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Infectious Ideas: Using Antimicrobial Copper Alloys in Hospitals,
by Alice Ro
Top: Hospital room with sani-station and touch-point hardware: grab bar, faucet, and light switch. Bottom: Sani-station in hospital lobby.
Alice Ro writes on behalf of Pensa, where she is director of research and strategy.
Copper Touch is a system of antimicrobial touch-point hardware and sani-stations (alcohol gel dispensers) designed to be deployed in hospitals to reduce infection. The system kills germs in areas people are most likely to touch while addressing some of the behavioral challenges of infection control: hand-washing and cleaning surfaces. The products also showcase the newly-proven antimicrobial properties of copper alloys; the sani-stations act as communication points to brand the material at the place where germs are top of mind.
The project began when the Copper Development Association (CDA) approached us at Pensa with the problem of encouraging hospitals, CDA's target market, to adopt copper alloys. Studies proving that these materials kill microbes faster and more effectively than any other antimicrobial material on the market and an EPA registration permitting health claims about these properties were not enough, so the CDA asked that we identify and design compelling hospital products that would inspire designers and manufacturers to use copper alloys wherever there was a need to fight infection.
Consistency, patient compliance, and error avoidance are all crucial factors in effective delivery of a therapy. This is the space where we excel: applying an understanding of human behavior to create solutions that work within our imperfect world.
To develop a solution, we first had to understand the challenges of infection control in hospitals and the experiences of a range of hospital stakeholders, including infection control officers, cleaning staff, administrators, doctors, nurses, patients, architects, and facility managers.
Antimicrobial effectiveness: copper vs. the competition. Copper alloys have also been proven to kill Staphylococcus aureus, Enterobacter aerogenes, Pseudomonas aeruginosa, and E. coli, in under two hours.
Design and medical science The number of Americans who die every day from hospital-aquired infections (HAIs) is equivalent to one jumbo jet plane crashing every day, according to Donald Wright, MD, MPH, of the US Dept. of Health and Human Services. Surely, there would be an uproar if our society allowed for such continuing aviation disasters, but HAIs just don't have the same prominence in public awareness. Hospitals are under a lot of pressure to rectify the situation—pressure that includes the cessation of Medicare payments in cases of HAIs and several state laws mandating transparency or reporting of HAIs—but fixing the problem is a struggle. The problem of the quantity of infections is compounded by antibiotic resistant "super bugs," created by the overuse of antibiotics.
In a real hospital room, it's quickly obvious that microbes on surfaces aren't the only issue. How many people touched this table? How does it get cleaned?
"The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored." —Peter Pronovost, pioneer of medical checklists
Through the work of Peter Pronovost, we came to understand that infection control is largely an issue of effective implementation. The medical establishment already knows how to prevent infection in an ideal world (hand-washing, for example), but they struggle to implement that knowledge effectively in the real world. Even beyond infection control, the issue of effective delivery is one of the major challenges in healthcare today. Consistency, patient compliance, and error avoidance are all crucial factors in effective delivery of a therapy. Fortunately for designers, this is the space where we excel: applying an understanding of human behavior to create solutions that work within our imperfect world. This is what we needed to achieve with copper: the CDA has already shown it kills microbes (effective therapy), but the key issue for us was effective implementation. Wash your damn hands! To help us identify what products most needed an antimicrobial surface, we spoke to many infection control officers. But time and again, as we tried to get an inkling of where copper alloys would be most beneficial, they responded with a variation of "That's nice, but we wouldn't need it at all if people would just wash their (damn) hands!"
Hand washing is the top weapon against the spread of infection.
What is the big deal about hand washing? Yes, it's key to preventing the spread of microbes, but why the frustration? It seems simple to do. But, the infection control profession has tried every educational method under the sun and papered hospitals with reminder posters, and compliance rates are still not sufficient. It became clear to us that the infection control officers' priority isn't a new technical solution (antimicrobial material), so much as a better behavioral solution.
