Wash your hands. Don’t touch your face. These are easy instructions to follow, but we’re in the midst of a pandemic in part because humans are terrible at hand hygiene.
That’s one of the challenges facing W21C, a one-of-a-kind research centre at the University of Calgary. W21C’s goal is to generate ideas about how to make health care delivery safer and then test those ideas to make sure they work before rolling them out to different health care systems around the world.
Human beings are creatures of habit. Knowing that something is good for us isn’t always enough motivation to change our habits, says Dr. John Conly, professor of medicine at UCalgary and medical director for W21C. “Sometimes we need technical and engineering solutions to help facilitate the changes we want,” he said.
It may sound like overkill to talk about engineering solutions to get people in modern hospitals to clean their hands. But it’s not. In hospitals, people do not abide by the rules of good hand hygiene. In a study published in 2019 in the American Journal of Infection Control, only two-thirds of Canadian adult inpatients said they washed their hands after using the toilet (the toilet! In the hospital!) and only 49 per cent said they washed their hands before eating. Of the 268 inpatients at five large Ontario hospitals who were surveyed, three-quarters said they did not want to receive any more information about hand hygiene while in the hospital. The math speaks for itself: some people who don’t wash their hands after using the toilet also don’t want any more information about why they should.
Infection risk is everywhere in a hospital. The invisible micro-organisms that can make us deadly sick flourish in hospitals. These bugs live in ceiling tiles and bed mattresses, in toilets and under them, and on doorknobs and in faucets, on skin wounds and in poorly sterilized equipment. They thrive on the drapes that hang between patient beds. They hitchhike on our clothes and skin when we go from one place to the next. They take advantage of design flaws with horrific results: between 2004 and 2006, 12 transplant patients died in the Toronto General Hospital from a bacterial infection, spread as water droplets from sinks at nearby hand hygiene stations splashed out of the basin and onto nearby surfaces.
Infections come with a high price tag, both in lives and dollars. According to the Canadian Patient Safety Institute, about 8,000 Canadians die from hospital-acquired infections each year. Another 220,000 get infected. In a study from researchers at W21C, the burden to the health care system of hospital-acquired infections is enormous: hospital-acquired cases of the intestinal bacterium Clostridium difficile, or C. diff., in Alberta alone cost more than $19 million per year on average. “When a patient has an infection, the resources required to look after them are tremendous. The patient has to go into isolation, staff and visitors need personal protective equipment. Sometimes patients are antibiotic resistant and so we need new antibiotics,” said Wrechelle Ocampo, a research associate at W21C. “A lot of effort goes into responding to infections and it’s very, very costly.”
W21C, short for Ward of the 21st Century, was built for finding out-of-the-box solutions to challenges like infection. The institute is home to an interdisciplinary team of specialists from medicine and engineering who partner with experts in architecture and even visual arts. It consists of two separate spaces: Unit 36 of the Foothills Medical Centre, and a research and innovation centre at the Cumming School of Medicine. The latter includes a simulation lab, complete with simulated patient, “Ward,” who groans, coughs and instantly develops high blood pressure when a researcher triggers it via a computer order. Unit 36 is Canada’s only “living laboratory.” It functions just like any other hospital ward, but it was set up by W21C with a dual purpose: to treat patients while testing new medical technologies and health system designs.
To walk through the living laboratory is to see a history of health care design over the last 15 years, both what worked and what didn’t. The unit was the first in Alberta to use COWS (computers on wheels), the mobile computer stations in hallways where health care workers can access a patient’s medical record. Outside the patient rooms, empty little cupboards hang on the wall with their doors removed. The cubicles were originally built so that the personal protective equipment (PPE) that health care workers don to protect them from infection would be at hand when needed. But the cubicles were too small for the large outfits.
One of the first big successes for W21C was in the area of infection control and came almost a decade ago. A nurse complained about frequent rips in the mattresses of patients’ hospital beds at Foothills. It’s expensive to replace mattresses but dangerous to ignore tears. In 2013, the FDA issued a safety caution about mattress surfaces, saying that damaged mattresses can be sources of contamination during infection outbreaks. In Calgary and elsewhere, staff often covered flaws with tape, a technique neither proven to decrease contamination, nor durable.
