Infection prevention and control practice is vital in the healthcare environment, especially in critical care settings like Intensive Care Units (ICUs), where patients are particularly vulnerable. One often overlooked aspect of infection control in healthcare settings is the choice of doorsets. To shed light on this crucial topic, Alyson Prince, a Built Environment Infection Prevention and Control Consultant Nurse spoke to us about the factors to consider when specifying doorsets for healthcare environments, keeping infection control at the top of the list.
The care environment comprises three elements that provide or support patient care:
- the building,
- the equipment
- the people, including staff and visitors.
The near-patient environment poses one of the highest risks to the patient and, therefore, it is important to understand its role in transmission.
Fomites are inanimate objects, that can be a known vehicle for transmission, which includes patient care items and environmental surfaces such as doorsets. Transmission of Multi-Drug Resistant Organisms (MDROs) from contaminated surfaces to patients may occur via direct contact from the hands or gloves of healthcare personnel, or indirect contact by cleaning substances through inappropriate materials.
Direct transmission occurs from healthcare workers’ hands or clothing becoming contaminated providing the opportunity for cross-infection to occur. Patients shed microorganisms that survive for a prolonged period in the air, in water or on surfaces.
The number of organisms present is determined by clinical activity, the number of people and the ability of the material to support microbial growth. Therefore, material selection and product design must lead to choices that minimise microbial growth, maintain product integrity and withstand stringent cleaning regimes.
Specification decisions
The ability of a doorset to withstand damage is paramount to prevent the acquisition of infection because when surface integrity is compromised, pathogenic organisms can stick to the surfaces and increase environmental reservoirs.
Alyson added, “In addition to this, it is also important to consider that the door contributes to the ability to balance the airflow within a space, which is critically important in the higher risk areas such as operating theatres”.
The impact of choosing the wrong door set can be catastrophic, especially if it leads to the spread of MDROs.
Alyson mentioned “It is well documented that organisms can survive on surfaces for extended periods resulting from hand touch contamination. It is important to note that if a poor decision is made at this point, this selection is likely to be replicated across a unit, or a wing of a building for the duration of the occupation of a space”
Another consideration from an IPC perspective is that these fixed elements may be present even where changes are made to the usage of the area, i.e. changes from lower-risk to high-risk settings such as critical care. A future-proof approach would include attempting to specify products that can meet the IPC requirements of all potential uses of a space.
Where the highest-risk settings are involved, it becomes even more important to ensure that the selection of fixtures or fittings such as door sets can reduce the risk of transmission of infection.
Cleaning Effectiveness
Cleaning within the healthcare setting has always been an integral part of tackling the fight against the spread of infection. It is widely known that the environment serves as a reservoir for organisms when they are not physically and effectively removed from the environment.
All surfaces in patient care areas should be smooth, waterproof, and easily cleanable. Unnecessary horizontal, textured, moisture-retaining surfaces or inaccessible areas where moisture or soil can accumulate should be avoided. Fixtures and fittings should be designed to allow easy cleaning and discourage dust accumulation.
Doorsets must be designed to withstand prolonged and rigorous cleaning protocols and to prevent the harbouring and spread of pathogens. Integrated panels or inaccessible areas within doorsets can create breeding grounds for bacteria and viruses, posing significant infection transmission risks. Raised beads around vision panels can trap dirt and moisture, providing ideal conditions for microbial growth and biofilm formation.
To ensure thorough cleaning and disinfection, doorsets must be constructed without any such features that could impede cleaning efforts. Flush vision panels are an excellent choice as they eliminate any recesses where contaminants can accumulate, allowing for easy and effective cleaning. It has been shown in numerous studies that these elements pose a risk for serious onward transfer to patients.
In addition to flush vision panels, other examples of features that enhance the cleanability of door sets include seamless surfaces, rounded edges, and non-porous materials. These design elements minimise the risk of contamination and facilitate thorough cleaning, contributing to infection prevention efforts in healthcare environments.
Materials used in their construction should be resistant to corrosion and degradation from cleaning agents, ensuring durability and longevity.
Colour & Aesthetics
Doors play a multifaceted role as demarcation points within healthcare environments, serving not only as physical barriers but also as visual indicators of different areas and levels of care. Colour-coded doors offer a clear and intuitive wayfinding system, enabling patients, staff, and visitors to quickly identify different departments, units, or zones within the healthcare facility. For example, doors leading to high-risk areas such as isolation rooms or operating theatres may be designated with a distinctive colour, alerting individuals to exercise caution and follow specific protocols before entering.
In addition to promoting efficient wayfinding, colour-coded doors contribute to the overall aesthetics of the facility, enhancing its visual appeal. By coordinating door colours with the facility's interior design scheme or branding elements, healthcare facilities can create a unified and welcoming atmosphere that supports patient and staff comfort and well-being.
Lifecycle Management
The lifecycle management of doorsets is crucial, as usage in healthcare spaces can range from heavy to severe. As a result, the risk of physical impact on doorsets is high in these environments, which translates to rapid and significant damage where the wrong product selections are made. It is essential to get the choice of doorset right the first time, as repair and replacement often entail downtime, something that clinicians and estates teams alike will say is not an option in critical care.
Alyson added “Even when a live environment can accommodate work, the risks associated with replacing doors in ICU wards are significant. Each replacement brings in tools, people, and potential contaminants, putting patients, staff, and visitors at risk. In addition to this, the reduction of environmental contamination which can occur from replacement works is a priority that adds complexity and cost to such activity”.
Sustainability balanced with durability.
Sustainability is also a key consideration in doorset selection. While sustainability is paramount, materials typically viewed as sustainable such as wood are the worst choice from an infection control standpoint if not appropriately incorporated.
Fully wrapped postformed doors offer a highly sustainable option, as they do not need frequent replacement due to damage compared to other choices. This is because one of the most sustainable practices in any setting is to install products that last. Repair and replacement produce waste that needs to be disposed of, and use additional materials, chemicals and energy; all of which can be avoided if the right products are chosen from the outset.
Financial sustainability is also secured through durable product choices. The impact on NHS Estate's budgets for the repair and replacement of doorsets can be significant, along with penalty charges and lost revenue associated with disrupted patient care. It does not take long for these costs to dwarf any small additional investment attached to specifying products that last.
Conclusion
Healthcare architects and NHS trusts must have confidence in the products they specify to ensure infection control standards are met. Any oversight in doorset selection can have dire consequences. Therefore, linking this discussion to new Furniture, Fixtures, and Equipment (FFE) specifications is crucial to ensure that infection control remains a top priority in healthcare environments.
Transmission can occur within the environment and overall increases the use of antibiotics, increasing antibiotic resistance, a real threat to the health of the population. We must design environments that reduce their risks to the patients and are safe and effective for use in the healthcare setting.
In conclusion, specifying doorsets from an infection control standpoint is vital in healthcare environments, particularly in critical care settings like ICU wards, and theatres. Architects, NHS trusts, and healthcare professionals must prioritise doorset selection to mitigate infection risks and uphold patient and staff safety and well-being.