Guidelines – Healthcare2006 AIA FGI

Highlights

August 2006Paula Buick

Perspective

Technological Integration1954 marked the

beginning of production for the Ericofon. Originally it was intended for institutional use. They found their biggest customers were hospitals. Imagine laying in a hospital bed, trying to reach over to a desk phone to dial. The one piece design of the Ericofon seemed to be "just what the doctor ordered". Silk sheets optional.

Knowledge

Guidelines 2006

WhoThe Facility Guidelines Institute – FGI AIA Academy of Architecture for Health AIA/AAH With U.S. Department of Health and Human Services

Funded DHHS/CMS, ASHE and NIH

Changes Bigger 175 pages to 325 Better format, legible, indexing and searching – CD – Punched

numbering [Clemson] and ‘Appendix’ Organization 4 Sections - ”All” - Hospitals - Ambulatory – OthersProcess Request Formal Interpretation and Change

1 GeneralSection 1Introduction – What, Why, Who, Major Additions Summary Interpretation Referenced Codes Listing, Web Sites

Code Life Safety CMS adopted NFPA 101Renovation NFPA 101 covering HCO -’affected areas’

NFPA 101 New HCO or Existing HCO ADAAG Accessibility Guidelines for Bldgs and Facilities Information Protection – HIPPA

Disaster Types Facility Response

Appendix – shaded boxes throughout is advisory only * not changed from 2001 Guidelines

Part 1 General 34 pages [17] - national codes, standards; EOC; Equip, D&C …

Part 2 Hospitals 151 pages [83 total-58+11+14]2.1 General Hospitals ** bed clearances ICUs -Intermediate Care –freestanding ED – MRI – Waste – AI PE new language air

2.2 Small Primary Care Hospitals ***2.3 Psychiatric2.4 Rehabilitation

Part 3 Ambulatory Care Facilities 63 pages [23]3.1 Outpatient [OP] Facilities 3.2 Primary Care OP Centers 3.3 Small Primary Neighborhood OP Facilities3.4 Freestanding OP D&T Facilities 3.5 Freestanding Urgent Care Facilities3.6 Freestanding Birthing Centers3.7 OP Surgical Suite3.8 Office Surgical Facilities ***3.9 Gastrointestinal Endoscopy Facilities ***3.10 Renal Dialysis Centers ***3.11 Psychiatric OP Centers ***3.12 Mobile, Transportable and Relocatable Units [use of means other than covered walkways shall be permitted]

Part 4 Other Health Care Venues 43 pages 4.1 Nursing Facilities4.2 Hospice Care **4.3 Assisted Living ** 4.4 Adult Day Care **

Overall Organization

1 General

1.2 Environment of Care significant expansion p15-20

Delivery of Care model shall be defined in the functional program [pt.focused/ family centered/ community centered]

Light and Views, Clarity of Access [wayfinding], Control of Environment, Privacy, Finishes [color palette] Water features – Aquariums – IAQs

2.2.2.5 Physical Environment2.2 Nomenclature – names and spaces indicated on the functional program shall be consistent with the submitted floor plan

3 Sustainable Design – Site, Waste Minimization, Water quality-Conservation, Energy.. IAQVOCs – moisture – dedicated exhaust systems

1.4 Equipment*Equipment list included in contract documents Equipment list specify new, existing to be relocated, owner provided NIC

1 General

1.5 Planning Design Construction p26

Interdisciplinary Design Team, Commissioning

1.5.2 Infection Control Risk Assessment Process2.1.3. Monitoring The owner shall also provide monitoring of the effectiveness of the applied ICRMR during the course of the project

2.2.1 Design Location of special ventilation and filtration such as ED waiting and intake areas

2.2.1.3 Air handling, ventilation needs in surgical svs, AI, PE, Labs etc

2.2.1.5 Finishes and Surfaces2.2.2. Construction location of susceptible pts; Impact of potential outages or emergencies and protection of pts during planned or unplanned ..

2.3 Infection Control Risk Mitigation2.3.2 Project Requirements the owner shall ensure that construction related ICRMR as well as ICRA-generated design recommendations, are incorporated into the project requirements2.3.3 IC Monitoring The owner … provide continuous monitoring of their effectiveness …2.3.3.1. … may be conducted by in-house IC&S staff or independent

Reference Site: CDChttp://www.cdc.gov/ncidod/dbmd/diseaseinfo/default.htmAspergillosis -Clinical FeaturesIn immunosuppressed hosts: invasive pulmonary infection, usually with fever, cough, and chest pain.

