Health facility design for infection control


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The South African Federation of Hospital Engineers was invited to make a presentation at the Green Building Design for Health Facilities Conference held in Cape Town on 23 August 2013.

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  • Please discuss routes of transmission (such as vector borne)Please add resources (IUSS, ICAN FIDSSA)Don't dwell on antimicrobial resistance which is of incidental significancePlease add a small climate and energy standards as competing issues.
  • Vinyl wall finishes recommendations differ province to province
  • Vinyl wall finishes recommendations differ province to province
  • Vinyl wall finishes recommendations differ province to province
  • Vinyl wall finishes recommendations differ province to province
  • Vinyl wall finishes recommendations differ province to province
  • We have forgotten this as we strive to achieve indoor comfort through ever more complex mechanical ventilation systems.
  • Issues of vinyl, toxicity and waste
  • Vinyl wall finishes recommendations differ province to province
  • Issues of vinyl, toxicity and waste
  • This presentation focusses on Ventilation as an important factor in addressing indoor infection control; however the importance of design for legionella control and legionella control programs should not be overlooked
  • Vinyl wall finishes recommendations differ province to province
  • Health facility design for infection control

    1. 1. Health Facilities Design for Infection Control Tobias van Reenen and Peta de Jager 16 August 2013, Cape Town
    2. 2. “It may seem a strange principle to annunciate as the very first requirement in a hospital is that it do the sick no harm.” Florence Nightingale
    3. 3. South African Constitution Everyone is equal before the law and has the right to equal protection and benefit of the law. Environmental rights in the Bill of Rights include the right to an environment that supports health and wellbeing. It also requires legislation to be developed to ensure that the environment is protected and that development that does occur is both sustainable, and justifiable:
    4. 4. Environment Everyone has the right a. to an environment that is not harmful to their health or well-being; and b. to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures that i. prevent pollution and ecological degradation; ii. promote conservation; and iii. secure ecologically sustainable development and use of natural resources while promoting justifiable economic and social development
    5. 5. IUSS Sustainability Guidelines Environmental objectives • Environmental objectives • Energy: The building is energy efficient and uses renewable energy • Water: The building minimises the consumption of mains potable water. • Waste: The building minimizes emissions and waste directed to landfill • Materials: Construction impacts of building are minimized • Biodiversity: The building supports biodiversity Mirebalais Hospital, Haiti – Nicholas Clark Architects Ltd.
    6. 6. Healthy, green health building: Economic objectives • Economic objectives • Transport: The building supports energy efficient transportation • Resource Use: The building makes efficient use of resources • Management: The building is managed to support sustainability • Local Economy: The building supports the local economy • Products and Services: The building supports use of more sustainable products and service
    7. 7. Healthy, green health building: Social objectives • Social objectives • Access • Health • Education • Inclusion • Social Cohesion
    8. 8. The ―Florence Nightingale‖ Approach • Florence Nightingale wrote over 150 years ago that open windows were the hallmark of a healthy hospital ward1 • Indoor microbial environments consist largely of human associated bacteria and pathogens. • Outdoor microbial environments have a profile that look like plants and soil and are comparatively harmless 1 Nightigalen F. (1859). Notes on Nursing. D. Appleton: London. 2Kembel, S. et al (2012)
    9. 9. • A 2012 study by University of Oregon proved that while clinics with open windows had more pathogens, closed window environments were more harmful2 • Ventilation method accounts for a greater variance in airborne bacterial pathogenicity than ventilation rates alone2 2Kembel, S. W., Jones, … Green, J. L. (2012). Architectural design influences the diversity and structure of the built environment microbiome. The ISME Journal, 6(8), 1469–79. Indoor air quality Photo: Etienne du Plessis South Africa’s oldest hospital: Somerset Hospital. Circa 1890
    10. 10. • TB leading cause of mortality in South Africa4 • South Africa has the 3rd highest incidence of TB cases in the world3 • 5th highest number of drug- resistant TB cases in the world3 • 60% – 80% of all TB cases co- infected with HIV5,6 3 WHO. (2011). 4 Statistics South Africa. (2011). 5 WHO. (2009). 6 Gandhi et al. (2006). Epidemiology North Carolina State Sanatorium, men’s ward, 1926
    11. 11. • TB is spread by the airborne transmission route • Consider the occupational risks7,8 7 Joshi, R., Reingold A. L., Menzies, D., Pai, M. (2006). Tuberculosis among health-care workers in low- and middle-income countries: a systematic review. PlosMed 3(12);e494 (after Dr Paul Jensen) 8 Menzies, D., Joshi, R., Pai, M. (2006). Risk of tuberculosis infection and disease associated with work in healthcare settings. Int J Tuberc Lung Dis 11(6): 593-605 (after Dr Paul Jensen) An issue of indoor air quality… Work location Incidence (worker relative to general population) Outpatient facilities 4.2 – 11.6 General medical wards 3.9 – 36.6 Inpatient facilities 14.6 – 99.0 Emergency rooms 26.6 – 31.9 Laboratories 42.5 – 135.3
