Hygiene requirements for health-care facilities RNDr. Sylva Rödlová, Ph.D František Kožíšek, M.D., PhD. Third Faculty of Medicine, Charles University,

Hygiene requirements for health-care facilities

RNDr. Sylva Rödlová, Ph.DFrantišek Kožíšek, M.D., PhD.

Third Faculty of Medicine, Charles University, Prague, D1

2014

Contents/structure

I. Hospital hygieneII. Building, technical and operational

requirements for health-care facilities

III. Infectious and non-infectious hospitalism and its prevention(nosocomial infections, hospitalism)

Hospital hygiene Health-care facilities Infectious and non-infectious hospitalism

Part I

Hospital hygiene

Factors influencing health of humans

1) Internal (heredity).2) External: environmental and

occupational conditions, life style, health care.

Health of population is influenced:– Health-care 20 %– Environment 20 %– Life style 60 %.


Health-care facilities (HCF)

Environment of specific and multiple risks

Environment shared by specific group of people

Environment of specific exposure routes

Environment, where treatment has priority over prevention and occasional rapid interventions to save human life push away standard use of protective aids or rules of work safety


Persons x risks

Patients

Medical staff

Other staff

Visitors

Biological factors (pathogens, opportunistic pathogens)

Chemical factors (pollutants)

Physical factors (ionizing and non-ionizing radiation, noise, lighting and microclimate, injuries)

Ergonomic factors

Psychological and organization factors


What is hospital hygiene ?What is hospital hygiene ?

Systematic and continuous use of complex of hygienic and epidemiological rules in specific conditions of HCF

Protection of patients: „not to leave HCF more sick then before“

The goal is not only to protect patients, but also the staff and visitors and also environment (before harmful impacts of HCF)


Tasks of hospital hygienePreventive tasks

to develop standard working procedures to ensure hygienic and epidemiologic aspects of HCF to coordinate programs to lower the risks of hospital infections to consult (new) building and reconstructions of HCF from hygienic

point of view occupational safety of medical staff etc.


Tasks of hospital hygiene

Intervention and surveillance

to control compliance of SOP (standard operating procedure)

to supervise disinfection procedures and sterilisation centres

to control microbiological quality of hospital indoor to monitor cleaning practice to monitor waste management to monitoring quality of food and its proper handling etc.


Organization of hospital hygiene

Department of hospital hygiene in HFC

State supervision (Department of Epidemiology of Regional Public Health Authority) to control compliance with legal requirements (Public Health Act) to approve operational rule preventive surveillance to investigate outbreaks and defined infections in HCF


Expert associations

Society for hospital epidemiology and hygiene of the Czech Medical Association

Deutsche Gesellschaft für Krankenhaushygiene (DGKH) = German Society for Hospital Hygiene

Swiss Society for Hospital Hygiene (SGSH) = Schweizerische Gesellschaft für Spitalhygiene

Austrian Society for Hygiene, Microbiology and Preventive Medicine (ÖGHMP)

Etc.


Part II

Building, technical and operational requirements for health-care facilities


Legal requirements on construction, technical and other equipments, indoor environment, operation

etc. in the Czech Republic are set up through dozens of acts/decrees

Building ActSpatial Planning ActFire safety & safety rules (act + decree)Material and technical equipment of HCF

(decree)Occupational Safety ActPublic Health ActAct on PharmaceuticalsRadiation Protection ActWaste Management ActEtc.


Construction & technical requirements on HCF


Construction & technical requirements on HCF

Spatial (city) planningArchitectonic aspects of constructionBuilding materials and furnishingsWater supply and sanitationHeating, ventilation, air-conditioning,

microclimatic conditions, noise (coming from HCF), lighting etc.

(Waste management)


Spatial planning

Environmental factors (terrain, orientation to cardinal points, climatic conditions, sources of pollution etc.)

Geological factors (stability, hydrogeology…)

Urbanistic factors (access, public transport, demography of catchment area…)

Spatial factors (possibility of expansion)EIA (Environmental Impact Assessment)


Architectonic aspects of construction

New building x reconstruction of older building

Structure and capacity of HCFHospital pavilions x one big building

(mono-block)Compatibility with requirements on

equipment and operation (e.g. separation of clean and unclean operations – in place or in time)

Economical possibilities


Building materials and furnishingsBuilding materials should not be source of

pollutionMaterials and equipments must be easy to

clean and maintain.Floors, stairs, doors, elevators, windows…

- safety (e.g. doors of WC in patient rooms have to be openable from outside etc.)