May disseminate to other organs, including brain, skin and bone. In immunocompetent hosts: localized pulmonary infection in persons with underlying lung disease. Also causes allergic sinusitis and allergic bronchopulmonary disease.

Etiologic Agent Aspergillus fumigatus, A. flavus. Less commonly A. terreus, A. nidulans, A. niger.Reservoir Ubiquitous in the environment. Found in soil, decomposing plant matter, household dust,

building materials, ornamental plants, items of food, and water.Incidence Not reportable. Population-based data available for San Francisco suggest a rate of 1-2 per

100,000 per year. Sequelae If severe granulocytopenia persists, mortality rate can be very high (up to 100% in patients

with cerebral abscesses). Patient outcome depends on resolution of granulocytopenia and early institution of effective antifungal drug therapy.

Transmission Inhalation of airborne conidia (spores). Nosocomial infection may be associated with dust exposure during building renovation or construction. Occasional outbreaks of cutaneous infection traced to contaminated biomedical devices.

Risk Groups Persons with severe, prolonged granulocytopenia (e.g., hematologic malignancy, hematopoietic stem cell and solid organ transplant recipients, and patients on high-dose corticosteroids). Rarely, persons with HIV infection.

Surveillance No national surveillance exists. Challenges Identifying modifiable risk factors for disease in immunocompromised persons. Improving

understanding of sources and routes of transmission from the environment.

Aspergillus http://www.aspergillus.org.uk/secure/articles/webbarnes.htm

Sources of infection: endogenous versus exogenous A major issue in the prevention of nosocomial aspergillosis is the question of whether infection in an individual patient was acquired in hospital, or in the

community: our most energetic prevention efforts in the hospital will not prevent the latter. There are many uncertainties in this area, not least the incubation period of the disease (estimated to vary from 48 hours to 3 months). Some light has been shed by the use of molecular typing methods (2,15,16,19). If the criterion used for "hospital-acquired infection" is the isolation of the same fungal strain from the patient and the environment, some 40 % of cases of invasive aspergillosis appear nosocomial (19). Further use of increasingly accurate typing methods will help to elucidate this question in the future.

Prevention of nosocomial aspergillosis:Outbreaks of nosocomial aspergillosis occur mainly among neutropenic patients. These have occurred in association with environmental disturbances:

hospital construction; contaminated fire-proofing materials, or air filters in the hospital ventilation system; contaminated carpeting. Routes of transmission: airborne route The first evidence for the protective effect of air filtration ..The recognition of a high incidence of aspergillosis in the hospital's BMT patients led to the

installation of high-efficiency particulate air (HEPA) filters. This was associated with a dramatic fall both in environmental counts of Aspergillus sp, and in cases of invasive disease (14).

..reports show that modern ventilation and filtration systems are capable of dramatically reducing aspergillus spore counts.(4,7)In summary, the prevention of nosocomial aspergillosis involves the proper installation, use, and maintenance of ventilation systems; and the elimination

of exposure to fungal spores generated by construction.(1,15,16) The environmental controls required to protect vulnerable patients are detailed in the CDC recommendations, shown in tables 1 and 2. Table 1 shows the measures needed to minimize exposure to fungal spores to produce the "protected environment" required for neutropenic patients: essentially HEPA filtration, directed air flow, positive pressure, a well sealed room, and high rates of room air changes.

Table 2 contains the full guidelines on prevention and control. Section 4 pertains to existing facilities with no cases of nosocomial aspergillosis: a couple of additional points may be made. It is worth emphasising the importance of preventing dust-accumulation by daily damp-dusting of horizontal surfaces. Some authorities feel that mould proliferation around sink outlets, etc, may represent another environmental reservoir: so water leaks should be cleaned up and repaired. BMT units should minimize exposure of patients to activities such as carpet cleaning or vacuuming, that may cause aerosolization of Aspergillus spores, and the ward vacuum cleaner should be fitted with HEPA filters.

