Building Zero Infection Hospitals Dr. Kithsiri Edirisinghe M.B.B.S., M.Sc., MD ( Medical Administration )TAE ( Australia ), Master Trainer ( Australia )IVLP ( USA) Deputy Chairman, International Institute of Health Sciences , Sri Lanka Director, Green Healthcare Pvt. Ltd

Objectives of the Session To give an insight to master planning of a hospital and to develop infection control policies. To give a basic knowledge in hospital design and how it could be effectively used in the prevention of HAI.

Content Hospitals and importance of HAI Evolution of hospital buildingsHospital design details and HAI

How does the hospital environment differ from other service environments?

Hospital Environment Highly dynamic environment Highest risks for the patient and the staff Human - Patients, Relations, Staff, Administrators Others - Technology, Infrastructure, Methods On top of this infections are everywhere !!!!!!Microbes too change all the time HAI Output & Outcome of the service process is entirely different to the expectation

HAI - Why is it Important ?Patient Risk management Mortality Morbidity Near misses Cost management Preventable long stay Antibiotic use Loss of opportunity Waste of resources

Morbidity from HAI , USA, 2002 Total HAIs in hospitals - 1.7 millionNewborns in high-risk nurseries - 33,269 Newborns in well-baby nurseries -19,059 Adults and children in ICUs - 417,946 adults and children outside of ICUs - 1,266,851 among

Source : R. Monina Klevens, DDS, MPH a Jonathan R. Edwards, MS a Chesley L. Richards, Jr., MD, 2002, Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, USA.

Mortality from HAI, USA, 2002 The estimated deaths associated with HAIs in U.S. hospitals were 98,987:Pneumonia - 35,967 Blood stream infections - 30,665 Urinary tract infections - 13,088 Surgical site infections - 8,205 Infections of other sites - 11,062

Source : R. Monina Klevens, DDS, MPH a Jonathan R. Edwards, MS a Chesley L. Richards, Jr., MD, 2002, Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, USA.

Overall annual direct medical costs of HAI to U.S. hospitals, 2009 All urban consumers - $ 30 billionRs 3,000 billion Rs 3,000,000,000,000.00 All Inpatient hospital services - $ 40 billionRs 4,000 Billion Rs. 4,000,000,000,000.00 Ours ???? Source : R. Douglas Scott, ( 2009) , The Direct Medical costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention

Insight to the evolution of infection control and hospital design

Sri LankaOldest hospitalsSanitation Drainage Not well documented

1847, Vienna, Oliver Wendell Holmes and Ignaz Semmelweis

Puerperal fever of the new born at Vienna Lying-In Hospital Patients with prolonged labor were at increased risk and children born to infected mothers were also more likely to become ill. Women whose babies were born outside the hospital were less likely to develop fever. Puerperal fever was spread by the hands of physicians and midwives.

Florence Nightingale and Hospital Design, 1910-17

Observations about hospital design based on her experiences during the Crimean War.Rejected the 18th-century concept of long hospital corridors.Nightingale believed that respiratory secretions were potentially dangerous, especially among the sick. Depriving patients of appropriate ventilation is nothing but manslaughter under the garb of benevolence.

Open windows interfere with ventilation & pass infection from ward to ward Need of isolation rooms Hospital should not be more than 02 stories since taller buildings interfered with sunlight and ventilation

A 'Nightingale Ward' at St. Thomas's Hospital

Private Rooms, USA, 1920

In 1920, Asa Bacon of Chicagos Presbyterian Hospital noted that hospitals are hotels for sick people. One disgruntled patient commented to him following his discharge: When I return, put me in a closet rather than in the ward!

What is the hospital ?Hospital is a place where :all patients and their loved one are received, treated and released in a friendly, dignified , and ethical manner maintaining the professional and institutional policies and standardsthus preventing, investigating, treating and rehabilitating patients with a view to exceeding patients and institutional expectations

How Can Hospital Design Support Infection Control?

