Using intelligent design to reduce infection rates

The challenge brought together some of Britain’s top designers and manufacturers, many of whom are renowned for design icons, from Virgin Atlantic’s Upper Class airline seats to Parker Pens.

Design Bugs Out, commissioned by the Department of Health and in collaboration with the Design Council, was a trailblazing project using design to confront the problem of healthcare-associated infection. In just nine months, it produced cutting-edge concepts for furniture and equipment designed to make cleaning easier and faster.

Following research with frontline staff in hospitals throughout the country, a panel of experts assessed which items could, if redesigned, have the biggest potential impact in reducing patient’s exposure to HCAIs.  Of the eleven products initially developed four – the commode, patient chair, bedside cabinet and over-bed table – have been evaluated in eight ‘showcase’ hospitals .

The innovative designs eliminate hard-to-clean joins and inaccessible areas, reduce numbers of components to allow easy disassembly and cleaning, tougher smoother surfaces which don’t harbour bacteria (and resist wear and tear) and a whole host of innovations which reduce ‘touch points’ and improve usability, comfort and functionality for patients.

Multi-perspective input
A report issued by the Department of Health in November evaluated the efficacy of these products from staff, patient and visitor perspectives on the ease of use and how quickly/easily they are to clean. Launching the report Health Minister Simon Burns said: “These four innovative and user-friendly furniture designs – now available for hospitals to buy – provide additional ways to help to reduce these infections. They will make it easier for staff to keep wards cleaner and help combat the spread of infections. This means keeping patients healthier, as well as saving the NHS money in the long term.”

This design methodology has now been used in a second breakthrough project commissioned by the Department and Health and run by the Design Council: Reducing violence and aggression in A&E. The year-long project unveiled prototypes during November with huge support from clinical staff.

By studying patient behaviour and interactions with staff, including incidents of aggression, the team of designers, psychologists and healthcare experts discovered the key to the problem lies in providing patients with a better understanding of the system they are in, and to display the relevant information at specific moments in the patient journey through A&E where frustration and misunderstanding is likely to be exacerbated.

Dr John Heyworth, Emergency Department Consultant at Southampton General Hospital and immediate past president of the College of Emergency Medicine said: “Violence and aggression towards staff and other patients in the emergency department is a major nationwide issue – it has been getting worse and has not shown any signs of letting up in recent years.

“But, while there will always be a small minority intent on causing trouble, there are others who can resort to aggressive behaviour because they don’t feel they have been communicated with effectively, their privacy has been compromised through limited space and they don’t know what to expect from their treatment pathway.

“Better processes for meeting patients and discussing what they can expect, better training for both clinical and admin staff on how to handle volatile situations and improvements in the design of departments can help to remove tension and create a calmer environment.”

The solutions were specifically designed to be simple to implement across both older and newer hospitals, be low-cost and avoid creating physical barriers between patients and staff, which could create a sense of alienation and lead to an escalation of the problem.

The prototypes unveiled include a new approach to greeting patients on arrival, answering their questions and ensuring they start the A&E experience positively.

A system of environmental signage, which designers have called information ‘slices’ was also revealed which conveys clear, intuitive, location-specific information. These give patients guidance about their physical location and where they are within the A&E process.

Another feature was a personal process map that explains what to expect from the treatment process and when to expect it, in order to manage users expectations of waiting times.

Digital screens providing live, dynamic information about how many cases are being handled and the current status of the A&E department, are also recommended.

The project also looked at how violence and aggression can be tackled more effectively by staff reporting of incidents and sharing information on how to spot the early signs and take steps to ‘de-escalate’ potential problems. Designers developed a suite of tools to facilitate staff-centred reporting, and an eight-week programme to help them work with managers to address incidents at a local level.

Toolkit solution
The third output of the programme was to provide an extensive toolkit of research and best practice for senior hospital managers, allowing them to factor in the new insights when making decisions about major refurbishments or alterations.