When construction is undertaken, the measures suggested to protect vulnerable patients include the use of impermeable barriers between patient care and construction areas; directing pedestrian traffic away from the area to prevent dust dispersal; and cleaning of the new premises before patients are moved there. Finally, air and environmental monitoring for spores may be indicated when building works are taking place adjacent to an area housing high-risk patients.

Is water a source of Aspergillus?At this point, we should consider the recent suggestion that hospital water supplies may be a source of Aspergillus species spores. They concluded that

showering resulted in aerosolization of spores and was a potential source of exposure (17). The Norwegian-led group of Warris and colleagues carried out a study in a paediatric BMT unit, sampling water from the taps in the unit as well as the mains supply. Filamentous fungi were recovered from all water samples, Aspergillus fumigatus from 60 % of tap samples (18). These results are of considerable interest, but larger scale studies are required.

1 General

1.6 Common Requirements p31

2 Building Systems2.1.2 PlumbingHot water recirculation – constant and non recirc <= 25’Dead end piping [branches with no fixtures] shall not be installed. Empty risers, mains & branches permitted

2.3 Electrical Lighting IES [Illuminating Engineering Society] references Pub RP-29 Lighting for Hospitals and HealthcarePub RP-28 Needs of elderly Visual Environment for Senior Living

2. General Hospitals p37 -134

Swing beds – Patient-Family Centered Care Rooms – AirFlow – Staff Emergency Assist location – Pts Observation – Documentation –Obstetrical Models – Surge Capacity – Fast Track – DeContam –

3. Nursing Locations3.1 Medical Surgical Rooms

3.1.2 Patient/Family Centered Rooms3.2.5 Protected Units – transplant, nurseries, NICU, parts of ED

3.3 Intermediate Care Units – ‘Step Down’ ->med/surg<ICU

3.3.1.3 Location …can be sep unit or designated part of ..

3.4.6 NICU3.4.6.1. Space requirements 120 sf and aisle adjacent to each min 4’ in multips. Single or fixed cubicle partitions aisle not less than 8 feet in clear and unobstructed width…

4.1 Obstetrical4.4. LDR LDRP – single occupancy [min clear 300 sf – 2001 – min

dimension 13’ exclusive closets etc] Dimension 15’preferable

2.1 General Hospitals p 37 -134

3.1.1 Capacity p 40New construction max 1 unless functional program demonstrates….Approval of a 2 bed shall be obtained from the licensing authority

New Single Rooms Construction3.1.1.2 Space Requirements*(1) Area 120 sf Clear Floor Area

exclusive of toilet rooms, closets, wardrobes, alcoves or vestibules [ExTC]

(2) Dimensions Clearances 3’ Foot - 3’ - 3’(3) Renovation waiver – AHJ 80 sf multips/100 sf singles

3.1.1.2 Single Pt Rooms12’ wide x 13’ deep ~ 160 sf exclusive of toilet rooms, closets, REQ

120 clear

3.3.3

REC

160 clear

* 2001 AIA

2.1 General Hospitals

3.1.2 Patient/Family Centered Care Rooms p413.1.3 Space RequirementsArea 250 sf Clear Floor Area ExTCDimensions Min clear 15 feet Additional area 30 sf per family member

30

250 clear

15

2. General Hospitals

3.4 Critical Care Units p493.4.2.1. Space RequirementsArea 200 sf Clear Floor Area [ExTC]*Dimensions Min Headwall 13’ *Clearances 5’ foot - 5’ transfer side - 4’ non transfer sideRenovation if not possible –AHJ waiver min 150 sfObservation – Documentation

200 clear

13

4

5

5

5.5.4

Where to put it ?

Where to put it ?

2. General Hospitals5. Diagnostic and Treatment Locations

5.1 Emergency Service p68Surge Capacity .. Up to 10 or a fourhold increase …

Adjacent space for triage and management Utility upgrades for those areas – Oxy H2O ElectricalExhaust – ventilation – routes to admission

Classification of Emergency Departments/Services/Trauma Centerswww.facs.org American College Surgeonswww.acep.org American College Emergency Physicans

5.1.3 Fast Track Area .. 20-30k visits p705.1.3.7.(5) Decontamination p73 – location, space min 80 sf clear floor,

surface specs 5.1.3.7. (5) Decontamination Area on the Exterior Perimeter

Markings, showerheads, secured access tel systems, airflow & ventilation, H2O runoff, Decontamination Area Interior – specified dimensions – ceilings wall and floors,