Chasing Zero HAIIt is time to change the headlines. It is time to set sail on our journey to zero HAIs and put the care back into healthcare and the trust back into the public trust

The Chasing Zero Department: Making Idealized Design a Reality, Charles R. Denham, MD, Peter Angood, MD, Don Berwick, MD, MPP,Leah Binder, MA, MGA,Carolyn M. Clancy, MD, Janet M. Corrigan, PhD, MBA and David Hunt, MD, FACS

Background

Recent attention in health care has been on the actual architectural design of a hospital facility, including its technology and equipment, and its effect on patient safety.

Key Elements of Breaking the Transmission of InfectionThe process of patient care The patient Personnel Environment Equipments & tools Methods Supplies

The Importance of Hospital Design and Equipments on HAIThe impact of facility design of the hospital & equipment and technology on the quality and safety of patients has been undervalued over the years! Establishment of Hospital buildings and related equipments are very expensive Therefore it is important to use current and emerging evidence to improve the physical environment in which nurses and other caregivers work, and thus improve both nurse and patient outcomes.

Where to Start?

Early Planning The Team ICT + project team Patient care services Process of delivery Use Government reports and guidanceWHO, international guidelines Decisions were made on the number of bays, single rooms, bed spacing, utilities and toilet

The Planning Stage Architects, builders, engineers and project managers have little or no knowledge on infection control ICT - Infection Control TeamParticipation of the ICT professionals in early stages Microbiologist, Medical director, Nursing director, Unit heads (doctors, nurses, others) Infection control risk assessment should be done at the initial stages

Hospital Design Conceptual design Master plan Master functional design Unit planningEquipment planning Detailed design Specifications Roof Floor Walls

Hospital Design Conceptual design Detailed design Final functional design

1. Conceptual design Master plan Unit planningPrimary functional design

A. Master planType of the hospital Special / GeneralMedical service plan Building structure & size Vertical transport & natural light Placement of clinical units Critical, High risk OT, ICU, NICU, LR Medium risk wards, Investigation units, OPD, blood bank Low risk General - Patient waiting, landscape

A. Master planPlacement of Support services - administration, facility servicesFacility engineering Sewer treatment plant, water treatment, medical gas Waste management system solid, liquid waste Stores Medical and General

OTBLOOD BANK & LABROOMS4.ETU5.RADIOLOGY6.RECEPTION7.ADMIN & PUBLIC RELATION8.OPD9.CANTEEN

10.KITCHEN11.SERVICE122333456789101111

B. Unit Planning Layout of the units Isolation rooms, ward to room ratio 80: 20 Bay concept (wards) MRSA , Meningococcal Ideal for developing counties due to issues in cost effectiveness 4- 5 beds per bay Spacing of beds Ideally 2.5 meters ( center to center ) Space for Bystander One way traffic ,natural light Unit waste managementDirty utility, Clean utility, linen store

B. Unit Planning

Organize functional design - Unit patient flow Identify potential areas of contact and intervention General infection control polices Special infection control protocols

HDU

C. Primary Functional Design

Need to structure the guidelines chronologically, so that the key action points are identified for each stage of the developmental process.Through Process analysis Look at the Patient flow & identify the critical areas / high risk areas of infection transmission

C. Primary Functional Design

Develop, strategies, policies, protocols to counter the threats posed General infection control polices Special infection control protocols Use Government reports and guidanceWHO , international guidelines

2. Detailed Design

Demarcation of unitsEnvironment - Air Ventilation, Water, Floor, Ceiling , walls & furniture, supporting Hand washing Equipment planning

A. Demarcation of Units

Color coding of the units and areas according to the risk levels Maintain one way traffic Restriction of peopleSpecial procedures

B. Environment - Ventilation

Common HAI Aspergilosis , TB, LegionellosisFungi Aspergillus Aspergillosis -Lobar Pneumonia - Spores Immuno-compromised patients, are at no greater risk for infection within the hospital than outside. Cancer/ HIV/AIDSOrgan / bone marrow transplant

B. Environment - Ventilation

Filtered ventilation Use of HEPA filters in all Critical areas Use central Air conditioning Use of air conditioning & humidity Use positive air pressure prevents corridor air, coming in to clinical units

