Scaling Up TB Infection Control Infrastructure Considerations

Transcription

1 Stop TB Programme Scaling Up TB Infection Control Infrastructure Considerations Sidney A Parsons, Ph.D. Pr. Eng. CSIR: Built Environment, Architectural Sciences. Tuberculosis Infection Strategy Developing Workshop Oct., WHO, Geneva, Switzerland

2 Understand the Hazard to Manage the Risk In attempting to arrive at the truth, I have applied everywhere for information but scarcely in an instance have I been able to obtain hospital records fit for any purpose of comparison Florence Nightingale (1863) Notes on Hospitals: Infection Ventilation Space (spacing and volume) Lighting Observation Nursing care Hospital administration process Steel beds (not wood), Glass mugs Functionality and Infection Control Slide 2

3 Infection Control Understanding the basics: Transmission dynamics: Food Fomites Water Air Air borne Infection: Environment Host immunity and resistance Procedures and associated risks Disinfection, decontamination and sterilisation for Minimising Transmission Slide 3

4 Wells Air Centrifuge, 1931 W. F. Wells*. On Airborne Infection, Study II. Droplets and Droplet Nuclei, Am J Hygiene, 1934: *Instructor, Sanitary Service, HSPH In 1931 Wells developed his air centrifuge to sample bacteria from air Slide 4

5 Droplets and Droplet Nuclei: The Origin Richard L Riley M.D. and Francis O Grady M.D., M.Sc. Et all Liberated by Coughing or Sneezes (respiratory tract activity): Large respiratory particles settle within about a meter of their source Fine particles nucleate into droplet nuclei carried by air currents Jennison [1942] Slide 5

6 Notes from Toman s Tuberculosis Questions and Answers (Second Edition 2004). Rieder H, 2004: Where is tuberculosis usually spread and how can spread be reduced The Number of cases capable of transmitting M.tuberculosis in a community (principally smear-positive cases) The duration of infectiousness of such cases The number and duration of encounters between a source of infection and susceptible individuals Slide 6

7 Mathematical model of airborne infection Wells-Riley Equation: Probability of infection = 1-e (-Iqpt/Q) Where: I = # infectors (i.e. # active pulmonary TB cases) q = quanta infectious units produced p = pulmonary ventilation rate/hr/per Susceptible t = hours of exposure Q = room volume Slide 7

8 Hierarchy of Controls for the Prevention of M.Tuberculosis Transmission Administrative Ensure OPD s can accommodate and support the rapid triage process and treatment of infectious cases Assess risk and develop appropriate written protocols based on the outcome of the assessment and administer Risk assessment and Infection control plans. Implement and enforce effective work practices including the management of patient care HCW and facility staff training Slide 8

9 Environmental Controls Administrative Dilution Ventilation with Pressure differentials Forced Natural Environmental Filtration Practicality? Ultraviolet germicidal radiation Efficacy Supported under laboratory conditions but no research to support in a clinical setting Slide 9

10 Infection Control Risk Assessment Some of the objectives of an Infection control Risk Assessment for TB would be to: To evaluate the management of the TB infection control program in a facility in order to reduce risk against infection (establish the constraints of the facility to implement such a programme). Review existing TB infection control protocols and patient flows through the facility being evaluated. Evaluate compliance with personal protection practices Evaluate facility engineering controls and maintenance practices, and to determine their effectiveness in reducing or preventing the likelihood of TB transmission. Slide 10

11 The Risk of Inadequate Maintenance When Evaluating facility management and engineering controls, including the maintenance practices, the risk assessment team should: Review the Original Design Specifications and Drawings Know What Safety Devices are Fitted Understand the Operation of the System (Control Algorithms and set points etc.) Understand the Operational Limitations and Determine Improper Settings Identify Poor Design and/or consequent Installation, Testing and Balancing errors Determine cause and effect of Equipment Failures and identify remedial measures as required. Slide 11

