Embed Size (px)
Citation preview
Calculation of estimates of HAIs in U.S. hospitals among adults and children outside of intensive care units, 2002; total = 1.7 million; 98,987 deaths
HRN = high risk newbornsWBN -= well-baby nurseriesICU = intensive care unitSSI = surgical site infectionsBSI – bloodstream infectionsUTI = urinary infectionsPNEU = pneumonia
SSI20%
BSI11%
UTI36%
PNEU11%
Other22%
133,368
424,060
263,810
129,519
274,098
-967
-21
-28,725
244,385
TOTAL
HRN
WBN
Non-newborn ICU
= SSI
Klevens, et al. Pub Health Rep 2007;122:160-6
Frequency of Infections in Long Term Care Facilities
Site of Infection Frequency / 1,000 pt-days Urinary tract 0.46 – 4.4 Respiratory tract 0.1 – 2.4 Skin, soft tissue < 0.1 – 2.1 Gastrointestinal 0 – 0.9
Disease outbreaks:• Respiratory tract:
• influenza, parainfluenza, & respiratory syncytial virus• Gastrointestinal tract:
• E. coli O157:H7, Salmonella spp, and norovirus
Nicolle LE. Emerg Infect Dis 2001;7(no.2)
CDC Environmental IC Guidelines, 2003 “the environment serves as a reservoir for
microbes but it is rarely implicated in disease
transmission except in the immuno-compromised
population…
Inadvertent exposure to environmental
opportunistic pathogens (e.g., Aspergillus spp.
and Legionella spp.) or airborne pathogens (e.g.,
Mycobacterium tuberculosis and varicella-zoster
virus) may result in infections with significant
morbidity and/or mortality.
Some Examples of What Can Happen If
Attention to the Environment is Ignored John Snow &
outbreak of cholera London, 1854
8/31- 9/2 > 600 deaths clustered around Broad St. pump
What about the 2 cases 5 mi away?
Inf. Control measure?
Some Examples of What Can Happen If Attention to the Environment is Ignored
Aspergillus in the OR! 6 patients with surgical site infection.All had had surgery in a 12 day period. Two expired. Source = moisture contamination of insulation in duct supplying air to the OR that was downstream from the air filtersLutz BD. Clin Infect Dis 2003;37:786-93.
It never ends….
Summary of Construction/Renovation - Associated Outbreaks of Disease, 1978-98
Fungal Infections: 27 published reports; majority caused by Aspergillus spp. Mortality among affected patient populations > 50%
Bacterial Infections: 5 published reports; majority caused by Legionella spps. Mortality > 30 %
Construction-Associated Aspergillosis Hematology-Oncology Ward
No. of CasesPreconstruction 1988-89 4
Construction 1989-92 28
Ongoing Construction after environmental controls 1992-93 4
Infect Control Hosp Epidemiol 1996;17: 360-64
Healthcare Associated Aspergillosis
53 clusters or outbreaks:
458 patientsOverall case fatality rate = 57.6%
In one half of these the probable / possible source =
Construction &/or demolition work
Infections observed even with concentration of Aspergillus spp in air was < 1 colony-forming unit /m3
Vonberg R-P, Gastmeier.Nosocomial aspergillosis in outbreak settings. J Hosp Infect 2006;63:246-54.
Acute-care/specialty hospital constructionRenovation
70%
New Construction30%
Renovation/expansion
70%
Modern Healthcare Construction Survey March 2004
In with the Good Air or…Heating, Ventilation, & Air-Conditioning (HVAC)
Facilities - Ventilation
HVAC system maintenance Monitoring of the system including relative
humidity, air pressure balance, air exchanges, exhaust, temperature.
HVAC in most hospitals and LTCFs recirculate air
Private room or “isolation” rooms does NOT necessarily = airborne infection isolation room (AIIR) – Verify this with your facility HVAC engineer
AIIR is not required in LTCFs; instead transfer resident with TB disease to facility with AIIR.
Airborne Infection Isolation Room
*Pressure differential>0.01 inch (2.5 Pa)
*Air exchanges > 6air changes/hr (ACH) min.; aim for > 12
*Airflow volume: exhaust > supply by10% or 50 cfm; aimfor 125 cfm
*sealed room,Approx. 0.5-sq. ft.leakage;
Ideally exhaustdirectly to outside
Negative Pressure, meaning air flows into the room from adjacent areas.