Each piece of equipment has its own cleaning protocols, different people are responsible for different objects, and the systems for letting staff know whether an object has been cleaned are far from fool-proof.
This brought us back to the idea of design playing a crucial role in effective implementation—in this case, of hand-washing. Design changes have already proven quite effective at improving compliance. Architects practicing Evidenced Based Design—a movement in health care design that emphasizes measuring the impact of design interventions on patient outcomes and building on the results— showed that strategic placement of hand sanitizer dispensers and sinks leads to more hand washing. Maybe our solution could improve compliance in a similar way through product design.
Cleaning chaos When observing hospital cleaning staff, we discovered that they deal with a surprising amount of complexity. Each piece of equipment has its own cleaning protocols to ensure it isn't damaged, different people are responsible for different types of objects (furniture vs. personal electronics vs. highly specialized medical technology), and the systems for letting staff know whether an object has been cleaned are far from fool-proof. This complexity leads cleaning managers to resist the introduction of new materials that require any special care, like polishing. We also found that cleaning, in general, is not very effective. Study after study showed dangerous microbes left behind even after thorough attention. It's another area in which hospitals are exerting a lot of effort but getting spotty results.
An improvised way to track if something needs to be cleaned.
Of course, copper alloy products would still need to be cleaned, but if we used low tarnish alloys, we could ensure that the cleaning staffs' work load would be unchanged. Cleaning could be made even easier by using only smooth, wipeable shapes. A distinctive look could be used as a reminder of key places to clean, like a visual checklist.
Infection control professionals realized that, while neither cleaning, handwashing, nor antimicrobial materials are enough on their own to prevent the spread of infection, combining tactics is very effective. They created "bundles," checklists of tasks that prevent infection together. Like bundles, our product(s) needed to work in a combination of ways to be successful.
Copper's tenacious mythology The silver color on a quarter is a copper alloy—but hardly anyone knows it. In fact, nearly every designer and engineer we spoke to said the same thing about copper alloys: they're not hard, not strong, they tarnish, and they look old-fashioned. Architects feared using copper would result in a 'steampunk' hospital. But in fact, there are registered copper alloys that resist tarnish and rival steel in strength and hardness. These come in colors ranging from silver to yellow to red, and include nickel silver, brass, bronze, and copper nickel.
Copper and many of its alloys are already informally 'branded.' For example, copper is associated with electrical applications, cookware, and high quality plumbing, while brass is linked to sailing equipment. Our challenge was to create a new association with antimicrobial action while highlighting the material's unexpected capabilities.
Many administrators have come to recognize that the patient experience impacts outcomes; stressed patients recover more slowly. Ignoring the patient experience puts the hospital at a competitive disadvantage.
A patient's journey Patients' perceptions of the safety of their hospitals, in terms of cleanliness, are based on the things they see during their first experiences there. Stefanie, a woman with an auto-immune disorder that required frequent infusions, described how her perception of one hospital was negative from the moment she entered the lobby. The dirty trash can beside the entrance immediately created a sense of mess and disorder. As she made her way through the hospital to the infusion department, she noticed all the doorknobs and elevator buttons she'd have to touch and worried about what germs could be growing there.
Trash can at a hospital entrance.
Fortunately, the hospital industry is beginning to pay more attention to the patient's point of view, diminishing unpleasant experiences like Stefanie's. Many administrators have come to recognize that the patient experience impacts outcomes; stressed patients recover more slowly. Ignoring the patient experience puts the hospital at a competitive disadvantage.
Copper Touch Our insights and analysis led to Copper Touch (pdf), a system of touch point hardware—doorknobs, light switches, grab bars, wall guards, drawer pulls, etc.—punctuated with sani-stations dispensing alcohol gel. Imagine how different Stefanie's experience would be if she went to a Copper Touch hospital: When Stefanie first enters the hospital lobby, she sees a standing sani-station. She uses some hand-sanitizer and germs naturally come to mind. This makes the sani-station the perfect place to inform her about the importance of hand cleaning, antimicrobial copper alloys, and the safe-to-touch hardware throughout the hospital that shares the same style and logo. As she walks throughout the hospital, she sees more sani-stations on the walls that enable her to clean her hands and that remind and enable others to clean their hands as well.
