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Introduction to CDC’s “Guidelines for Environmental Infection
Control in Health-Care Facilities”Lynne Sehulster, PhD, M(ASCP)
Division of Healthcare Quality PromotionCenters for Disease Control and Prevention
Atlanta, GA 30333
Hosted by Paul Webber [email protected]
Sponsored by 3M Canada www.3m.ca
Objectives of Today’s Presentation
After the completion of this session, the participant will:
Be familiar with the overall content of the EIC guidelines;
See how the guidance is applied to an airborne disease outbreak; and
Be familiar with performance measures and standards on environment of care
Target Audiences for the EIC Guidelines
Hospital epidemiologists Infection control practitioners Laboratorians Facility managers and engineers Housekeeping and laundry staff Administration
Where Can I Find the EIC Guidelines?
Part II Recommendations:– MMWR 2003; 52 (RR-10): 1-44– Errata: MMWR 2003; 52 (42): 1025-6
Full text version:– http://www.cdc.gov/ncidod/hip/enviro/
guide.htm Print version:
– ASHE will print in the near future
CDC Contributors to These Guidelines
Division of Healthcare Quality Promotion:– Lynne Sehulster, PhD; Matthew Arduino, DrPH; Joe
Carpenter, PE; Rodney Donlan, PhD Division of Bacterial and Mycotic Diseases:
– David Ashford, DVM, DSc, MPH; Richard Besser, MD; Barry Fields, PhD; Michael McNeil, MBBS, MPH; Cynthia Whitney, MD; Stephanie Wong, DVM, MPH
Division of Parasitic Diseases:– Dennis Juranek, DVM
Division of Oral Health:– Jennifer Cleveland, DDS, MPH
HICPAC Sponsor:– Raymond Chinn, MD, Sharp Memorial Hospital, San Diego
U.S. Organizations Whose Standards are Incorporated into
These Guidelines
American Institute of Architects (AIA) American Society of Heating,
Refrigeration, and Air-conditioning Engineers (ASHRAE)
Association for the Advancement of Medical Instrumentation (AAMI)
U.S. Federal Regulatory Agencies
Environmental Protection Agency (EPA) Department of Labor, Occupational Safety
and Health Administration (OSHA) Food and Drug Administration (FDA) Department of Agriculture (USDA) Department of Justice (DoJ)
Air Section Subtopics
Airborne microorganisms HVAC components and function Construction Special care settings
– Airborne infection isolation (AII)– Protective environment– Operating rooms
Other aerosol hazards (infectious)
Ventilation Specifications
SpecificationsAirborne Infection
Isolation (AII)Protective
Environment (PE)
Air pressure Negative Positive
Room air changes
> 6 ACH for existing areas; > 12 ACH for new construction or
renovation
> 12 ACH
Sealed Yes Yes
Filtration on supply air 90% (dust-spot testing) 99.97% (HEPA)
Recirculation No Yes
Ventilation Specifications
SpecificationsCritical Care
RoomOperating Room
Air pressurePositive, negative,
or neutralPositive
Room air changes > 6 ACH > 15 ACH
Sealed No Yes
Supply air filtration> 90% (dust-spot
testing)90% (dust-spot
testing)
Recirculation Yes Yes
Ventilation Specifications
Specifications Isolation Anteroom
Air pressure Positive or negative
Room air changes > 10 ACH
Sealed Yes
Supply air filtration > 90% (dust-spot testing)
Recirculation No
Construction Issues
Multidisciplinary team Risk assessment prior to project start External construction – keep dust out! Internal construction – contain the dust! Barriers Surveillance and air sampling
External Construction
Keep the facility air pressure positive to the outside
Ensure that roughing filters are changed frequently
Seal and caulk windows, especially in PE Keep doors closed as much as possible Wet dust surfaces Protect immunocompromised patients from
dust during transfers
Internal Construction
Dust containment, removal and moisture control– Educate construction workers and staff– Prepare the site– Notify staff, visitors, patients re: precautions– Relocate patients and move staff as needed– Monitor for adherence to infection control– HVAC system maintenance; water system– Daily clean-up and removal of debris
Particle Sampling
Simple to perform, immediate results Verify HVAC system performance:
– Filtration efficiency– Rank order from “dirty” to “clean”
Verify infection control measures during construction:– Construction barrier and dust
containment
Impact of Aspergillosis, 1996
10,190 hospitalizations; average length of stay = 17.3 days
1970 deaths; mortality rate = 19.3% Economic burden in health care = $633.1 million Conditions associated with secondary diagnosis of
aspergillosis:– pneumonia, other respiratory infections, cancer or
leukemia, HIV infection
Dasbach EJ, Davies GM, Teutsch SM. Clin Infect Dis 2000; 31: 1524-1528
Impact of Aspergillosis, 1996
When there is a secondary diagnosis of aspergillosis in cancer or leukemia patients:– 26 more hospital days– $115,262 in additional costs– 4 times the mortality rate compared to
similar patients without aspergillosis
Dasbach EJ, Davies GM, Teutsch SM. Clin Infect Dis 2000; 31: 1524-1528.