Alternative: if no direct exhaust, filter return air through HEPA [removal efficiency = 99.97% particles 0.3 μm diameter
Facilities - Examples of Ventilation Parameters for Select Rooms
Operating Room: Positive pressure (net movement of air out of room
into adjacent area) Total air changes / hour (ACH) = 15; 3 of these with
outdoor air Patient Room-hospital / Resident Room-LTCF :
Neutral pressure Total ACH = 2
Toilet Room (hospital & LTCF): Negative pressure (net movement of air into room
from adjacent area) Total ACH = 10 All air exhausted to outdoors
Facilities - Water and Plumbing
Plumbing and sewer system maintenance FGI Guidelines: ICRA applies to LTC for water as
well; example = outbreak of Legionella in PA Nursing home in 2002
Legionellosis: Water treatment if Legionella cases identifiedGuidance: CDC EIC & Pneumonia Guidelines; OSHA Technical Manual (Chapter 7)
http://www.osha.gov/SLTC/legionnairesdisease/index.html
Decorative Water Features: Do Not Install!
17
Outbreak of Legionellosis in Facility in WI 8 cases; only exposure = walking through lobby WF Outbreak despite proper maintenance of the featureHaupt TE, ICHE 2012 – see also:Palmore T ICHE 2009
Protecting Patients: Handwashing Station Design
Handwashing station as a source of P. aeruginosa outbreak, ICU & Postoperative solid organ transplant unit! 12/36 infected expired. Sink design resulted in contamination of environment
Hota S, et al.Infect ControlHosp Epidemiol2009;30:25-33.
Water: Examples of Uses and Infection Prevention Interventions Whirlpools / Hubbard Tanks
Maintain with appropriate disinfectantNote: use by physical therapy has dropped dramatically
Hemodialysis water quality: treatment & monitoringRefer to CDC Env. IC Guidelines; lots of requirements
and one of few areas where routine cultures of water and dialysate are required
Handwashing sinks : Need to be convenient and accessible for useAre soap and paper towels available?
Ice machines: Do not handle ice directly by hand; dispensing
device is betterMaintain and disinfect based no manufacturer instructions
CDC/HICPAC 2003 Guideline for Environmental Infection Control (EIC): Key issues
Air-handling systems Construction, renovation, remediation, repair
and demolition IC & ventilation requirements for AII; PE
rooms; ORs Water - controlling the spread of waterborne
microorganisms; routine prevention Strategies to prevent-control legionnaires
disease (LD) Preventing LD in PE & hospitals with BMT
patients Environmental sampling Environmental Services cleaning and
disinfection
Selected CDC EIC Performance Measurements Documentation of active involvement of ICP in all phases of
a health-care facility’s demolition, construction, and renovation; include:ICRA for construction barriers Daily monitoring, documenting presence of negative
airflow within the construction zone or renovation area. Monitor & document daily the negative airflow in AII rooms
and positive airflow in PE rooms Document policies to identify and respond to water damage.
Policies- either repair and drying of wet structural or porous materials within 72 hours, or removal of the wet material if drying is unlikely within 72 hours
Facilities Construction and Renovation
FGI Guidelines 2006 require an Infection Control Risk Assessment (ICRA) for hospitals and nursing homes [facility guidelines institute]2007 Michigan Dept of Community Health
Minimum Design Standards require ICRA; available at:
http://www.michigan.gov/lara
Basic: Assess air and water quality The Joint Commission (TJC) requiring IPC input
into Utility management and ICRA as of January 2002
ICRA
Infection Control Risk Assessment (ICRA) Required by 2006 FGI, CDC, TJC Michigan Min. Design Standards based on
FGI 2006 edition Multidisciplinary team process and
documented
Matrix & Forms available at: www.ashe.org or www.premierinc.com/safety
ICRA Matrix at www.ashe.org
Facilities Construction and Renovation
Construction and Renovation Barrier containment
Excavation-keep dust out; Construction keep it inside the construction zone
Alternative ventilation Utility disruption contingencies
Example of ContainmentBarriers
1 hourfire RatedContain-ment
Facility Guidelines Institute (FGI) for Design and
Construction of Hospitals and Health Care Facilities-2010
2014 edition underway
FGI Guidelines for Design and Construction of Hospitals & Health Care Facilities, 2010
Regulatory
- Over 40 state, local healthcare licensing agencies have adopted AIA standards into their own state rules
Accreditation - Since 2001 TJC: Environment of Care Stds. - Since January 2002 requires ICRA in CAMH
(TJC Comprehensive Accreditation Manual for Hospitals)
The Joint Commission (TJC)
Infection Prevention & Control and
Environment of Care Standards
The hospital conducts comprehensive, proactive risk assessments that evaluate the potential adverse impact of buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and other people coming to the hospital’s facilities
JC: The EOC – IPC Connection EC.7.10 The hospital manages its utility risks :
