Designing for IC


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Designing Facilities for Infection Control

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Designing for IC

  1. 1. The presentation is solely meant forAcademic purpose
  2. 2.  Why is health planning so important in designing?• How does the built environment help support appropriate IC practices?• The importance of keeping a balance between the home vs clinical environment• Evidence Based Design – how can we use this information to improve the built environment?
  4. 4. It is the imbalance between classical triad of epidemiology i.e. agent, host and environment which leads to the initiation of disease process : To which hospital acquired infections are no exceptionSurveillance, Prevention and Control of Infection, Comprehensive Accreditation Manual Volume 5.Joint Commission of Accreditation for Hospital Organisations, USA 2000;2-6.
  5. 5. Etoh at al, AJA;2006; 203-206;42
  6. 6.  Most of the hospitals are not scientifically designed, physical facilities are most inadequate and are overcrowded No segregation facilities for septic and clean cases, especially in surgical and maternity wards Patient placement is generally found to be faulty Requirements of air conditioning and ventilation are not met properly Overcrowding in nurseries and ward units It is of paramount importance to plan infrastructure for IC requirements
  7. 7. Myth Reality Sampling will  Has no effect on reduce HAI Antibiotic Prescription (Except outbreaks)  Good IC Practices & Design Guidelines for Environmental Infection Control in Health-Care Facilities; HICPAC, June, 2003
  9. 9.  Protective zone  Sterile zone ◦ Reception ◦ Operating suite ◦ Waiting area ◦ Scrub room ◦ P.A.R. ◦ Anaesthesia Room ◦ Trolley bay ◦ TSSU ◦ Changing room Clean zone  Disposal zone ◦ Pre-op room ◦ Dirty wash room ◦ Recovery room ◦ Disposal corridor ◦ Plaster room /x-ray unit ◦ Janitor closet ◦ Staff room ◦ Store 20
  10. 10. Zoning of Operating Room (Sterile) Super CleanAseptic Ultra Clean 21
  11. 11. Vertical Laminar Flow in OT 22
  12. 12. Structural Lay out of OT • Size of the OT: 20X20X10 • Protected Environment: Sealed rooms & windows • Walls: non porous, smooth without crevics • Floor : non porous, smooth, anti-skid & anti- static material. • Drains, sewage pipes to be avoided • Principles of Structural Zoning pack stores – 11 ACHHoffman, PN, Williams, J, Stacey, A et al. Microbiological comimssioning and monitoring of OT suites. Areport of a working party of the Hospital Infection Society/Hosp Infect, 2002:52:1-28
  13. 13. a) STERILE ZONE:(i) Temperature: 21°C ± 3°C(ii) Relative humidity : 40% to 60%(iii) Fresh air allowance : 10 per hour with total air changes 20- 25 per hour(iv) Air filters : through HEPA filters with filtration level up to 0.3 microns and 99.97% efficiency with pre filters & microvee filters in the system.(v) Positive pressure = 25 Pa(vi) Laminar Air Flowb) OTHER AREAS: Fresh air changes minimum 5 per hour and total 15 per hour. HDPE washable filters with filtration level up to 5 microns.
  14. 14. Myth Reality HePA filters and laminar  HePA filters; in all OTs flow should be ON only  Once the system is when surgeries are in switched off the progress moisture in the filters supports growth of fungal strains American Institute of Architects; Retrieved 2008-03-04
  15. 15. HVAC Ducts – Out of Sight Out of Mind!A STORY OF A MUMBAI TERTIARY CARE HOSPITAL•Most ductwork is concealed above false ceilingsA well respected hospital in Mumbai decided to revamp theirair conditioning system for a suite of operation theatres.•False ceilings were torn down, ductwork dismantled butbefore they were disposed of, the consulting engineer for thenew AC system decided to look inside these ducts and washorrified to see all the dirt stuck to the walls of the ducts.•He had all the dirt removed and weighed and found that therewas 17kgs of it, including construction debris and greencoloured lint, which could only have come from the greencotton garments worn by the team of surgeons and theirassistants inside the operation theatres.(Source: AC and Refrigeration Journal (ISHRAE), Oct-Dec 2005 Issue )
  16. 16.  Structure: - Size: 22sqm / ICU bed - Lighting 300 lux - Separate dirty and soiled linen utility room and janitor closet Ventilation: - Positive Pressure - 8 -10 ACPH - Temperature: 20-25*C - Relative Humidity: 40%-60%
  17. 17. All of them emphasize the importance of: Adequate isolation facilities At least one cubicle per eight beds Sufficient space around each bed- at least 22 sqm, WHB between every other bed / alcoholic dispensers Ventilation including positive and negative pressure ventilation for high risk patients. Sufficient storage and utility space. Floors and walls should be easily cleanable and non porous. Dirty utility should have separate stand / shelf per bed, bedpans, urinals, to be kept dry and hand wash solutions / basins at each bedside.