12 Extreme / Extensively Drug-Resistant TB (XDR TB) XDR first reported March 2006: Resistance to level 2 drugs suspected and identified in studies of samples from 49 countries internationally First reported outbreak (2005/06), Tugela Ferry, South Africa A Moll, NR Gandhi, R Pawinski, U Lalloo, AW Sturm, K Zeller, J Andrews, G Friedland 53 of 221 MDR-TB patients identified as XDR-TB 50% not tested previously for TB 40 tested for HIV and all found positive 52 died within 16 days of sputum collection Slide 12

13 MDR & XDR-TB cases expected to be treated by country 2007, 2008 The Global MDR-TB and XDR-TB Response Plan, June WHO, Stop TB Partnership Slide 13

14 Slide 14

15 Infection Control measures and the design response. Infection Control measures must inform the need However The Design of the facility offers the solution by responding to that need Slide 15

16 Sustainable, Safe and Effective Functional and Healthcare Facilities Findings from 5 Case Studies in South Africa Sidney Parsons, Renée du Toit, Nic Combrink, Angela Baker The challenges of developing a TB Hospital: The original business case and needs interpretation The design briefing document submitted to the implementing agent How aware the hospital management were of the protocols and functional procedures called for in the TB Guidelines for healthcare provision. Design to ensure implementation of procedures, and; Appropriate Infection Controls (Administrative, Environmental and Personal), against Infection required (Reasons for and methodologies to be adopted by the design team). Slide 16

17 Sustainable, Safe and Effective Functional and Healthcare Facilities Findings from 5 Case Studies in South Africa (cont.) Sidney Parsons, Renée du Toit, Nic Combrink, Angela Baker Healthcare planning Departments having little appreciation of epidemiological issues and procedures placing the responsibility on healthcare programs finding solutions for bed needs, and design teams needing to fish for the needs. Healthcare Planning Departments transgressing into the design domain ignoring the need for developing the essential Briefing Document : Focus on Impact and Building Durability issues far outweighing the need to address to functionality issues. Emphasis by building professionals on the Detailing, Documentation and Construction, rather than functionality and procedural issues. Following the lead from the Planners with respect to unequal emphasis on Building durability and Impact. Costing and development of business proposals most often based on historical, uniformed data. Slide 17

18 The need for an appropriate briefing document The Modern Challenge: Scant appreciation of the need of a detailed brief for the planners, with very little input by healthcare staff on needs, with planners confusing the difference between a business plan and briefing document. Environments predisposed to infection which are not conducive to healthcare provision, least of all healing should be identified, in order to ensure against the inappropriate accommodation and mixing of; Patients with infectious diseases Immune-compromised patients (and staff) Paediatric patients Limited understanding of the dynamics of infection control needs (e.g.. airborne infectious diseases) by building professionals and maintenance staff Parsons; WHO Workshop: Making Healthcare Facilities Safe, IFHE 2006 Slide 18

19 Current Facility Shortcomings (out-patient areas): Unsuspected cases visiting OPD s that have not been designed for triaging of suspected pulmonary cases OPD s not designed for the number of visitors Patient flow paths in Hospitals (and clinics) due to department relationships (i.e. Laboratory, sputum collection and waiting areas) In most cases no outside waiting areas. Slide 19

20 Observed practices due to design constraints No No physical separation among among pts pts until until sputum sputum smear smear results results available Rare Rare isolation beds; beds; no no negative pressure rooms. rooms. Clinics Clinics & wards wards crowded with with TB TB suspects and and susceptibles (PT s (PT s& HCW s) Slide 20

21 Patient Pathways Veranda outside clinic Number given by security Home / referral clinics Proposal to separate patients suspected to have TB from other OPD patients, particularly from HIV positive patients Problem: many HIV patients with Pulmonary TB are sputum negative Separate facilities for MDR and XDR TB Treatment? R du Toit, Health Facility Planning Slide 21 First Visit Paed OPD Paed 0-4 yrs Assessment consult Immunisation Paed 5-12 years consulting Pharmacy General antibiotics Repeat visit OPD reception admitting clerk: (computer) data & pt record ANC/ O&G/ FP SOPD / other Wait/cons ult Triage incl. cough SN/clerk/Sister? Adult Waiting & assessment room: vitals, urine testing, blood sugar MOPD consulting X-ray General wards Sputum neg. MOPD Wait MOPD / shared Procedure / dressing / blood Clinic referral Pt via OPD reception TB wards TB confirmed TB suspect patients Sp- Sputum wait & collection & TB sputum lab nebulisation CD4 counts Sp+ TB section Nurses Education History TB drugs DOT TB doctor X Ray? TB social worker? VCT for hospital