2. General Hospitals5. Diagnostic and Treatment Locations

5.1 Emergency Service5.1.3.8 (2) Observation/Holding Units p74Area 100 sf clear floorDimensions Clearances HW Sink 1:4 or fraction Toilet 1:8 or major fractionNourishment

5.1.3.11 (1) Bereavement RoomSTC 65 walls 45 floors & ceiling

Refer to STC sound table p 129

2. General Hospitals‘8 feet’ corridors*

5. Diagnostic and Treatment Locations5.3 Surgery 5.3.2 Operating and Procedure Rooms – Class A, B C* p77new Construction (d) op Rooms perimeter walls, ceilings and floors including penetrations shall be sealed

5.3.3. Pre- And Post Operative Holding Areas* P79

Space RequirementsArea 80 sfClearances 4’4’4’

5.3.3.2 PACU’s*Space RequirementsArea 80 sfClearances 5’4’4’

Separate and additional recovery space may be necessary to accommodated patients. If children receive care, recovery space should be provided for pediatric patients and the layout of the surgical suite should facilitate the presence of parents in the PACU

2. General Hospitals

80

4.4.4

80 80

w

54

3.7 Outpatient Surgical Facilities Surgical Procedure Rooms* p 222Defined by American College of Surgeons

2. General Hospitals3. Ambulatory Care

Class A

Minor

Topical Local

No IV Spinal Epidural

150 sf ExVC

min clear 12’3’6” side foot head

Class B

Minor/Major

Oral Parenteral

IV

250 sf ExVC

min clear 15’3’6” side foot head

Class C

Major

General

Regional

400 sf ExVC

min clear 18’4’ side foot head

Note: 2.0 General Hospital 5.3 Surgery 5.3.2 Operating and Procedure Rooms – Class A, B C* p77

5. Diagnostic and Treatment Locations5.3 Surgery 5.3.2 Operating and Procedure Rooms – Class A, B C* p775.3.2.1 General Operating Rooms*

New - (d) Renovation5.3.2.2 Special [CardioVascular Ortho Neuro]* p785.3.2.4 Surgical Cystoscopy Rooms*

2. General Hospitals

Renovation

350 sf ExC

min clear 15’

400 sf ExC

min clear 20’

New Special New

600 sf ExC

min clear 20’Surgical Cysto

350 sf ExC

min clear 15’

Special Renovation

Ortho 360 sf CV/Neuro 400 min clear 18’

UroCysto 250

5. Diagnostic and Treatment Locations5.3 Surgery - Summary Peri-Op 5.3.3. Pre- And Post Operative Holding Areas* P79Space RequirementsArea 80 sfClearances 4’4’4’5.3.3.2 PACU’s* Mass DPH Ratio 3:1 ORSpace RequirementsArea 80 sfClearances 5’4’45.3.3.3 Phase II Recovery* Mass DPH min 50% of PACU requirementLounge Chair Area 50 sf Clearance 4’4’4’ HW Sink 1:4 Chairs

Single Room Area 100 sf clear Clearance HW Sink Req

2. General Hospitals

80

4

8080

5

w

50

4.4.4.

50

4.4.4.100

80

4.4.4

80

4.4.4

Pre & Post PACU Phase II Single

2. General HospitalsSTC sound table p 129

5. Diagnostic and Treatment Locations5.4 Interventional Imaging Facilities p825.4.1 Cardiac Cath lab located in Imaging suite permitted

Area 400 sf clear floor ExCDimensions Clearances

5.5.1 Imaging Suite General* p835.5.2 Angiography* p84A5.2.1.1 (1) The procedure room should be min 400 sfA5.2.3 Viewing areas should be min 10’ lengthA5.4.1 Radiographic rooms should be min 180 sf [dedicated chest smaller]A5.4.2 Tomography and radiography/fluroscopy (R&F) rooms min 250 sfA5.5.4.3 Mammography rooms min 100 sfA5.5.5.3 MRI Control Rooms min 100 sf and may be larger