Material and technical equipment of HCF

Czech Decree No. 92/2012 Coll., on requirements on minimum material and technical equipment of health-care facilities

All kinds of HCF: hospitals, outpatients clinics, one-day surgery clinics, spa facilities, pharmacies, ambulances, residential care…


General requirements

1. Construction and technical arrangements have to allow functional and safe operation of HCF.

2. HCF must constitute operationally closed and functional

unit, be situated in non-residential premises

complying to general building requirements, be supplied by drinking water, hot water

available, be equipped by sewerage have system of ventilation and heating have electricity connection


General requirements

3. Rooms for

a) manipulation with biological material,b) surgeries, orc) endoscopic interventions or higher risk of

infections

must have washable surface of walls min. up to 180 cm. All furniture and floors should be easily to clean and disinfect.


Other requirements on outpatient clinics

Minimum (floor) space for doctor´s office (13 m2), waiting rooms and operating rooms

Requirements on basic equipments of doctor´s office (and specialized medical offices – for all fields), hospital units, etc. etc.


Water in HCFWater in HCFHospital hygiene Health-care facilities Infectious and non-infectious hospitalism

Water in HCFWater in HCF

Obligatory supply of tap drinking water Air- conditioning and hot water quality:

important to prevent infections through inhalations and inoculations

Rehabilitation pools, spa bath Requirements on „ultra-clean“ water in

HCF


Water supply in HCF Two possible modes of operation:

Operator of HCF = customer: water from public supplies or from another (legal) person delivering drinking water for public use (most usually) or

Using own source of water

Different obligations Plumbing (care) as minimum obligation for both

options


Operators of HCF as customer Less obligations…

Own, additional water treatment in HCF:

not necessary in most units,

ultra-clean water sometimes required in special departments (hemodialysis, pharmacy, sterile water to wash endoscope and other medical tools). sterile water for patients with serious deficit of immunity


Hot water and air-conditioning system

Habitat for some ubiquitous microorganisms (Legionella, NT mycobacteria, Pseudomonas, amoebae…) – opportunistic pathogens

Risk of infection: inhalation (aerosol) and inoculation (e.g. eye washout)

Sensitive population: immunocompromised persons

Most often risks: legionellosis (pneumonia) or Pontiac fever caused by bacteria Legionella pneumophila


Rehabilitation spa and poolsRequirement on water quality, but also on

treatment and recirculation of waterCzech Rep.: Decree No. 238/2011 Coll.Risks microbiological and chemical

(disinfection by products)


Protection from adverse effects of noise in HCF


Protection from adverse effects of noise

Public Health Act and lower regulationHygienic limits of noise and vibrations

(various protected areas and buildings; day – night: 6:00 – 22:00 and 22:00 – 6:00)

Sound mechanical wave composed of frequencies

within the range of hearing and of a level sufficiently strong to be heard,

Noise unwanted sound.



Health risks of noise: specific, non specific

Specific: hearing impairmentNon-specific: hypertension, ischemic heart

disease, annoyance and sleep disturbance ( disturbing of healing and recovering process), changes in the immune system (?)



Outdoor protected area: hygienic limit = basic level of acoustic pressure A LAeq,T (50 dB) + corrections

Indoor protected area (buildings): hygienic limit = basic level of acoustic pressure A LAeq,T (40 dB) + corrections


Protected indoor area time Correction (in dB)

Hospital room 6.00 – 22.0022.00 – 6.00

0-15

Operatingl theatre While in use 0

Docor´s office, consulting room

While in use - 5

Waiting rooms, entrance halls, restaurants, café

+ 15

Noise limits for indoor protected areas in HCF


Ventilation of HCF


Ventilation of HCFGovernmental order 361/2007 Coll.

(occupational safety)Workplace has to have sufficient

ventilation (air exchange) either through natural means or with forced ventilation

Minimum amount of outside air: a) 50 m3/hour for employees working in category I or IIa


Microclimatic (indoor) conditions

Decree of Ministry of Health 6/2003 Coll.


Microclimatic (indoor) conditions of HCF

Temperature: 24,0 2,0 /warmer season/ 22,0 2,0 /colder season/

Air flow: 0,16 – 0,25 m.s-1 /warmer season/ 0,13 – 0,20 m.s-1 /colder season/

Relative air humidity: < 64 % /warmer season/ ≥ 30 % /colder season/

Relative humidity in room of patients should be higher than 55 %


Indoor microbiological quality HCF

Visible moulds and fungi on walls unacceptable

Concentration of bacteria (or moulds) ≤ 500 CFU / 1 m3 air

This limit not relevant for rooms requiring higher indoor air quality !


