Curtains and contamination – a brief history.

Love them or loathe them, since the curtain rail was invented at the turn of the last century and the first NHS hospital was opened by Aneurin Bevan in 1948, curtains have formed an omnipresent backdrop within the acute care.

Essential as they have been to patient privacy, an understanding that curtains could serve as reservoirs for pathogens has been developing over several decades. As early as the 1970s and 1980s, studies were beginning to explore the potential for various hospital surfaces to harbour infectious organisms.

However, it wasn’t until more recently, around the early to mid-2000s, that more focused research began to highlight curtains as a significant source of contamination.

For example, a study published in 2008 in the journal Infection Control & Hospital Epidemiology ¹ specifically examined hospital privacy curtains and found that 42% of sampled curtains were contaminated with VRE (vancomycin-resistant enterococci), a common healthcare-associated pathogen.

Further studies have supported these findings, confirming that curtains can often be contaminated with pathogens within a week (or even days) of being freshly hung ².

Consequently, these studies have driven changes in hospital protocols, leading to more frequent cleaning or replacement of curtains, and an increased use of disposable and antimicrobial curtains.

Unexpected implications of the move to disposables

The rise of the disposable curtain has had significant implications for the environment in terms of increased waste, use of plastics and the safety of releasing antimicrobial coatings on disposal. Recycling of these products is possible but requires large amounts of energy.

There is also an impact on patient flow. Curtain changing should be done in a way which minimises cross-contamination. Proper procedures therefore take time and involve putting the bed area out of use during changing.

Curtains pose a specific cross-infection challenge

Because curtains are used to maintain patient privacy, they are touched both immediately before and after administering nursing care.Whilst a nurse will usually wash their hands before visiting a patient, pathogens could then be passed from the patient and back to the curtain when the nurse leaves, thereby creating a cycle of cross-contamination.

Are antimicrobial coatings the answer?

The difficulty in keeping fabric surfaces clean has led to the development of antimicrobial coatings, however, the efficacy of this approach is far from being clinically proven.

For example, a 4-week study published in the Journal of Infection Control and Hospital Epidemiology in 2012 ³ found that one antimicrobial coating extended the median time to first contamination from 2 to 14 days. Another study showed improved results using a different coating, however given the range of available fabric and coating combinations, more independent and comprehensive research is required to establish how effective antimicrobial coatings are, especially against the more resistant pathogens. In any event, protection against pathogens likely falls far short of the minimum 6-month changing cycle practiced by many trusts.

There is also the possibility that antimicrobial coatings could lead to the development antimicrobial resistance (AMR), therefore their use should be limited to critical applications.

National Standards of Healthcare Cleanliness – an opportunity missed?

In 2021, NHS England issued new guidelines for cleaning, representing a major step forward in harmonising standards ⁴. Areas of the hospital are graded by Functional Risk Category and cleaning frequencies are recommended for various surfaces depending on their likelihood of contamination by touching.

High frequency touch points were identified including:

      • light switches/plastic pulls

      • door handles and push plates

      • bed rails

      • trolleys and

      • bedside locker handles

Despite curtains being a high frequency touch point in virtually every hospital setting, they were omitted from the list.

The blind spot in relation to curtains becomes more apparent when you compare the cleaning recommendations for each surface.

In medium risk areas such as treatment and consulting rooms and general outpatient departments, high frequency touchpoints should be cleaned once per week. Daily cleaning is recommended for high-risk areas such as operating theatres, intensive care, cancer, and endoscopy units.

By contrast, guidance on the cleaning or changing frequency of curtains simply defers to “the local curtain changing programme” and specifies a minimum cleaning/changing cycle of every 6 months (or when visibly soiled) even in the highest Functional Risk Category.

This inconsistency in the recommended cleaning frequency of curtains versus other high frequency touch points

(daily versus twice a year) illustrates the nature of the underlying problem: it is neither practical nor financially viable to recommend that NHS Trusts change or launder their curtains every day. Instead of taking the opportunity to tackle this issue and perhaps propose alternative solutions, the new guidelines simply pass responsibility back to the local hospital.

Easy to clean, hard surface privacy screens

One possible and very practical solution would be to eliminate fabric surfaces altogether in favour of privacy screens with a smooth, hard surfaces which are easy to keep clean using traditional cleaning methods.

Some manufacturers, such as Silentia, offer a range of hard surface, folding privacy screens which can be wall-mounted in place of existing curtains. Well-designed privacy screens take up little wall space and feature a single touch point, such as a handle, which staff use to open and close the screen without touching the panels. This means that simply wiping down the handle breaks the cycle of cross-infection quickly and effectively.

Screens, which can be cleaned in-situ, and without removing the patient, have a minimal impact on patient flow and bed use. Cleaning can be integrated seamlessly with the hospital’s standard cleaning routines, making infection control much easier to manage.

A good quality screen will have a much smaller impact on the environment as it will last a long time, and can be maintained and reused.

This approach has been embraced in Scandinavian countries such as Sweden and Denmark.

In Denmark, for example, the government has not specified curtains or fabric-based screens in new build hospitals since 2013 based on the premise that all surfaces in close proximity to the patient must be cleanable.

In the early 2000’s when the UK started moving from washable to disposable curtains, the Swedish chose a different path and began using folding, hard surface screens. As a result, if you walk into a hospital in Sweden today, you are unlikely to find curtains hanging in any medium to high-risk area.

Some trusts in the UK have started to incorporate folding screens into new builds or refurbishments, however curtains are still the predominant privacy solution, and many hospitals rely on the default changing policy of once every 6 months, or when visibly soiled.

Conclusion

Curtains have long been a proven source of pathogens which become rapidly contaminated.

More research is urgently needed to establish the effectiveness of antimicrobial coatings and the possible unwanted consequences in relation to AMR and the environment.

The use and management of disposable curtains can have negative impact on the environment and is disruptive to patient flow.

Curtains are high frequency touch points, but cleaning or changing them every day is neither practical nor cost effective. This is possibly the reason the issue is avoided within the 2021 NHS cleaning standards publication. As a result, infection control leads have been left with inadequate guidance on how to deal with the important risk posed by curtains.

Practical and easy to clean alternatives such as wall-mounted folding screens are readily available and in use in other countries such as Sweden and Denmark (as well as in an increasing number of hospitals in the UK). These alternatives should have a lower carbon footprint and are less disruptive to patient flow.

Is it perhaps time for the NHS to reassess its longstanding relationship with curtains?

For further information on Silentia privacy screens please contact us.  

Tel: 0870 850 2384

Email:  silentia@lisclare.com

Reference

1. Trillis III F., Eckstein E.C., Budavich R., Pultz M.J., Donskey C.J. Contamination of hospital curtains with healthcare-associated pathogens. Infect. Control Hosp. Epidemiol. 2008;29:1074–1076. doi: 10.1086/591863

2. Ohl M., Schweizer M., Graham M., Heilmann K., Boyken L., Diekema D. Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria. Am.J. Infect. Control. 2012;40:904–906. doi: 10.1016/j.ajic.2011.12.017.

3. Schweizer M., Graham M., Ohl M., Heilmann K., Boyken L., Diekema D. Novel hospital curtains with antimicrobial properties: A randomized, controlled trial. Infect. Control Hosp. Epidemiol. 2012;33:1081–1085. doi: 10.1086/668022.

4. National Standards of Healthcare Cleanliness 2021, NHS England, April 2021