Building Hospitals to Stop Infection in its Tracks - The EReq Case

For the past 18 years Guilherme Coelho has worked as a healthcare architect, collaborating on projects with MSF, the International Committee of the Red Cross and recently with the Technical University of Braunschweig. His role as a healthcare architect has ranged from designing medical facilities capable of handling emergency responses, supporting the development of Internet of Things (IoT) tools for monitoring hand-hygiene compliance, and notably, working on essential requirements (EReq) for the optimal architectural guidelines for preventing the spread of infection in healthcare facilities.  

The EREq guidelines for infection prevention and control (IPC) in the hospital-built environment are at the core of Guilherme’s role as a Case Manager with the MSF Sweden Innovation Unit (SIU). The EReq Case was initiated, alongside the Operational Centre Brussels (OCB) Medical Department, with the aim of identifying and delineating the most crucial design criteria to optimize hospital built environments in order to facilitate the optimal behaviour of healthcare workers.

In the following Case Leader Insight interview, Guilherme shares some insight into the need for EReq, the mentality shift that needs to happen around the key role healthcare architecture can play in preventing unnecessary spread of infection, the challenges of the innovation process, and some advice for those looking to champion innovation in humanitarian health.  

Some Context - the need for healthcare design in infection prevention & control

The hospital-built environment is recognised as one of the core components of the WHO infection prevention and control programme for national and acute healthcare facilities. In an effort to promote effective and standardised clinical practices, WHO has stressed that emphasis should be made to optimise the healthcare environment, ensuring a system that supports the effective implementation of IPC practices.

Healthcare facilities in any setting are complex buildings with rigorous functional and technical requirements intended to facilitate optimal patient outcomes. Inadequately designed facilities can increase the risk of Healthcare-Associated Infection (HCAI) and create unsatisfactory and dangerous conditions for patients and staff alike. According to WHO, it is estimated that the prevalence of health care-associated infection varies between 5.7% and 19.1% in low- and middle-income countries at any given time, compared to between 3.5% and 12% in higher income environments, making it one of the leading causes of morbidity and mortality in the health sector globally in addition to another point of healthcare disparity that demands attention.

The need for well-designed healthcare facilities is critical in resource-limited settings and in emergencies, where the detrimental consequences of inappropriately designed facilities could have a substantial negative impact - an impact that may not always be traced back to its true source due to resource limitations.

Screen Shot 2019-01-05 at 21.07.05.png

Beyond the excessive number of deaths and the substantial costs incurred, HCAI can be also responsible for long-term disabilities, prolonged hospital stays and the increased resistance of microorganisms to antibiotics. Antimicrobial resistance (AMR) is recognised by the WHO as an increasingly serious threat to global public health. This increased prevalence of drug resistant infections result in longer stays in hospitals and more intensive treatments which naturally result in higher costs.   

Faced with the clear realisation of the potential devastation associated with the spread of drug resistant pathogens in hospital settings, particularly in humanitarian or low resource settings, there is a distinct need for intervention at all levels of the healthcare environment. Based on field insights and mounting literature one promising point of intervention for tackling the spread of hospital acquired infection head on is in the design of the hospitals themselves - exactly where the EReq Case comes into play.

Where did the idea for the EReq case initially come from?   

“It all actually started in 2013 while I was working together with the medical and logistic department of MSF Operational Centre Brussels (OCB) on guidelines for the planning and design of healthcare facilities. During the development of the guidelines - interviewing experts and visiting several healthcare facilities, the subject of infection prevention and control really emerged as a very important topic. I realised that the information we had available, the evidence and my own knowledge around this was quite sparse. We had to do something to improve the safety of staff and patients receiving treatment at MSF field facilities, but also for any other healthcare facilities in resource-limited settings. This was really the start of the EReq Case.

So, from there we started to connect with the key stakeholders that were knowledgeable about Infection Prevention and Control (IPC) and confirmed that, ‘yes’, this is something very important that needs to be addressed. In 2016 the SIU started to support the development of a project correlating the design of healthcare facilities and IPC, recognising the value of further developing guidelines on the topic.”  

