The presentation is solely meant for

Academic purpose

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?

OT ICU DIALYSIS CSSD LAUNDRY HK ENDOSCOPY ISOLATION AIR-CONDITION KITCHEN

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 exception

Surveillance, Prevention and Control of Infection, Comprehensive Accreditation Manual Volume 5. Joint Commission of Accreditation for Hospital Organisations, USA 2000;2-6.

Etoh at al, AJA;2006; 203-206;42

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

Myth

Sampling will reduce HAI

Reality

Has no effect on Antibiotic Prescription (Except outbreaks)

Good IC Practices & Design

Guidelines for Environmental Infection Control in Health-Care Facilities;

HICPAC, June, 2003

19

CLEAN

PROTECTIVE

STERILE

DISPOSAL

Protective zone ◦ Reception ◦ Waiting area ◦ P.A.R. ◦ Trolley bay ◦ Changing room

Clean zone ◦ Pre-op room ◦ Recovery room ◦ Plaster room /x-ray unit ◦ Staff room ◦ Store

Sterile zone ◦ Operating suite

◦ Scrub room

◦ Anaesthesia Room

◦ TSSU

Disposal zone ◦ Dirty wash room

◦ Disposal corridor

◦ Janitor closet

20

21

Zoning of Operating Room (Sterile)

Aseptic

Ultra Clean

Super Clean

22

Vertical Laminar Flow in 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 ACH

Structural Lay out of OT

Hoffman, PN, Williams, J, Stacey, A et al. Microbiological comimssioning and monitoring of OT suites. A report of a working party of the Hospital Infection Society/Hosp Infect, 2002:52:1-28

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 Flow b) OTHER AREAS: Fresh air changes minimum 5 per hour and total 15 per hour.

HDPE washable filters with filtration level up to 5 microns.

Myth

HePA filters and laminar flow should be ON only when surgeries are in progress

Reality

HePA filters; in all OTs

Once the system is switched off the moisture in the filters supports growth of fungal strains

American Institute of Architects; Retrieved 2008-03-04

A STORY OF A MUMBAI TERTIARY CARE HOSPITAL

•Most ductwork is concealed above false ceilings

A well respected hospital in Mumbai decided to revamp their

air conditioning system for a suite of operation theatres.

•False ceilings were torn down, ductwork dismantled but

before they were disposed of, the consulting engineer for the

new AC system decided to look inside these ducts and was

horrified to see all the dirt stuck to the walls of the ducts.

•He had all the dirt removed and weighed and found that there

was 17kgs of it, including construction debris and green

coloured lint, which could only have come from the green

cotton garments worn by the team of surgeons and their

assistants inside the operation theatres.

(Source: AC and Refrigeration Journal (ISHRAE), Oct-Dec 2005 Issue )

HVAC Ducts – Out of Sight Out of Mind!

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%

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.

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.

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

Special 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

Infectious Disease Isolation Room

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!

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.

Bubble Diagram

Storage Safety

Autoclave

Bio-Safety Cabinets

Clean – Soiled

PPE

Drains

Disposals

Private rooms make the spread of infection less likely because patients

and visitors do not share space and equipment with other patients

Considerations for Design, Equipment and Ventilation

Though nursing of single pt. is ideal, 2-4 single rooms/30 bed unit is sufficient

Centers of beds 8ft apart in pavilion ward

1 Wash Hand Basin (WHB) /4-6 beds in Rig’s ward

Floor space area/bed – 7 sq m excluding corridor of 2.4 m

Single bed rooms- 14 sq m

Not only principles of asepsis and

hygiene

◦ 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

Item Standard

Distribution Piping System

Material (Copper Pipe) ASTMB 819.00; 2002

Fittings BS EN 1254-1: 1998 Part 1

Copper to copper joints silver copper-phosphorous brazing alloy

BS 1845 / BS 1044

pipeline isolation and lockable line valve

HTM 2022 / EN737 / NFPA 99

Rigid retractable pendant HTM 2022 / EN 737 / NFPA 99

Terminal outlets (PB Type compatible)

NFPA 99 compliant. Imported products to be CE marked / UL Listed 54

Water Treatment

Drinking Water

Flush Water

RO Water

Microbial Analysis

Endotoxin Analysis

Effluent Treatment

Give her a cup of coffee

Organise an immediate consult

And let her know that her daughter-in law was also concerned

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

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