    12. 12. Routes of infection Adjacent Areas Instruments Room Air Floor Personnel Mouth HandsBody Adapted from Memarzadeh, 2003 Patient Susceptible Infection Site Building Services Vector s
    13. 13. Sekgoma Memorial Hospital, Serowe
    14. 14. Sekgoma Memorial Hospital, Serowe
    15. 15. Occupants/equipment NOT ADAPTABLE or tolerant of indoor conditions Occupants/equipment ADAPTABLE or tolerant of indoor conditions Ventilation design philosophy • Hierarchy of Design Solutions Fully mechanical ventilation Hybrid systems with climatic adaptability Fully passive ventilation Occupiedarea
    16. 16. • Planning for passive ventilation, heating and cooling • Layout and zoning for passive design responses Specialist areas (ICU, surgery) Intermediate areas (Trauma, food services) General areas (Wards, waiting and public areas) Ventilation design philosophy
    17. 17. • National Building Regulations and Building Standards Act (Act 103 of 1977) • SANS 10400 XA • SANS 10400 O • SANS 204 (Incorporated) Standards and regulations
    18. 18. • Ventilation SANS10400-0 • Table 2 all but prohibits recirculation in health care buildings. • Table 2 Excludes l/s/person calculations for health care buildings Standards and regulations
    19. 19. WHY RECIRCULATE? • Consider a conditioned space which is maintained at 22C: • Cooling plant energy cost is reduced by between 80% and 95%: Advantage: • Lower energy and operating cost at the cooling plant. • Smaller cooling plant and lower capital cost Disadvantage: • More difficult to maintain indoor air quality Source: Dr J Dirker UP Standards and regulations
    20. 20. Adaptive approach -Increased air movement (-2°C) • Precise relationships between increased air speed comfort have not been established. • Provide ability to control air speeds to < 0.8m/s • >0.2m/s can be considered draughty with HVAC Thermal comfort ASHRAE55Figure5.2.3 Airspeedrequiredtooffsetincreased temperature
    21. 21. Climatic classification (CSIR, 2010)
    22. 22. Climatic classification Description Köppen-Geiger Class. Area in km² Percentage (%) Equatorial climates (0.2% of area) Aw 2296.00 0.20 Arid climates (70.89% of area) Bsh 192269.00 16.59 Bsk 275927.00 23.81 Bwh 188784.00 16.29 Bwk 164629.00 14.20 Warm temperate climates (28.91% of area) Cfa 42918.00 3.70 Cfb 93405.00 8.06 Cfc 84.00 0.01 Csa 5120.00 0.44 Csb 18395.00 1.59 Cwa 31162.00 2.69 Cwb 140405.00 12.11 Cwc 3564.00 0.31 Total 1158958 100.00
    23. 23. Responsive design approaches
    24. 24. Bongani MDR TB Hospital, Mpumalanga THERMALCOMFORT Design for climate Skills of a multi-disciplinary team: but not business-as-usual
    25. 25. Surfaces and materials • Smooth, hard, impervious surfaces create best hygienic environments • Smooth, hard, impervious surfaces create the worst acoustic environments studies/butaro-district-hospital/
    26. 26. Antimicrobial resistance
    27. 27. Surfaces and materials • Vinyl and tiled finishes create cavities behind which cannot be cleaned when bonding system fails • Paint wall finishes recommended above vinyl • Design/select fixtures which do not hinder cleaning
    28. 28. Surfaces and materials • Consider materials’ environmental lifecycle • Origin • Durability • Toxicity • Recycling • Disposal • Consider vinyl if: • BRE A+ Rating = 100% recyclable • Pass VOC emissions test • Consider toxicity of adhesives studies/butaro-district-hospital/
    29. 29. Planning IUSS Central Sterile Service Department
    30. 30. Engineering Services
    31. 31. Healthy, green health building: A 3–pronged approach • Consumption and emissions • Benchmarks, targets, minima • Monitoring and progressive improvement • Rework professional duties, interdisciplinary relationships and incentives • Life cycle analysis • Components and materials • Whole building • Appreciate sector-specific challenges
    32. 32. 32 2013/08/27 QUESTIONS?
    33. 33. Resources & References Bibby, C., & Hodgson, M. (2013). Prediction study of factors affecting speech privacy between rooms and the effect of ventilation openings. Applied Acoustics, 74(4), 585–590. ASHRAE 55-2004; Thermal environmental conditions for human occupant, 2004. ISO 7730:2005 Ergonomics of the thermal environment -- Analytical determination and interpretation of thermal comfort using calculation of the PMV and PPD indices and local thermal comfort criteria CIBSE AM10; Irving, S., Ford, B., & Etheridge, D. (David W. . (2005). Natural ventilation in non-domestic buildings. CIBSE. (2000). CIBSE Applications Manual AM13: Mixed mode ventilation. CCIBSE. CIBSE Knowledge Series KS17— Indoor air quality and ventilation. Nightingale, F. (1859). Notes on Nursing. D. Appleton: London. Kembel, S. W., Jones, … Green, J. L. (2012). Architectural design influences the diversity and structure of the built environment microbiome. The ISME journal, 6(8), 1469–79
    34. 34. Resources & References • CDC • CSIR • FIDSSA –Federation of Infectious Diseases of South Africa • ICAN –Infection Control African Network • MRC - Medical Research Council • National Department of Health – • NHLS – National Health Laboratory Services • NIOH – National Institute of Occupational Health • NICD – National Institute of Communicable Diseases • SAFHE – South African Federation of Hospital Engineering • WHO