B. Environment-Ventilation

Preventing - TBIsolation rooms with an air lock room Use negative air pressure Sealed rooms windows, self closing doors

B. Environment-Ventilation

Preventing LegionellosisLegionella is an important cause of community and hospital-acquired lower respiratory tract infections Storage tanks, cooling towers of AC Clean water - Chlorination, Thermal eradication, UV light

B. Environment - Water Water born disease Enteritis Disinfecting water sources Chlorination, Thermal eradicationWater treatment plants Policies to supply safe water to patients

B. Environment- Floor Avoid Tiles and corrugated surfaces as much as possible Use heavy duty floors in general areas Granite Make it washable Keep the flow dry all the time Carpeting Avoid in high risk areas, vacuum daily and periodical steam cleaning

B. Environment- Floor Bacteria on hospital floors predominantly consist of skin organisms,- e.g., coagulase-negative staphylococci, Bacillus spp.and diphtheroids , S. aureus and Clostridium spp. Floors need to be dry and smooth with no gutters Use vinyl floors in patient areas - cleaning, maintenance , sound, replacement, use of proper wheels

B. Environment - Ceiling & Walls Pathogenic microorganisms adhere walls or ceilings when the surface becomes moist, sticky, or damaged Walls and ceilings should have a smooth, impervious surface that is easy to clean , wall pictures Wall coverings should be fluid resistant and easily cleaned, especially in areas that contact with blood or body fluidsFalse ceilings Harbor dust and pests that may contaminate the environment if disturbed.Avoided in high-risk areas unless adequately sealed.

Daycare Centre

OPD Waiting area

B. Environment - Furniture and Fittings Furniture is thought to be a minor infection risk, but prolonged survival of VRE MRSA and VRE have also been recovered from privacy curtains, scrub suits, and plastic aprons Possibility of their being acquired by patients or health-care workers and spread from one person to another. Surface of future Use of curtains Vinyl and regular washing Beds - Power coated, remoteBed head panel

B. Environment -Furniture and Fittings Surface of furniture, should be easy to clean Use of curtains Vinyl and regular washing Beds - Powder coated, remoteBed head panel Railing on corridors, door handles Entertainment systems - key boards Waste management system and the process

Typical room

C. Hand Washing Hand washing is the single most important method to prevent hospital infections. Each patient room, examination room, and procedure room needs at least one sink placed close to the entrance Large enough to prevent splashing. Shallow sinks may cause contamination of hands by bacteria residing in the drain- linked to a hospital outbreak of multidrug-resistant gram-negative bacilli Each sink should be equipped with a hands-free control, soap dispenser, and paper towel holder.

C. Hand Washing Get more natural light near the sink Wash Basins were stand alone so any splashes fell on the floor rather than a work top. Long handle tapsHands free taps for the Critical CareAlcohol hand gel mounted on the ends of beds.Access to examination gloves and a trash receptacle should be readily available

D. Equipment Planning Use equipment with smooth surfaces which are easy to clean Plan the layout for minimal spills and contamination Protocols for effective use of equipments DosDonts CSSD

3. Final Functional Design Finalize Hospital infection control policiesTrain staff & Place controlling mechanismQuality standards & Reporting systems Quality audits Organizational culture for infection controlAlign infection control polices to performance evaluation system of the human resource department Educate visitors Output specifications

Output Specification Output specifications for support services CleaningCateringLaundryWaste disposalPest control Utilities management. Model output specifications available on - www. dh.gov.uk

References 1. J.M. Stockleya, C.E. Constantinea, K.E. Orrb, Building new hospitals: a UK infection control perspective, The Association of Medical Microbiologists New Hospital Developments Project Group, UK , Journal of Hospital Infection (2006) 62, 285299.

2. Gary A. Noskin and Lance R. Peterson, Engineering Infection Control through Facility Design, Northwestern Memorial Hospital and Northwestern University, Medical School, Chicago, Illinois, USA, Volume 7, Number 2April 2001 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections.

Thank you !

***