Hall with wall sani-stations and touch point hardware: doorknobs, wall guards, push plates, and elevator buttons.
This approach is in line with the Broken Window Theory, which posits that shoddy environments encourage shoddy behaviors like vandalism, while well-cared for environments encourage good behavior. The cohesive look of the Copper Touch hardware serves to create an atmosphere that is conducive to best practices and keeps hand cleaning in the forefront of the minds of staff, visitors, and patients like Stefanie. It also provides Stefanie with a sense of security, knowing that this hospital has given infection prevention top priority.
Assorted Copper Touch hardware, made mostly of nickel silver ( a copper alloy that has a steel-like finish) with details in copper nickel (a pale peach alloy) to remind users of the copper content.
Design for health This project was initially conceived with laboratory science addressing efficacy while design would simply contribute style and appeal. But shifting the focus to the real goal of lessening HAIs allowed Pensa to hone in on the issue of effective implementation of this exciting material. While Copper Touch's antimicrobial copper alloys protect common hospital touch points, the cumulative impact of the system also works towards changing human behavior and increasing hand washing, addressing the issue that concerns hospitals most.
In a larger sense, Pensa's design concept, the Copper Touch system, illustrates how effective delivery of a therapy (which in this case is antimicrobial material) is as necessary to success as the effectiveness of the therapy itself. The healthcare industry is in need of improved delivery of all sorts of treatments, and the knowledge and approach of designers will be crucial to addressing this need.
Alice Ro is director of research and strategy at Pensa, a strategic design consultancy in Brooklyn. For more information about Copper Touch, download the project pdf here.
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In addition to your Copper touch concept,
we could envision a system in which patient would automatically receive Video/Text messages (health advice about sanitizing information) on their cellphone as soon as the patient enter the hospital.
(to avoid spam there would be an unsubscribe link on the message..)
Look at the Dyson air blade, it makes people want to dry their hands after washing because to do so is fun and a joy. In the same way product design can increase hand washing in hospitals. I think the biggest problem is that hospital staff are so damn busy and have so much going on they forget. - it is not a priority for them to wash reguraly.
David, you are spot on that it is out of the designers hands. Although I appreciate the branding to increase sanitation, behavior change is the real challenge here.
It is a stretch by any means to consider this single sentence as a call for culture change, especially in a 2,000 word article. And adding more sanitizers raised compliance only by a few percentage points. Nurses are stuck at 40%, docs at 30%. The greatest product in the world won't change that rate, it is something out of the designer's hands.
The author goes on to talk about bundles, combinations of things to lower HAIs. But again, ironically, Pronovost's book will attest that making a bundle is worthless without the culture change to adhere to the bundle. It won't work if people aren't going to follow the bundle.
Of the over 250 alloys registered with the EPA, many are very tarnish resistant. Silver nickel (actually doesn't contain any silver metal) and copper nickel are very tarnish resistant because of the nickel content, and their strength and hardness can rival some steels.
The solution lies in designing a product that changes the HAI culture in hospitals today.
It may be true that there are copper alloys which don't cause this affect, but they probably are not antimicrobial. The reason copper is antimicrobial is because its such a strong reducing agent. It breaks down biomolecules to kill bacteria, and makes things stink.
(http://knowledge.ls3p.com/2009/09/09/copperbrass-surfaces-are-natural-disinfectants/)
There's also further research going on at the Medical University of South Carolina (http://www.musc.edu/pr/copper.htm)
I'd be curious to see renderings of this system after it's gotten a patina. I'd like to hear more about the copper alloys that resist tarnishing, as it seems like this will be a key factor for implementation. While it looks great on a roof, tarnished copper simply doesn't 'look clean' and as a result likely creates a significant barrier to adoption.