Are hospitals getting left behind?

Many readers will already know that cleanroom technology has its roots in hospitals, with most of the early research being carried out during the Second World War on the airborne dispersion of micro-organisms and the aerodynamics of particles.

The principles of the turbulently ventilated room were established by the 1960s and, when industry in general took an interest in the new "clean" technology, further developments followed with the introduction of unidirectional (laminar flow) ventilation. Since those early days, cleanroom technology has moved on at a rapid pace and we are now at the point where many existing cleanroom installations have dropped off the scale of what is deemed to be a clean environment; and many of these are to be found in hospitals up and down the country. But why should this be? Hospitals are often refurbished and one would therefore assume that the clean areas would have been brought up to the standard relevant at that time, so why do hospitals have a problem with contamination control?

Existing technology You only have to glance through the pages of this magazine to get a glimpse of the problem: article after article on MRSA, E.coli, cleaning and decontamination. It is interesting to read about measures being introduced to combat these problems as if they are new technology, when most of them have been around for years. They are only new technology in the hospital sector, and that is why I ask, "has cleanroom technology left hospitals behind"? The basic requirement in hospitals is that of microbial contamination control. There are four areas in a hospital that have differing control requirements: the aseptic pharmacy unit; the operating theatre; the isolation ward and the general ward. Other areas, such as the neo-natal and special care baby units, are simply a variation of one of the above.

Repeated mistakes I have visited many hospitals during the course of my work at HiTech Controlled Environments, some of which were better than others, but all of which seem to make the same mistakes over and over again, a few of which I will highlight here. The aseptic pharmacy units are without doubt very good at microbial control, as one would expect. The workforce is usually very well trained in cleanroom procedures and has a good understanding of how cleanrooms work. But they are let down by the facilities themselves. Most of these cleanrooms are built using old technology by people who do not fully understand the requirements of the facility itself, and are then maintained by a maintenance company that has probably never seen a cleanroom until the day they walked through the door. This increases the workload of the pharmacy staff to maintain the aseptic condition of the facility, and that in turn increases the running costs. The operating theatre is a place where people are "cut open", and is the place where cleanroom technology has its roots. Yet few, if any, operating theatres can be classified as a cleanroom. They are mostly a room with a unidirectional (laminar) air flow over the work area; outside this area the cleanliness level drops off, dramatically in some cases. OK – you might argue that the most important item, the patient, is in a clean area; but what about all those items outside the clean area that are brought in later? More to the point, contamination control procedures in the operating theatres are often very lax, and in some instances non-existent. I have seen theatre staff leave the theatre to check up on some detail without changing garments, and that includes theatre shoes. From a contamination control point of view, this is a cardinal sin. Isolation wards also leave a lot to be desired. The idea of such a ward is to isolate a highly infectious patient or to protect immuno-suppressed patients, and they will either be under a positive or negative air pressure according to the type of patient being isolated. The problem again is with the facility: they are generally built by people who have little understanding of the requirements of an isolation ward, and maintained by people who have no idea about contamination control. The biggest problems I have come across are associated with HEPA filters, or rather the lack of HEPA filters; the lack of filter testing where they are installed and the lack of any method of "safe change" for the filters. HEPA filters must be tested to prove that they are not leaking past their seals or damaged, otherwise what is the point of the isolation ward? Furthermore, a "safe change" facility is required to protect maintenance staff from the microbes in the filters. I know of at least one large teaching hospital where the above precautions are not met due to the costs involved. That brings me to the general ward: is it a cleanroom or not? When we discuss cleanrooms in industry, it is often in the context of particle counts, BS EN ISO 14644 and the EUGGMP. However, a hospital is a very different place, with the emphasis not so much on particle counts as contamination control. Cleanroom procedures, however, are very good aids to contamination control, even when applied to an ordinary building such as an office, the home or the general hospital ward. Look at MRSA for instance. It is extremely difficult to cure once infection has occurred, making the problem one of prevention, or contamination control. There are a number of cleaning agents that are effective against these microbes, yet they are not widely used in hospitals. Why not? There are no effective contamination control procedures implemented in hospitals. Again, why not? Cleanroom technology has come a long way since those early days, and the science of contamination control has travelled with it. I suppose that my question shouldn't be has cleanroom technology left hospitals behind, but rather has the science of contamination control left hospitals behind? The root of the problem is that hospitals do not discuss their requirements with the right people. Building contractors and air conditioning sub-contractors often do not fully understand the requirements of the controlled environment – and a hospital is, or should be, a controlled environment. HiTech Controlled Environments is one of many companies that specialise in contamination control and the controlled environment. The expertise is out there, it's time for hospitals to use it.