  18. 18. Isolation cubicles with self closing door and airlock. Air lock is supposed to have following functions:a) They provide a barrier against loss of pressurization and against entry / exit of contaminated air into / out of the isolation room.b) They provide a controlled environment in which protective garments can be donned without contamination before entry into the room.c) They also provide a physical and psychological barrier to control behavior of staff in adopting infection control practices. ICU is planned with 15 air changes per hour (5 fresh + 10 re-circulation) as per minimum ASHRAE standards. Positive pressure gradient of 15 Pa is recommended between isolation cubicle and main ICU.
  19. 19.  S - Standard isolation : for patients who require contact or droplet isolation; N - Negative isolation : for patients who require air borne droplet nuclei isolation e.g. Tuberculosis; P - Positive isolation : for patients who are profoundly immunocompromised e.g. transplant and oncology patients •S - Standard isolation: for patients who require contact or droplet isolation; •N - Negative isolation: for patients who require air borne droplet nuclei isolation e.g. Tuberculosis; •P - Positive isolation: for patients who are profoundly immuno-compromised
  20. 20. Infectious Disease Isolation RoomSpecial Ventilation Requirements• Ante Room• Air Pressure – Negative • Clean to Dirty• ACPH - > 6 • > 12 during new construction• No recirculation• Direct Exhaust to outside• HEPA at exhaust
  21. 21.  Separated entries and exits: for soiled, clean and sterile goods Strict separation of the staff working in the 3 different areas Room ventilation separated - for good production conditions Straight workflows - for simple, reliable working routines to have an economic and ergonomic production Patient related utensils - washed and disinfected at the user area – as soon as possible!
  22. 22.  Ventilation – ◦ Min. 6-10 ACH, Clean to Soiled ◦ Temp: 18-22 deg C + 5 ◦ RH – 35-50% ◦ Exhausted to outside/ Exhausted to a filtered partial re- circulation system Configuration of systems that provide steam, hot/cold water, purified water, compressed air, electrical power, air exhausts and drainage of sewage are important considerations while installing equip. Adequate Hand Washing facilities in or near all decontamination, preparation, sterilization and sterile storage Storage facility for sterile items areas.
  23. 23. Bubble Diagram
  24. 24.  Storage Safety Autoclave Bio-Safety Cabinets Clean – Soiled PPE Drains Disposals
  25. 25. Private rooms make the spread of infection less likely because patientsand visitors do not share space and equipment with other patients
  26. 26.  Considerations for Design, Equipment and Ventilation Though nursing of single pt. is ideal, 2- 4 single rooms/30 bed unit is sufficient Not only Centers of beds 8ft apart in pavilion principles of ward asepsis and 1 Wash Hand Basin (WHB) /4-6 beds in Rig’s ward hygiene Floor space area/bed – 7 sq m excluding corridor of 2.4 m Single bed rooms- 14 sq m
  27. 27. ◦ Stringent criteria for preparation (Risk levels I, II, III)◦ Differences in intervals between preparation and use (depending on how materials are stored)◦ Traffic Control: segregation of aseptic area◦ Risk Level II: Environmental control, positive pressure, environmental and end product testing◦ Risk Level III: (including material prepared from unsterile components): monitoring physical env, env. Micorbial sampling, terminal sterilization
  28. 28. Item StandardDistribution Piping System Material (Copper Pipe) ASTMB 819.00; 2002 Fittings BS EN 1254-1: 1998 Part 1 Copper to copper joints silver BS 1845 / BS 1044 copper-phosphorous brazing alloypipeline isolation and lockable HTM 2022 / EN737 / NFPA 99 line valveRigid retractable pendant HTM 2022 / EN 737 / NFPA 99Terminal outlets (PB Type NFPA 99 compliant. Imported compatible) products to be CE marked / UL Listed 54
  29. 29.  Water Treatment Drinking Water Flush Water RO Water Microbial Analysis Endotoxin Analysis Effluent Treatment
  30. 30.  Give her a cup of coffee Organise an immediate consult And let her know that her daughter-in law was also concerned
  31. 31.  Take leave Be by her bed side Get the best doctor Get the best hospital; from treatment & HAI point of view (designed) Show her; son-in-law is in total control
  32. 32.  Health Care Design publication Vol 10,no 10 – The Centre For Health Design Evidence Based Health Care Design – Rosalyn Cama 2009 A Visual Reference for Evidence Based Design – Jain Malkin 2008 Healing By Design – building for health Care in the 21st Century- Roger Ulrich The role of the Physical Environment in the Hospital of the 21st Century : A Once-in-a-Lifetime opportunity. Healing spaces – The science of place and well-being – Esther M Sternberg MD 2009 Future opportunities for learning - Healthcare facilities: The environment and users‟ behavior, and how these relate to the acquisition of hospital acquired infection. A pilot study to be presented in Manchester in the UK in September 2011