Clean rooms in HCFHospital hygiene Health-care facilities Infectious and non-infectious hospitalism

Clean rooms in HCF

Higher air quality required (e.g. in operating theatres, intensive care units, ARU, sterile tents etc.)

Number of particles (solid aerosol: 0,5 μm and 5 μm) limited and rooms are designed in special ways and equipped by special technical means

Nine categories (classes) according to the standard EN ISO 14 644-1 Classification of Air Cleanliness


Classes of cleanliness (EN ISO)


Recommended classes for some rooms in HCF

Room ClassSuperaseptic operational theatre

5-6

Background of superaseptic o.t.

7

Aseptic and septic o.t. 7

Background of aseptic and septic o.t.

8

Surgery room 8

ICU – burns, transplantations 5-6

CU – post operational 8

ARU 7


Clean rooms in HCF

Treated air - excess pressure


Air-condition in supra-aseptic operating theatre (laminar air flow above the operating table protects the patient)

LightingLighting


Lighting in HCFLighting in HCF

Health risks? Visual tiredness accident at work…

Governmental order 361/2007 Coll. (occupational safety); § 45

Day light, artificial light, mixed light Lighting (intensity) has to be relevant to work

(illuminance; Em) Lighting should not be cause of dazzle (blind):

unified dazzle indicator (UGRL) Colour rendering index (CRI; Ra) is a quantitative

measure of the ability of a light source to reproduce the colours of various objects faithfully in comparison with an ideal or natural light source


Part III

Infectious and non-infectious hospitalism and

its prevention(nosocomial infections,

hospitalism)


Nosocomial infectionsA nosocomial infection, also known as a

hospital-acquired infection (HAI), is an infection (either exogenous or endogenous origin) whose development is favoured by a hospital environment. It occurs in causal relationship with hospital (HCF) stay or medical intervention. It may become visible even after discharge from HCF.

Term nosocomial comes from Greek nosokomeion, which means „hospital“ (nosos = illness, komeo = take care about…).


Epidemiology of nosocomial infections

USA: about 2 millions patients per year; cause of death 88,000 persons/year (1995), costs about 4.5 – 11 billions USD.

France: prevalence 6.87% in 2001 a 7.5% in 2006 (up to 30% at ICU); about 9000 death per year.

Italy: prevalence about 6.7% (2000), i.e. 450 to 700 thousands patients per year; 4,500 to 7,000 death.


Epidemiology of nosocomial infections

Czech Republic: data on national level not yet available; ongoing pilot project

Brno (St. Anna hospital) ARU (2007-2011): 2925 patients - 570 HAI

(19.5%); total prolongation of hospitalization: 410 days/ 2011)

Of 570 HAI: 31 % exogenous, 31 % endogenous; 38% not identified

2011 – main cause of HAI Klebsiella pneumonie (31%), Pseudomonas aeruginosa (16%).


Epidemiology of HAI Source of infection (patient, staff, visitors) Transmission route (direct contact,

inoculation, inhalation, implantation, ingestion…)

Sensitive human (= patient weakened by primary illness)

Risk of HAI increase directly with1. number of invasive interventions,2. duration of hospitalisation (colonization

with multirezistant nosocomial strains),3. spectrum of medication.


Spectrum of HAI agents Spectrum of agents is changing – 1950s

mostly Staphylococcus aureus; 1970s gram-negative bacteria (e.g. Pseudomonas aeruginosa); since 1980s mostly gram-positive bacteria with multiple resistance – vancomycin resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA).

Microorganisms of low virulence x immunocompromised patients.


Epidemiological measures

Hygienic regimen of patients (personal hygiene, hospital bedding and dress, placement and movement of patients etc.)

Regime of care (protective means, washing and disinfection of hands, individual single-use aids, disinfection and sterilization…)

Regime of visits (mostly airborne diseases…)

Czech Decree No. 306/2012 Coll., specifying conditions for prevention of origin and transmission of infectious diseases and hygienic requirements on management of HCF and social care


Hygienic measures

Regime of hospital catering (nutritional and hygienic aspects)

Cleaning rules (aesthetic and hygienic aspects – effort for microbiologically safe environment);

Disinfection and sterilization Waste management (according to type

of hazardous wastes)


Disinfection and sterilizationHospital hygiene Health-care facilities Infectious and non-infectious hospitalism

Disinfection and sterilization Requirements given by decree 306/2012 Levels of disinfection: mechanistic cleaning

disinfection high level disinfection, double disinfection sterilization

Standard operational procedures Physical methods of disinfections (boiling,

boiling under pressure, disinfection in special machines T> 90°C, UV irradiation, etc.)