The toolkit includes advice and guidance on the best ways to reduce the incidents of violence and aggression through better department layouts, sightlines, lighting, décor, seating, and systems and procedures. For detailed information, visit this website:

Design Council’s project manager Chris Howroyd, who led on both projects, explains one of the most important elements of the design process: “Designers lived and breathed the daily routines of staff and patients and the problems and issues they’re dealing with every day. As well as observing behaviour and systems at work, they talked to patients, visitors and practice NHS staff to gather insights. Designers call this ethnographic research and, driven by their people-centred perspective, it often yields crucial insights”.

‘Intelligent design allows ideas to be prototyped and tested and iterative improvements to be made before large sums of money are committed. Our model aims to take the risk out of innovation by providing a neutral space for public sector professionals and staff to come together with the private sector to tackle intractable problems. Previous challenges show that the model works and it also showed that it’s possible to get the private sector involved in healthcare innovation with relatively small incentives.’

The commode: Existing commodes tend to be made up of multiple parts, with complex junctions between different materials. This makes them difficult and time-consuming to take apart for thorough cleaning. The design team (PearsonLloyd and Kirton Healthcare) developed a simplified construction that makes cleaning the commode quicker and easier, reducing the risk of HCAIs. Aesthetic and functional changes also improve patient comfort and dignity.

A detachable plastic shell and robust stainless steel frame make the commode easy to clean and easy to store. Using a top-loading system for the pan instead of mounting it on the underside of the seat eliminates gaps and openings, preventing waste from contaminating any hard-to-reach parts of the commode. And fewer touch-points between patient and commode reduce the chance of cross-infection through contact with contaminated surfaces.

The Commode has adjustable armrests so patients can slide directly onto it from a bed or chair. Adjustable footrests also make it easier for patients to get into and out of the Commode. Research also found that making a commode look like a piece of furniture can be off-putting for patients. The new design actually looks like a toilet instead of a chair, which helps put patients at ease when using it at the bedside.

Over bed table: Geoff Hollington designed the over-bed table for patients which eliminates hard-to-clean corners, is made of special durable, scratch-resistant materials, and is easier for patients to use unaided. The smooth, easy-clean surface ensures high resistance scratches and heat. A contoured edge contains spillages and the side contact areas have been designed with patient tissue viability in mind.

The Bedside Cabinet: Existing bedside cabinets are difficult to clean. Their complex internal spaces, inaccessible surfaces, angular joints and rough, absorbent materials can harbour liquids, dirt and bacteria.

The solution now being used is a revised version of the traditional bedside cabinet made from durable, wipe-clean plastic that reduces the number of hard-to-reach corners and surfaces without cutting down patient storage space.

Removable drawers with cutaway sides are easy to clean and can be reached by patients without having to get out of bed. The backless design of the cabinet frame, its wipe-clean fascia and integrated handles reduce the number of inaccessible surfaces, allowing rapid cleaning.

Rotationally-moulded plastic is durable, easy to clean and minimises the need for joints and crevices that can harbour bacteria. An in-built radio frequency identification (RFID) lock in the bedside cabinet allows patients to secure their belongings without a traditional lock and key mechanism, which is difficult to clean.

The Patient Chair: Foam padding and vinyl coverings may be comfortable, but their tendency to degrade over time can compromise hygiene. Also, existing chairs are often difficult to disassemble, making cleaning problematic.

Using this insight the design team (PearsonLloyd and Kirton Healthcare) developed a wipe-clean frame and foam-filled waterproof cushions with removable fabric cases make this chair easy to clean regularly without compromising patient comfort.

The removable cushions include Intelli-Gel™, which provide superior pressure management and comfort for the patient and are held in place by magnets. The cushions and fabric cases are interchangeable and can be replaced individually if they are damaged, making the chair more cost effective. A gas lift in the stainless steel frame means that the height of the chair can be adjusted to suit individual patient needs.

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