The nurse brought her concerns to two graduates of the university’s biomedical technology program, Iwain Lam and Fabrizio Chiacchia. At the time, they were looking to develop medical products they could bring to market quickly. The pair drew out a sketch for a repair patch on a napkin, started a company now called Surface Medical Inc., and turned to W21C.
Over two years, W21C organized trials for the duo’s prototypes, and carried out microbiology studies and focus groups. The end product, CleanPatch, was tested on beds on Unit 36.
W21C gave Surface Medical a way to validate its product in a “real-world setting,” said Lam, president and CEO of Surface Medical. “Without that support, it would have taken us a lot longer and a lot more money to turn the idea of a repair patch into a medical device.”
The company released CleanPatch in 2012. It works like a bandage for hospital beds and other equipment like wheelchairs, and is the only class 1 medical device for repair of the surfaces of mattresses in the world. Registered and approved in Canada, the U.S., Europe and Australia, CleanPatch is now sold in 15 countries.
To date, W21C has been involved in the research and/or testing of more than 100 products and processes, with several key studies related to infection control, said Conly. They include a washable computer keyboard made by an Edmonton company and later bought by a German manufacturer; XSensor, a pad that can sense pressure sores on bedridden patients; and procedures for PPE during an Ebola outbreak.
Conly said one of the downsides for health innovation in Canada is that Canadian health systems rarely procure made-in-Canada products. W21C’s successful products are more likely to be picked up in American or European hospitals before Canadian facilities come on board. “It’s a microcosm of what we see in Alberta and in Canada. We always seem to think if it’s made in the U.S. or Europe it’s better,” he said. The next major challenge for W21C is hand hygiene, which we know all too well now is critical to control the outbreak of infections.
In 2015, researchers from W21C partnered with artists at Vancouver’s Emily Carr University of Art + Design with the goal of creating a cheap technology that could increase use of alcohol-rub hand dispensers. These dispensers are mounted on the walls of hospitals, medical clinics and public places like airports. Once the lever is pulled, the nozzle squirts a foamy cleanser onto the hand of the user. In hospitals, staff and visitors are supposed to use it before and after every patient contact.
W21C researchers set out to modify the standard dispenser with an interaction design — that is, something interesting enough to keep people thinking about hand hygiene. Interaction design is what draws people to iPhones — they’re designed to increase the interaction between the product and user. “Interaction design could keep hand hygiene at the forefront of people’s minds and increase compliance,” said Conly.
The W21C team designed a sensor that fits into any wall-mounted dispenser and connects to a screen. When someone pulls the lever on the dispenser, three responses are triggered: first, the cleaner spurts out. At the same time, data is sent to a centralized server so researchers can track hand hygiene, important for monitoring during infection outbreaks. And a visual display starts on the nearby screen. In the version that researchers tested on Unit 36, colourful cartoon hands fly across the screen. Before the COVID outbreak, another version for kids was planned for roll-out at the Alberta Children’s Hospital this summer, featuring cartoon animals and a voice that says “good hand-washing!”
“Our feeling was that if we merged science with art and interaction design, we would be able to come up with a better solution than what others have done before. We consider that to be an innovative step in promoting hand hygiene,” said Conly.
The evidence to date suggests people are more inclined to clean their hands with an interaction-design dispenser. In surveys conducted by W21C published in abstract form, 75 per cent of staff and patient families surveyed said the device increased their awareness of hand hygiene, while 92 per cent agreed it was a helpful reminder to practice hand hygiene. Frequency of hand hygiene use went up 20 to 30 per cent, said Conly.
Researchers hope the technology will be used around the world, especially in low- and middle-income countries. Though it sounds like a high-tech approach to a simple act, the model was designed to be affordable. The sensor can be locally sourced anywhere in the world, for less than $10 CDN. Even old black-and-white televisions can be connected to the sensors, and the software is available for free online, along with a tutorial and set-up guide.
Hand hygiene and infection control will become even more important in the context of new and emerging viruses, says Conly. “We live in a complex world where we live in tight quarters in which infectious virus transmission events may occur … there will always be a need for hand hygiene. The importance of these health care innovations cannot be overstated.”