Chemical methods of disinfections (agents registered according to Biocide Act), mostly substances based on chlorine, phenol, iodine, quaternary ammonium salts, etc.


Disinfection• High level disinfection (killing all growing

stages of microorganisms, but not cysts of protozoa or helmints) „chemical sterilization in solutions“ (old term), e.g. solution of 2 % glutaraldehyde for 2-3 hours, Persteril (Acidum peraceticum) 0,5 % for 10 minutes etc.

Tools disinfected with this method are intended for immediate use or not more than 8 hours storage (covered by sterile drape in closed boxes).

Process has to be recorded: date, name of patients, disinfection solution, concentration, exposure (time), signature.


Sterilization Final stage, incl. drying and proper

packaging and storage Approved physical and chemical

sterilization procedures (technical standards, e.g. EN 550)

Physical: saturated steam under pressure, hot water under pressure (e.g. for surgery tools for immediate use), dry heat, radiation, etc.

Chemical: formaldehyde, ethylene oxide, etc.

Defined expiration time of packaging materials


Hygienic requirements on operation of HCF

Public Health Act (258/2000 Coll. as amended) +

Czech Decree No. 306/2012 Coll., specifying conditions for prevention of origin and transmission of infectious diseases and hygienic requirements on management of HCF and social carePrevention and surveillance of infectious diseases

Hygienic requirements on management of HCF and social care


Decree No. 306/2012

Receiving and principles of care about patients in HCF and institutions of social care

Sterilization, higher level disinfection, disinfection

Handling with bedding and dressCleaningPrinciples of waste management


State supervision / enforcement … Requirements on material and technical

equipment of health-care facilities: Regional Authority – Dept. of Health Care

Microclimatic conditions, noise, lighting, occupational issues, disinfection and sterilization, routine operation of HCF (cleaning…): Regional Public Health Authority – Dept. of Epidemiology and Dept. of Occupational Safety


Non-infectious hospitalism

…any deviation from „usual“ course of disease, developing in relation to hospital stay; there is no infectious cause, but rather in area of mental hygiene, social relations, ethic of medical staff and other „stressors“


Definition of HOSPITALISM

1a : the factors and influences that

adversely affect the health of hospitalized persons

b : the effect of such factors on mental or physical health

2 : the deleterious physical and mental

effects on infants and children resulting from their living in institutions without the benefit of a home environment and parents


Syndrome of hospitalism Group of symptoms, which develop

because of long stay in hospital or similar HCF and separation from family; it concerns mainly children

Symptom: apathy, sadness, loss of appetite, lack of interest; disproportionate reaction of patient to his/her environment – not interested in contacts, sulkiness; tearful; animosity

All these moods may have negative impact on health status of patient


Important stressors

Disease (inconvenience, feeling of loss, lower self-confidence)

Break in current social contacts, isolationUnknown surroundings (isolation,

sensorial deprivation, impersonal „sterile“ atmosphere, unpleasant lighting, noise or bad odour, loss of privacy)

Change in daily (biological) rhythmBuilding new social contacts

(confidence/distrust)


Important stressors

Anonymity of patient – number, diagnosis, but loss of name

Inadequate information for patients Stay among other seriously ill people.

May be the first personal experience with death; concern about own health (death)…


Hospitalism = recognized disease Hospitalism appears under adjustment

disorders at F43.2, in the World Health Organization's classification of diseases (ICD-10).

F43.2 Adjustment disorders = state of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event.


Prevention of hospitalism

Physical and psychical activity – reading, radio, exercise; toys for children, colours

Reduce negativism Keep patients in good mood Allow visits from family, friends – if

possible Reduce pains (if there is)


Professional behaviour in contact with patient

To communicate (talk) with patient, not to treat (nurse) him/her with silence

To motivate patient, encourage him/her To adjust hospital surroundings to be

patient friendly Not to exchange special medical

information in front of patient Show interest about patient Satisfy spiritual needs of patient


Professional behaviour in contact with

patient Ensure adequate information to patients Establish closer contact with family Respect dignity and character of patient Provide feeling of safety to patients Unlimited visiting hours

Doctor can become a patient too!


Thank you

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Documents

Hygiene requirements for health-care facilities RNDr. Sylva Rödlová, Ph.D František Kožíšek, M.D., PhD. Third Faculty of Medicine, Charles University,