14. The hospital labels controls for a partial or complete emergency shutdown.
15. The hospital identifies and implements processes to minimize pathogenic biological agents in cooling towers, domestic hot/cold water systems, and other aerosolizing water systems.
16. The hospital designs, installs, and maintains ventilation equipment to provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies for ventilation systems serving areas specially designed to control airborne contaminants
EC.8.30 The hospital manages the design and building of the environment when it is renovated, altered, or newly created
Dust/particulate - lack of control Fumes (welding, roof work, demolition); vibration;noise Water penetration or leaks (potential mold contaminants) Dead end plumbing lines (Legionella spp.) Debris removal - improper Traffic patterns - improper; lack of emergency egress Barriers - improper (must be 1hr fire rated); not floor-deck Fire alarms or sprinklers not operational
Daily cleaning of work site -lacking
Construction- Related Problems: Observations by State Surveyors…
Facilities - Waste Michigan DEQ New rules to interpret Michigan
Medical Waste Regulatory Act Enforcement primarily from MDEQ/MIOSHA under
general waste and Bloodborne Infectious Diseases Rules
Dept of Transportation finalized new rule on Infectious Substances- hospitals exempt except for training
Policies and procedures for disposal should include Waste categorization, packaging, collection,
transport and disposal
Bloodborne Infectious Diseases
Rules, MI Occupational Safety & Health Administration (MIOSHA), effective 10/18/2001 Regulated waste” means any of the following:
(i) Liquid or semiliquid blood or other potentially infectious material (OPIM)
(ii) Contaminated items that would release blood or OPIM in a liquid or semiliquid state if compressed
(iii) Items which are caked with dried blood or OPIM and which are capable of releasing these materials during handling.
(iv) Contaminated sharps. (v) Pathological and microbiological waste that contains
blood and OPIM
Bloodborne Infectious Diseases
Rules, MI Occupational Safety & Health Administration (MIOSHA), effective 10/18/2001 R 325.70010 Regulated waste disposal.
closable, leakproof containers or bags that are color-coded or labeled
Immediately after use, contaminated sharps shall be disposed of in closable, leakproof, puncture-resistant, disposable containers that are labeled or color-coded
Bloodborne Infectious Diseases
Rules, MI Occupational Safety & Health Administration (MIOSHA), effective 10/18/2001 OPIM:
of the following: (i) Any of the following human body
fluids: (A) Semen. (B) Vaginal secretions. (C) Amniotic fluid. (D) Cerebrospinal fluid. (E) Peritoneal fluid. (F) Pleural fluid. (G) Pericardial fluid. (H) Synovial fluid. (I) Saliva in dental procedures. (J) Any body fluid that is visibly
contaminated with blood.
(K) All body fluids in situations where it is difficult or impossible to differentiate between body fluids.
(ii) Any unfixed tissue or organ, other than intact skin, from a living or dead human.
(iii) Cell or tissue cultures that contain HIV, organ cultures, and culture medium or other solutions that contain HIV or HBV; and blood, organs, other tissues from experimental animals infected with HIV or HBV
MEDICAL WASTE RULES in MICHIGAN
Agency that enforces = MI Dept of Environmental Quality (MDEQ) Andrew Shannon at 517-335-1146 or e-mail
to: [email protected] Components:
Definitions On site storage, decontamination, & disposal Registration Medical Waste Management Plan – Required
of all facilities that product medical waste