We had to do something to improve the safety of staff and patients receiving treatment at MSF field facilities, but also for any other healthcare facilities in resource-limited settings. This was really the start of the EReq Case.
— Guilherme Coelho

One of the first field efforts associated with this Case and the requirements for the hospital built environment and IPC, was at an MSF hospital based in Haiti. This work set the baseline for the EReq project development to come further down the line and highlighted the need for multi-disciplinary teams to be involved in the development and implementation of humanitarian innovation efforts - something that is being released across the board when it comes to innovation efforts, these things don’t happen in isolation and despite planning the innovation process is rarely linear:

“The Haitian project was a very specific work, focused on containing an outbreak of a resistant pathogen in the neonatal intensive care unit (ICU). This was a multidrug resistant pathogen which lead to pneumonia and bloodstream infections, in this environment it meant very high mortality rates. We were invited to provide a consultancy to develop the design to improve the existing building in collaboration with a multidisciplinary team of experts. From there we were able to develop a proof of concept, which was the base for the EReq project proposal”  

Image – dedicated patient zone divided by partitions.

Image – dedicated patient zone divided by partitions.

Disseminating innovation - matching need with innovators   

Identifying a need or a problem, formulating a potential solution, and surrounding yourself with a great multi-disciplinary team are only the tip of the iceberg when it comes to disseminating innovation in humanitarian settings, or any setting for that matter. As highlighted by Guilherme below, there is a distinct need for the development of facilitating structures that will allow current and future innovators to connect, collaborate and share information - this is something we are dedicated to working on at the SIU. While serendipitous connections may be useful, it is not a reliable process that will meaningfully scale humanitarian innovation in the long term. There are enough unknowns as it is:

To start these projects, it’s not just enough to have a good team and a good idea, you really need a constellation of factors aligned to make it move forward, and decision makers awareness and support are important in this.  
— Guilherme Coeho

Balancing real short term need and the potential value of experimentation

The very nature of humanitarian healthcare activities don’t necessarily lend themselves to experimentation in an attempt to validate innovations. How can this be overcome - if at all? Guilherme champions partnerships with organisations who may be able to mutually benefit in addition to balancing the priorities of a humanitarian organisation who may not have the scope to dedicate finite resources to validation and experimentation of new innovations, despite the probable long term benefits:

Image – separation of the scrubbing area from the soiled material and housekeeping store room.

Image – separation of the scrubbing area from the soiled material and housekeeping store room.

“Because this subject was recognised as such an important issue in the field and beyond we managed to make contact with academic institutions that were conducting research in the area of infection prevention and control in hospitals settings, but with a focus on high income countries. We have now engaged with partners such as Robert Koch Institute, Charité University of Medicine and the Technical University of Braunschweig and a number of other experts in this field. We partnered with the goal of writing a joint proposal to achieve the initial objective of the EReq project, to find evidence-based design recommendations. So, they are now running with this and taking the responsibility to identify funding and MSF SIU will support as an expert consultant ensuring we reach a point where there are outcomes that we can use in the MSF healthcare facilities.”  

Innovation transferability and cultural context  

It will come as no surprise that innovation in health is not a copy and paste exercise in any context. Having said this the EReq guidelines have set out with the aim of delineating the minimal, or essential, viable built environment elements required for a clinical setting, positioning itself as a rare innovation that can meaningfully transfer between contexts with relative ease:  

“MSF works in more than 70 countries across the world, so we’re dealing with a significant variety of needs and expectations. This is something that typically slows down the dissemination of innovation as each technical recommendation might need to be tailored to a specific context. However, when it comes to the requirements for IPC for the design of healthcare facilities, there is little influence from the cultural surroundings and not many variations.  

For example, if you are going to provide a surgery to extract a bullet from a patient it doesn’t matter if it is in the Middle East, Africa or South America, the ideal procedure for surgery will be similar. “The size of an operating room is not going to change because of the context, MSF has the same guidelines for clinical practices worldwide, and we are aiming to do the same for the design of healthcare facilities, identifying recommendations that could be introduced in the majority of MSF contexts, if not at all contexts.

Coming back to the specifics of the infection control case we are trying to define what is absolutely essential, the very minimum for every single hospital, where the specificities of the context couldn't have influence on the requirements for the built environment.”  