5.5.6 Ultrasound*5.5.7 Cardiac Cath Lab*5.6 Nuclear Medicine*A5.6.3 PET Facilities Space Requirements

2. General Hospitals

2. General HospitalsGeneral Finishes p 1138.2.3.2 Flooring* 8.2.3.7 PE and Anterooms

shall have seamless flooring with integral coved base

8.2.3.4 Ceilings p 113Semi-Restricted [AI- PE – Specialized Radiology, Minor Surgical Class A…]Smooth Scrubbable NonPerforated If lay in … gasketed and clipped

10.2.2.2 Protective Environment Rooms p 120

(4) If AI is necessary for PE patients an ante-room shall be provided

10.2.2.4 (3) (a) Operating and Delivery Room Ventilation p 120

Rec air changes 20-25 ACH ceiling heights between 9’ and 12’Refer to appendix on this page for more details [NIH –ASHRAE Transactions

2002 Vol 108 pt 2]

2. General Hospitals10.1 Plumbing10.1.2.5 (2)(b) Floor Drains Cysto Operating Rooms – if insisted upon ….

Location and instructions to prevent trap dry out… 10.2 Heating Ventilating and HVAC Systems p 118

10.2.1.1 Mechanical System Design (2) Air Handling Systems(5) Renovation – if modification affects > 10% system capacity…. Designers shall Utilize pre- renovation water/air flow rate measurements to verify that sufficient capacity is available and that renovations have not adversely affected flow rates in non-renovated areas

10.2.1.3 Testing & Documentation –’owner shall be furnished’10.2.2 Specific Locations AI rooms (1) design.. Permitted .. to include

provisions for normal patient care during periods not req isolationRemodeling Guidance 118, Operating Rooms 120, Anesthetic Agents 122

10. 5 Electronic Safety and Security Surveillance Systems p 12910.5.1. Electronic Surveillance Systems

Door, Access Control, AV monitoring, Pt Location, Infant Abduction10.5.1.1 Devices are not required but if.. Unobstrusive, tamper resistant10.5.1.2 … devices located so not readily observable by general public or patients10.5.1.3 … emergency electrical system

2. General Hospitals 3. Ambulatory Facilities

3.9 GI Endoscopy Facilities p 2331.2 Functional Program – description … hours…1.4 Shared Services [IP-OP] - services may be shared to avoid duplication1.4.2 If IP OP are performed same room, functional program should describe

in detail scheduling and techniques used to separate IP and OP 2.3.1 Procedure Rooms

Area 200 sf ExVTCClearances 3’6” side head foot of stretcher/table

2.3.2 Patient Holding/Prep/Recovery Area2.3.2.1 General (1) meets the size requirements of a stepdown recovery area

[3.7-2.4.2.1]

80 80

w

54

GI prep/recov

100

Single

2. General Hospitals 3. Ambulatory Facilities

3.9 GI Endoscopy Facilities p 2333.2 Instrument Processing Rooms P 235

Dedicated processing room(s) for cleaning and decontaminating instruments shall be provided.

3.2.1.3 Layout The cleaning area shall allow for the flow of instruments from the contaminated area to the clean assembly area and then to storage. A physical barrier shall be provided to prevent droplet contamination on the clean side.

A3.2.2.1 This may require soaking sink(s), rinse sink(s, automated cleaning device(s), or a combination.

5. Construction Standards5.2.1.1 Corridor Width (1) min public 5’ except where pts are transported on

stretchers shall be 8’ [Doors 3’8”] (2) Staff access corridors may be 3’8” [Doors 3’]

Exam Room Table 60 years ago

3.0 Ambulatory Care Facilities p 189

3.1 Outpatient Facilities 3.1.2 Exam rooms* p 190

Area 80 sf clear floorDimensions Clearances 2’8” * sides foot exam table

3.1.2.2 Special Purpose Rooms – Eye ENTArea 80 sf clear floorDimensions Clearances 2’8”sides foot table, bed or chair

3.1.3 Treatment Rooms [ExTC]*Area 120 sf clear floor*Dimensions Minimum 10’ clearClearances 3’ 0” sides foot bedHW sink

3.1.4 Observation Rooms [rooms to isolate suspect, disturbed pts]

Area 80 sf clear floor [ExTC]Dimensions

2.82.82.8

80 sf Clear

10’ min

3.3.3

120 sf Clear

Staff – Lounges, Lockers – where are they?

Clinical – Pharmacy – Lab – Dietary ..