Building Zero Infection Hospitals

1. 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

2. 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.

3. Content • Hospitals and importance of HAI • Evolution of hospital buildings • Hospital design details and HAI

4. How does the hospital environment differ from other service environments?

5. 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

6. 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

7. Morbidity from HAI , USA, 2002 • Total HAIs in hospitals - 1.7 million • Newborns 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.

8. 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.

9. Overall annual direct medical costs of HAI to U.S. hospitals, 2009 • All urban consumers - $ 30 billion • Rs 3,000 billion • Rs 3,000,000,000,000.00 • All Inpatient hospital services - $ 40 billion • Rs 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

10. Insight to the evolution of infection control and hospital design

11. Sri Lanka • Oldest hospitals • Sanitation • Drainage • Not well documented

12. 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.

13. 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.”

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

15. Private Rooms, USA, 1920 • In 1920, Asa Bacon of Chicago’s 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!”

16. 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 standards • thus preventing, investigating, treating and rehabilitating patients • with a view to exceeding patients and institutional expectations”

17. How Can Hospital Design Support Infection Control?

18. Chasing Zero HAI “It 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,ÞÞ Janet M. Corrigan, PhD, MBA and David Hunt, MD, FACS

19. 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.

20. Key Elements of “Breaking the Transmission of Infection” • The process of patient care • The patient • Personnel • Environment • Equipments & tools • Methods • Supplies

21. The Importance of Hospital Design and Equipments on HAI • The 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.

22. Where to Start?

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

24. The Planning Stage • Architects, builders, engineers and project managers have little or no knowledge on infection control • ICT - Infection Control Team • Participation 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

25. HospitalDesign • Conceptual design • Master plan • Master functional design • Unit planning • Equipment planning • Detailed design • Specifications • Roof • Floor • Walls

26. Hospital Design • Conceptual design • Detailed design • Final functional design

27. 1. Conceptual design • Master plan • Unit planning • Primary functional design

28. A. Master plan • Type of the hospital – Special / General • Medical 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

29. A. Master plan • Placement of Support services - administration, facility services • Facility engineering – Sewer treatment plant, water treatment, medical gas • Waste management system – solid, liquid waste • Stores – Medical and General

30. 10 8 11 9 7 3 6 1 3 1 2 5 1 3 2 4 • OT • BLOOD BANK & LAB • ROOMS 4. ETU 5. RADIOLOGY 6. RECEPTION 7. ADMIN & PUBLIC RELATION 8. OPD 9. CANTEEN 10. KITCHEN 11. SERVICE

31. 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 management • Dirty utility, Clean utility, linen store

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

36. HDU

37. 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

38. 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 guidance • WHO , international guidelines

39. 2. Detailed Design • Demarcation of units • Environment - Air – Ventilation, Water, Floor, Ceiling , walls & furniture, supporting • Hand washing • Equipment planning

40. A. Demarcation of Units • Color coding of the units and areas according to the risk levels • Maintain one way traffic • Restriction of people • Special procedures

41. B. Environment - Ventilation • Common HAI – Aspergilosis , TB,Legionellosis • Fungi – Aspergillus – Aspergillosis -Lobar Pneumonia - Spores • Immuno-compromised patients, are at no greater risk for infection within the hospital than outside. Cancer/ HIV/AIDS • Organ / bone marrow transplant

42. 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

43. B. Environment-Ventilation • Preventing - TB • Isolation rooms with an air lock room • Use negative air pressure • Sealed rooms – windows, self closing doors

44. B. Environment-Ventilation • Preventing Legionellosis • Legionella 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

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

46. 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

47. 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

48. 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 fluids • False ceilings • Harbor dust and pests that may contaminate the environment if disturbed. • Avoided in high-risk areas unless adequately sealed.

49. Daycare Centre