The size of an operating room is not going to change because of the context, MSF has the same guidelines for clinical practices worldwide, and we are aiming to do the same for the design of healthcare facilities, identifying recommendations that could be introduced in the majority of MSF contexts, if not at all contexts.
— Guilherme Coelho

The worthy hurdle of evidence  

“One of the biggest challenges of the project is how we find evidence. How do we associate a change in the design of the hospitals with patient outcomes? To make a robust claim directly to this is quite difficult from a scientific perspective. How can we isolate the built environment and associate design features to clinical outcome? So scientifically speaking it is a challenge we are working though in terms of how we find evidence to support guidelines recommendations.

However, based on rationality and expert's opinion, you would assume that the impact of the design of hospitals at patients' outcomes to be relevant. The EReq recommendations speak only to the most essential requirements, we looked specifically at what were the most minimal changes that could be made to result in the highest impact at the quality of care.”

What is around the corner in 2019 for this Case?   

“We are still not at the tipping point when it comes to realising the value of hospital design in infection prevention and control. This subject is still surprisingly not a high priority in operations despite its obvious importance. A lot of things are now moving forward compared to the past, but we still have not reached that tipping point. I would say that the discussion about infection prevention and control and its link to the design of hospitals still has some way to mature.”   

The IPC recommendations for the health structure are key for many preventative measures and how they are used depend on our capacity to implement this knowledge into actual tools and practical interventions. This can range from the Hand Hygiene App currently used within MSF (developed by the MSF Operation Centre Amsterdam) in order to support IPC leads in their work of monitoring and training medical and non-medical staff with regard to hand hygiene compliance. This kind of digital tool is a great example of how to transfer knowledge such as the EReq guidelines into a suitable format with great impact potential, even beyond MSF contexts.  

Image – Hand-hygiene mapping

Image – Hand-hygiene mapping

We are also exploring further possibilities including training of field logisticians/log constructors regarding the principles of essential requirements for IPC in health structures and the integration of parametric design.

So, what will it take to get there? Can we move from reactivity?   

“It's hard to say what it will take but we are optimistic. If we have another Ebola outbreak this will push the discussion about IPC forward, but if we have an earthquake the operational priorities may be different. It will ultimately take a constellation of things happening at the same time to change this.”

As alluded to by Guilherme, this highlights that while operational priorities might be constantly shifting depending on the global context it will be important for us to capitalize on different projects in MSF where a focus on the built environment can be included from early stages, in addition to communicating and disseminating the opportunity and impact in order to reach a critical mass of buy-in.  

“I would say that one of the biggest challengers we have is to change the mentality of people regarding the subject. We are dealing with the invisible enemy when it comes to infectious disease - we don’t see them, so we don’t sufficiently fear them. Something visually appearing clean doesn’t mean there are no pathogens there. Furthermore, in resource-limited settings it can be difficult to prove that a death or the transmission of a pathogen or infection was acquired in the hospital setting itself.

So, it’s here we are missing clear proof that the hospital environment is actually having a huge impact on patient outcome. All these factors can make it hard to recognise and communicate the problem.”  

I would say that one of the biggest challengers we have is to change the mentality of people regarding the subject. We are dealing with the invisible enemy when it comes to infectious disease - we don’t see them, so we don’t sufficiently fear them.
— Guilherme Coelho

Moving forward – mentality shifts, partnerships and evidence   

According to Guilherme, to achieve the audacious goal of preventing and controlling hospital acquired infections it is crucial we strive to enhance the current evidence and knowledge of the particularities of architectural projects of healthcare facilities in humanitarian contexts by developing, testing and validating design requirements that lead to more efficient and context-adapted medical buildings.  

“Humanitarian organisations, academic institutions and other relevant stakeholders should ultimately work in close cooperation to improve the body of evidence in this largely neglected field of architecture, by conducting affordable and high-quality research adapted to resource-limited settings.  The need and potential positive impact on health outcomes are undeniable.

Moreover, what is really necessary is an adjustment of mentality. We have to reconsider the role of the hospital-built environment in healthcare outcomes. As a community we need to recognise the impact of the design of medical buildings on the quality of a patient’s treatment and recovering process.”

Visit the EReq case page here and reach out to Guilherme Coelho here.

This was the first in a series of Case Leader Insight interviews with those paving the way in the MSF Innovation space. If there is anything in particular you would like us to consider in these interview extracts going forward feel free to get in touch with any questions or comments at siu@stockholm.msf.org