22 Current Facility Shortcomings (in-patient accommodation): All types of existing rooms have been pressed into service as MDR and XDR wards, including offices, staff housing units, etc. Wards were originally designed for low-cost habitation by noninfectious TB patients 6 patients and more per room (20 in some facilities) Low floor to ceiling height (2,4m) and Inadequate thermal performance of the building design - windows closed when cold Design for long stay patients in certain healthcare settings need attention ( Landscaped areas for outdoor activity, occupational therapy etc.) Slide 22

23 Low floor to ceiling heights with inadequate ventilation and thermal performance. Slide 23 A.R. Escombe

24 Current Ventilation Shortcomings (Observed): Rooms ventilated using passages and other patient rooms possible cross infection opportunity Natural ventilation is dependent on user-controlled opening windows Inconsistent wind conditions vary natural ventilation rates Inappropriate mechanical ventilation measures. Slide 24

25 Administrative measures by informed design: Active triaging of PHC patients in all identification areas - Clinics, OPD s etc. Early separation into appropriately designed rooms for further diagnosis and management Improved management of patients by infectious status and TB strain Improved management of patient movement within controlled zones Improved service levels in laboratory testing, diagnosis and notification Isolation rooms of as-yet-undiagnosed patients in all TB Admission wards in all facilities Drastic reduction in number of patients per room recommended. Improved management of patient flow in all health facilities (patient pathways) Slide 25

26 Detailed attention to air rate and flow management: Air dilution and pressure gradient design, irrespective of wind conditions, to ensure clean air workspaces Effective dilution ventilation by natural or mechanical means (or by mixed mode systems) Pressure gradients relative to room functions and layouts On-site validation of ventilation design prior to occupation standard methodology in development Regular re-assessment as part of facility risk management SOP Slide 26

27 Health Facilities: The design response Infection Control measures must inform the need However Design of the facility offers the solution by responding to that need But The solution must be validated to ensure quality of outcome Slide 27

28 The Risk of Inadequate Maintenance Integrated design approach for engineering controls and for least risk maintenance of all systems to ensure effective infection control strategies. Appropriate Design Parameters Service level Agreement Procurement Policies Operating and Maintenance Manuals Maintenance FM Standards of Procedures for environmental Services Slide 28

29 The Risk of Inadequate Maintenance: Environment & Health Whilst being the prime means of intervention, certain systems my also be the primary Pathogenic transmission mechanism if not maintained: Air Systems Water Systems Environmental (Cleaning) Services Services Handling Laundry and Bedding Regulated Medical Waste Guidelines for Environmental Infection Control in Health Care Facilities Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC) Slide 29

30 Issues still to be addressed Resulting from the policy, further attention must be paid at facilities treating infectious patients over an extended period (2-6 months) to providing access to broader basic social services e.g.: Postal services Banking facilities Visitors Education Home Affairs processes ID documents etc. Support for Children far from home Community Services support for breadwinners under treatment A balance needs to be struck between the constitutional rights of patients, of staff and the broader community and the affordability of public health measures in order to protect and uphold those rights. Slide 30

31 Advocacy and resource mobilization On a national level, guidance needs to be provided to healthcare facility planners and designers Engineering and Architectural societies worldwide, need to be informed of the need to include IC in their design guides (e.g. ASA, ASHRAE, CIBSE. RHEVA, IFHE, UIA etc). Life cycle costing needs to be undertaken IC for airborne diseases needs to be included in the patient safety arena. Inform and Educate Slide 31

32 The World Needs Safe and Effective Functional Planning to Ensure Sustainable Healthcare Provision Thank You Slide 32