Healthcare-Associated Outbreaks of IPA
Activities that cause increases in counts of airborne Aspergillus spores
Building demolition, construction, renovation, repair
Bird droppings in air ducts supplying high-risk patient care areas
Contaminated fireproofing material Damp wood, sheet rock
Aspergillosis Outbreak Hospital A
February, March 1996; September 1996 940 bed facility; Oncology Center is a 3-
story building connected to the hospital Pressure differentials, HVAC system
checked monthly Construction immediately adjacent to the
Oncology Center A. flavus emerges, previously A. fumigatus
Investigative Findings: 1996
21/29 surveillance-identified patients met case definition of “definite” or “probable”
Housekeeping procedures inadequate; clean “wet”
Univariate analysis: location near the stairwell
Large volume samplers detected A. flavus, while small volume samples were negative
Investigative Findings: 1996
Pressure differentials– 25 PE rooms, 3 of which were negative
relative to the corridor (-0.35 to –3.2 Pa)– Air pressure in the central stairwell was
positive relative to the corridor of the unit– Oncology Center was neutral – negative
compared to the adjacent hospital
Environmental Control Measures: Spring 1996
Reviewed the function of the HVAC system Doors engineered to close automatically; kept
closed at all times Wet dusted and cleaned surfaces Sealed windows, exterior walls
Environmental Control Measures: Spring 1996
Closed nearby entrance; redirected pedestrian traffic
Construction policy Air sampling for fungal spores N95 respirators for high-risk patients
Environmental Control Measures: Fall 1996
Closed the stairwell between the HSCT and leukemia units
Conducted case-control studies Additional environmental cultures Reviewed housekeeping procedures Large volume air sampling Supplemental HEPA filtration when
structural modification not feasible
Water Section Subtopics
Waterborne microorganisms Facility water systems Strategies for controlling Legionella spp. Cooling towers Hemodialysis and water quality Ice machines Hydrotherapy AERs and dental unit water lines (DUWLs)
Modes of Transmission of Microorganisms in Water
Direct contact (hydrotherapy) Ingestion of water (drinking water, ice) Indirect contact (improperly reprocessed
medical device) Inhalation of aerosols (showers) Aspiration of contaminated water
Updates on Air and Water
Updated recommendations for air and water infection control measures:
Guidelines for Preventing Health-Care-Associated Pneumonia, 2003
Available at: http://www.cdc.gov/ncidod/hip/pneumonia/ default.htm
Environmental Services Section Subtopics
Principles of cleaning and disinfection Cleaning spills of blood/body substance Carpeting, cloth furniture Flowers and plants Pest control Special pathogen concerns and cleaning
Should Environmental Sampling Be Done?
NO, not routinely Environmental sampling may be useful:
– To verify the effectiveness of a new cleaning and disinfecting process
– To identify environmental reservoirs during outbreak situations
– Coordinate sampling with the laboratory
Environmental Sampling Section Subtopics
Principles of environmental sampling
Air sampling Water sampling Environmental surface sampling
Laundry and Bedding Section Subtopics
Epidemiology Collecting and sorting soiled
linens Laundry processes Antimicrobial-impregnated
articles Pillows, mattresses Air-fluidized beds
Animals in Healthcare Facilities Section Subtopics
Animal-assisted activities, animal-assisted therapy, resident animals
Service animals Animals as patients in healthcare
facilities Research animals in healthcare
facilities
Regulated Medical Waste Section Subtopics
Epidemiology Categories of medical
waste Management of waste Treatment of waste Discharge of blood, body
fluids to the sanitary sewer CJD issues
EIC Guidelines Performance Measures
Document infection control professionals’ involvement in all phases of construction
Monitor and document airflow for AII and PE, especially when occupied
Monitor water in hemodialysis settings monthly for endotoxin and bacteria
Determine source(s) of NTM Identify and respond to water damage
JCAHO – 2004 Standards for the Management of the Environment
of Care
Planning and Implementation Activities– EC 1.10 – EC 1.30: safety risks, smoking
policy, safe environment– EC 2.10: security risk management– EC 3.10: hazardous materials and wastes– EC 4.10 – EC 4.20: emergency management
JCAHO – 2004 Standards for the Management of the Environment
of Care
Planning and Implementation Activities– EC 5.10 – EC 5.50: fire safety and Life Safety
Code® issues– EC 6.10 – EC 6.20: medical equipment– EC 7.10 – EC 7.50: utilities management – EC 8.10 – EC 8.30: environmental
management
JCAHO – 2004 Standards for the Management of the Environment of Care
Measuring and Improving Activities– EC 9.10 – EC 9.30: monitoring and analyzing
environmental conditions; implementing recommendations to improve the environment of care
JCAHO – 2004 Standards for the Management of the Environment of Care
Standard– Performance expectation
Rationale– Background, justification
Elements of Performance– Steps needed to achieve the standard
Thank You!
Protect patients, protect healthcare personnel, and promote safety, quality, and
value in the healthcare delivery system
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