisms will continue to transfer via touch until they are shed from the skin of the host or have been killed by antimicrobial agents.

Therefore, plumbing system designs that call for touchless fixtures decrease the likelihood of nosocomial infections by significantly reducing the chain of contaminated elements a person touches in a hospital, thus preventing the spread of many pathological organisms.

Hygienic Handwashing

The use of touchless faucets is so important (and logical) to ensuring a hygienic atmosphere that it is the single design specification for scrub sinks for operating rooms, according to the Association of periOperative Registered Nurses, the leader and expert on patient safety in surgical settings.

"In general, there is only one specific feature we recommend for surgical scrub sinks: that it allows hands-free operation," says Ramona Conner, RN, MSN, CNOR.

It is also recommended that surgical scrub stations are constructed of stainless-steel and that the sensor faucets have a laminar flow without aerators. Plus, they must be designed to have enough room to allow scrubbing up to the elbow. However, hygiene doesn't necessarily stop once the user is done. Some surgical scrub stations are optionally programmed for an extended delivery period of water after users have removed their hands from the detection zone. Providing 20 seconds of rinse time for the sink area helps cleanse the sink for subsequent users.

Sensor-operated faucets also increase hygiene in public and patient restrooms. Surprisingly, the dirtiest area in the bathroom, as far as germs are concerned, is the sink itself, and most specifically, the handles to the tap have the most germs on them. That's because when you wash, bacteria are shed from the hands and collect in the sink area.

A research study on public restrooms, titled "Enteric Bacterial Contamination of Public Restrooms," showed that total coliforms (aerobic bacteria found in the colon or feces) were present on 17.3 percent of the 248 surface samples taken from hospitals. Sink drain surfaces resulted in positive samples of coliforms 80 percent of the time, followed by the rim of the sink (20 percent) and then the area under the soap dispenser (10 percent).

Results like these exemplify the need to incorporate touchless fixtures to reduce nosocomial infections because touching contaminated faucets or sinks after using the restroom or in-between patients can negate the benefits of washing just as if the procedure was skipped.

The final step to hygienic handwashing is drying, but again, touching contaminated surfaces to retrieve towels can negate the effects. That's why touchless, forced-air dryers are ideal for maintaining the highest levels of hand hygiene. In fact, research by the Mayo Clinic5 states that warm-air drying ranks the highest (best) when compared with other methods of drying when bacterial samples were taken after drying hands. The clinical trial declared "the forced-warm-air method as the best method for removing bacteria from the washed hand."

Conservation

Forced-air hand dryers are a good source of savings in terms of operational cost vs. the cost of paper towels and labor savings to maintain restrooms. The energy to operate the new generation of hand dryers is generally less than 10 percent of the cost of paper towels, including the elimination of associated labor costs for ordering, storing, replenishing dispensers, collecting and disposing of paper towels.

There also is a conservation advantage for sensor-operated plumbing fixtures that save a significant amount of water. Based on the assumption that both manual and sensor-operated faucets flow 2.2 gpm, and users follow the Food and Drug Administration's Food Code handwashing procedure, there would be a savings of 1.057 gallons of water per handwashing.

This savings is realized because sensor-operated faucets are "turned off" unless a user's hands are in the "active area," while manual faucets waste considerable amounts of water due to the continuous flow while the user lathers his hands.

Additional water waste can be accounted for in applications with manual faucets because water may continue to run when the user reaches for a towel to dry his hands or use the towel as a buffer between hand and fixture to turn off the faucet, to avoid re-contamination. Also, because users are now accustomed to sensor-operated faucets, manual faucets are often left running out of habit.

While the FDA recommends pre-rinsing for four seconds, scrubbing for 20 and then finishing with a final rinse of four seconds, it is reasonable to expect that most people do not follow this protocol exactly, but the comparison highlights the waste that occurs when manual faucets are installed.

Consider, for example, a hospital that is staffed 24 hours a day with 400 beds (roughly 1,000 people a day, including visitors). On average, if each person was to use a restroom with sensor-operated faucets twice a day and washed their hands once more before lunch, this equals 21,000 handwashes or 22,197 gallons of water saved each week or 1.15 million gallons of water each year.

The 'Next Generation'

It's time again to prepare for the "next generation" of plumbing products - networkable plumbing systems. There are electronic products on the market that monitor the plumbing activation and allow for fixture lock-out or remote activation from a central control system. While most of these applications have been found to have value in the institutional markets (courthouses, prisons and correctional facilities), their benefits have found their way into healthcare installations.

Computerized water-control systems, which regulate water flow for networked plumbing products, help healthcare facilities managers control the plumbing system and conserve water in areas of the hospital designated for patients that require behavioral monitoring, such as chemical detoxification and psychological wards.

Based on microprocessor technology, these programmable plumbing systems deliver a certain amount of water to a specific area at an exact time determined by the facility manager.

Healthcare facilities are prime examples of the need to control the plumbing system. A networked system allows for remote control over all plumbing fixtures in the facility. Toilets can be shut down from a computer before a room search, thus preventing contraband flushing. Depending on the parameters that are established by the facility manager, this "plumbing system lockdown" can be designated for an individual room, specific wings, certain floors or the entire facility at the touch of a button.

Networked plumbing systems also allow the preprogrammed parameters to be adjusted so fixtures can be activated from the master computer, overriding any lockout. This function allows for complete control over patients who have lost all privileges to operate the plumbing in their room. Also, system report features on the central command computer allow monitoring of water usage by individual fixtures, and alarms will alert staff to violation locations.

Another example for the need of networked plumbing systems in healthcare facilities is to curb abuse of water. Locker room showers have been identified as a large source of water waste in facilities, considering some users leave them running after they are done.

With automated water control systems, facility managers determine when the showers can operate and for how long, providing maximum control, as well as flexibility in scheduling.

Another shower function of this system is just like using common electronic faucets. As a person enters the shower's sensor range, the system will deliver tempered water for a predetermined amount of time. This offers more control, as the sensor will re-activate after each cycle, ready for another user, but only during the time that was programmed into the system. Push-button units operate in the same way as sensors, except the shower requires manual activation of an electronic push button.

The facility benefits of water control systems include: elimination of "contraband disposal systems;" random delay time between successive flushes eliminates a person's ability to anticipate when the next activation is allowed; programmed lock-out feature combats flooding due to intentional clogging by limiting number of flushes within a specified period; programmed run-times of showers and lavatories conserve water because water flow ceases after programmed run-time expires; no mechanical failures due to push-button abuse; and no adjustments are required like mechanical metering valves as the run-time expires even if push-button is held in the on position.

Resources
1 "Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force," Centers for Disease Control and Prevention, MMWR 2002; 51 (No. RR-16).

2 National Center for Health Statistics. Vital statistics of the United States. 119th ed. Washington: U.S. Census Bureau. Statistical abstract of the United States; 1999.

3 "Microbiological Hazards of Household Toilets: Droplet Production and Fate of Residual Organisms," American Society for Microbiology, Applied Microbiology, Aug. 1975, Vol. 30, No. 2, pp. 229-237.

4 "Comparative surface-to-hand and fingertip-to-mouth transfer efficiency of gram-positive bacteria, gram-negative bacteria and phage," Journal of Applied Microbiology, Oct. 2002, Vol. 93, No. 4, pp.585-592.

5 "Effects of 4 Hand-Drying Methods for Removing Bacteria From Washed Hands: A Randomized Trial," Mayo Clinic Proceedings. 2000;75:705-708.