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Traffic Control Strategy in Traffic Control Strategy in SARS Outbreak ControlSARS Outbreak Control
Muh-Yong Yen, Yu-sen E. Lin, Ih-Jen Su, Mei-Shang Ho, Kuang-Huan Tan,
Chen-Hsen Lee
Jen-Ai Municipal Hospital, Taipei City
Veterans General Hospital, Kaohsiung
STOP SARS at the bedsideSTOP SARS at the bedside
Life finds the way
SARS is looking for the niche/leak to jump into next
victims (HCW)
Niche, leakNiche, leak
Waves nichereasons/solution
1st wave 20-30 % mask & glove2nd wave 3-5 % PPE, NPIR3rd wave 1 – 0.1 % intubation teamNext wave ??
New concept !New concept !
HCW first, Patient next
Traffic Control
Myth of negative pressure
IntroductionIntroduction
The health officials shut down and quarantine the hospital to control nosocomial transmission.
More than one thousand persons afected, chaos and panic rapidly ensued within the hospital.
The president of Taiwan made an executive decision to evacuate the hospital within 36 hours.
METHODSMETHODS
Renovation of hospitalsA hospital: 67 bedsB hospital: 18 beds
Comparison Hospitals746 NPIRs
Hospital A, Hospital A, 松山松山 The first floor is an admission office
that has a special pathway which leads the patient directly to the elevator
The third floor is designated ward for
suspect SARS cases, the fourth floor is for probable or confirmed cases.
Hospital A, Hospital A, 松山松山 A residential apartment within 2 meters to
the east. A “negative-pressure like” environment all windows due east were sealed air tight. A 16-inch exhaust fan was installed in
patient’s rooms due west.All doors/bottom gap of patient’s rooms were
sealed.
Hospital A, Hospital A, 松山松山The exits and staircase of each floor was
sealed to prevent air interflow between floors.
A separate central air conditioning system was used to circulate air within each floor with 50% of air-exchange rate.
All of the exhaust air to the west was blow to a 60 by 30 meters restricted area,
Hospital B, Hospital B, 松德松德a 4-story healthcare facility for patients
with tbc / chronic diseases.the first floor is the admission office with
a special pathway to the elevator. The second floor is an 18-bed patient
ward in negative pressure isolated room (NPIR).
The path to elevator was isolated with wooden/acrylic boards to differentiate the pathways for patients from the HCWs.
There is a separate entrance/exit for each HCW to enter/leave the ward to avoid crossing or overlapping with the traffic of contamination zone that the patients have passed through.
Each zone was clearly designated by wooden/plastic barriers
To avoid casual breakthrough by any directly passing and contacting from contaminated zones into clean zones.
Each nurse’s station was shielded with transparent plastic shield to prevent interchange of material between nurse’s station (clean zone) and the hallway (intermediate zone)
Zone of ProtectionZone of Protection
biochemical warfare
clear zone inter-zone contamination
Enter with PPE, leaving with Decontamination
Checkpoint Hand washingCheckpoint Hand washing
Before entering/leaving each patient’s room, to prevent any contact transmission from the gloves to the knob, HCWs were required to disinfect their hands.
After entering/leaving the room and door was closed, their hands were again disinfected for protection of the next procedure.
Disinfect-Touch-Disinfect was enforced in all zones.
Traffic into HospitalTraffic into Hospital
Case mix and contact transmission inside ER
A “triage and dispatch” station is located outside the hospitals.
Traffic ControlTraffic Control
Zone of Protection
Checkpoint hand washing
Traffic into Hospital
ResultResult
During the study period, 462 HCWs including 85 physicians, 295 nurses, and 82 administrative personnel and volunteers were clinically evaluated for SARS in study hospitals.
2 nurses contracted SARS, PCR (+)
Using Using Traffic ControlTraffic Control Strategy During Outbreak Strategy During Outbreak Control to Minimize Nosocomial Infection of SARS Control to Minimize Nosocomial Infection of SARS
Among Health-Care WorkersAmong Health-Care Workers
Test Hospital Comparison H Hospitals
Bed A (67) B (18) Total (85) (746)
Suspected 0 (0 %)* 0 (0 %) 0 ( 0%) 43 (5.76 %) Probable 2 (2.98 %) 0 (0 %) 2 (2.35 %) 50 (6.70 %)
Total** 2 (2.98 %) 0 (0 %) 2 (2.35 %) 93 (12.47 %)
* SARS case divided by number of patient bed ** p = 0.004, Chi square, Fisher exact test
Muh-Yong Yen, et al. 2003Muh-Yong Yen, et al. 2003
NPIRPPE
Traffic control
contact
Respiratory
DiscussionDiscussion
Given that PPE and NPIR are tested and available throughout Taiwan, we postulated that PPE and NPIR appear to be unsatisfactory for preventing HCWs from contracting SARS virus if the standard operative procedure was not adherent strictly, which was not unusual in the time of outbreak.
DiscussionDiscussion
We suspect that HCWs especially those of inadequately trained cleaner, part-time workers, may still acquire the SARS virus through inappropriate donning or removal of PPE and accidentally transmitted the virus by hands afterwards.
DiscussionDiscussion
“Traffic Control” differentiates the pathways of patients and the HCWs within the hospital with barriers so that each pathway may not be casually overlapping or crossing, casual contamination will than be blocked.
the integrated checkpoint hand washing spots are mandatory to be accessible throughout the hospital.
DiscussionDiscussion
the checkpoint hand washing within traffic line may strengthen the adherence and to increase frequency of hand washing.
when working in the restricted traffic control area with physical barrier, HCWs/part-time workers will upraise their consciousness to a surroundings of self-control and discipline and to a highest grade infection control standard.
DiscussionDiscussion
our data suggest that probable or suspect SARS case patients may not need to be housed in standard NPIRs for their entire stay.
For stablized patients which indicate that the viral load of contamination is mild.
They may be placed in a step-down regular wards with minor renovation and traffic control instituted.
Using Using Traffic ControlTraffic Control Strategy During Outbreak Strategy During Outbreak Control to Minimize Nosocomial Infection of SARS Control to Minimize Nosocomial Infection of SARS
Among Health-Care WorkersAmong Health-Care Workers
Test Hospital Comparison Hospitals PMH
Bed Total (85) (746) (580)
Total** 2 (2.4 %) 93 (12.5 %) 62 (10.7 %) HCW 0.5 % / 0*** 2.0 %
* SARS case divided by number of patient bed ** p = 0.004, Chi square, Fisher exact test *** SARS hospital ( 松山 三重 )
Muh-Yong Yen, et al. 2003Muh-Yong Yen, et al. 2003
The EndThe End
Thanks for your attention