APIC Webinar July 28, , Design & Construction of Healthcare Guidelines: Updated roadmap for infection prevention & control practice 8/3/2010

Transcription

1 APIC Webinar July 28, , Design & Construction of Healthcare Guidelines: Updated roadmap for infection prevention & control practice Judene Bartley MS, MPH,CIC Vice President, Epidemiology Consulting Service Inc (ECSI) and Consultant, Safety Institute, Premier healthcare alliance Beverly Hills MI 1

2 Agenda for 2010 Guidelines Update Overview of the Health Guidelines Revision Committee (HGRC) process; -- Current status and major changes Top infection-related issues & implications ASHRAE Ventilation Standard What is it? What does it mean for IPs? Agenda for 2010 Guidelines Update General Evidence-based documentation; CDC publications/ documents; IP preferred terminology in ICRA; Surgical suite terminology Water Sink design, placement; Numbers; ABHR Toilet placement in ICU/CCU; HCW exposure Surfaces & Antimicrobials Ventilation ASHRAE Standard 170 -The official ventilation guide Switchable AII---Why not? Use for all patients. Protective Environment or "PE bundles" Update and Status of 2010 Guidelines 3 HGRC meetings over 3 years completed Processed over 1688 proposals Guidelines Committee reviewed all comments & provided substantiation for actions SC resolved errors; controversial decision in Steering Committee All rejected proposals or modified have documented substantiations Document published January

3 Focus Groups Bariatric accommodations Staff effectiveness/ retention Sustainable design Functional program Patient movement Infection prevention/ control Surfaces and furnishings Psychiatric facilities Planning, design and construction process Nursing facilities Common elements Medical oncology: New Children s hospitals Emergency facilities Small hospitals Reorganization Engineering Information technology Imaging Wayfinding Focus Group Core IPC members Judene Bartley Steering Committee -Chair Russ Olmsted, IP St Joseph Ann Arbor APIC liaison Linda Dickey, IP UC Irvine APIC- co-liaison Brenda Hackett, IP, MD Anderson Andy Streifel, IH; U. Minnesota Arjun Srinivasan MD, CDC/DHQP Paul Jensen PE, CDC/DTBE Farhad Memarzadeh PE, PhD, NIH Maureen Harvey RN,CCN; Ramona Conner, RN AORN Std Marie Allo MD, Surgeon/ID; San Jose Dan Thompson MD, Surgeon; CCU, Albany NY John Fishbeck TJC Standards; Todd Hite Former AHJ Key Topics by Book Part Part 1 General: PDC; ICRA Part 2 Hospitals: General; Small; Psych; Rehab Part 3 Ambulatory: Outpatient; Primary care Outpt; Small Primary; DX/TX; Urgent Care; Birthing Ctrs; Office Surg;GI Endo; Psych Outpt Part 4 Nursing Facilities; Hospice; Assisted Living; Adult Day care Part 5: Mobile Units Part 6- ASHRAE Ventilation Standard 170 3

4 Top IC Topics Pt 1: General; Terms Glossary- Front of the book; New terms; Handwashing and hand sanitation dispenser terminology Clear floor area - improve existing language Appendix [ best practice ; community standards ] Procedure/Treatment/Exam Room definitions Update ICRA terms: Infection preventionist; Hospital epidemiologist Text flow reorganization - ICRA part of Planning, Design, Construction (PDC) Operating room areas: Not "sterile" core but AORN language: o Restricted; Semi and; Non restricted General Zones (Ø sterile core )- use AORN Zone: Ø Substerile - If one at all, prefer: OR emergency sterilizer room 4

5 Top IC Topics - Pt 1: Sinks Handwashing Handwashing and hand sanitation dispenser terminology Hand sanitizing dispensers cannot replace handwashing stations in new construction Provided in any room where hands on patient contact is performed Station shall not be accessed through a door, doorway, or barrier Stations shall not be used for other purposes Sinks shall be at least 9 inches deep and 16 inches sideto-side Top IC Topics Pt1: Sinks Handwashing and hand sanitation dispenser terms No removal from patient room or toilet room even if a private room Clarified that if anteroom present with a sink outside the room, it can t replace one inside room or toilet room. Enhanced use of ABHR ABHR can replace sink in toilet room (TR) if TR space footprint doesn t permit one in addition to room sink Anatomy of a Waterborne Disease Outbreak: Root Cause Sink? Scene of the Outbreak : Recently constructed 24-bed Medical-Surgical ICU (MSICU), academic teaching hospital, Canada Dec 2004 July 2006; 36 patients infected/colonized with outbreak strain of Pseudomonas aeruginosa o 17/36 (47.2%) had fatal infection o Source of the outbreak strain: Splashed from HW sink drain installed in ICU rms. o Fluorescent marker testing found splashes traveled up to 1 M from drain Dec 2004 Take home: It s not about the aerator! Hota S, et al. ICHE 2009; 30:

6 Anatomy of a Waterborne Disease Outbreak: Handwashing station? ICU Room Design The Defendant Redesigned hand- Washing station Hota S, et al. ICHE 2009; 30:25-33 Key Corrections Ended Outbreak Offset water flow; reduced water pressure Offset: Swing gooseneck spout Ideal: Water contact at basin curvature More on Faucets Tap Water & P.aeruginosa in MICU Water cultures + molecular analysis of isolates from water & hands of personnel Findings 11.4% of 484 water samples + 38 patients with P. aeruginosa 11/21 faucets contaminated with patient isolates before recovery from water cultures! Conclusion: Carriage of P. aeruginosa by patients was source of contamination of environment and vice versa Rouges AM, et al. J Hosp Infect 2007;67:

7 Problems: Laminated Surface/Backsplash; Wrist Blades Impeded; Spout Flow Directly into Drain See handouts for next slide for readability Top IC Topics - Pt 1: Sinks See Handout # Guideline for Design and Construction of Health Care Facilities 2010 Sink Design Features Sinks in hand-washing stations shall be designed with deep basins to prevent splashing; designed to prevent splashing to areas where direct patient care is provided particularly those surfaces where sterile procedures are performed and medications are prepared. The number and location of hand-washing stations shall be determined by the functional program and the ICRA. Hand-washing stations shall be convenient and accessible for health care personnel; other users. Sinks shall have well-fitted and sealed basins to prevent water leaks onto or into cabinetry and wall spaces. Sensor-regulated water fixtures shall meet user need for temperature and length of time the water flows. Electronic faucets shall be capable of functioning during loss of normal power. Hand towels shall be dispensed so that users need touch only the towels and not the dispenser. Basin: porcelain, stainless steel, or solid surface materials. If the basins are set into plastic laminate countertops, at a minimum the substrate shall be marine-grade plywood (or equivalent) with an impervious seal. The water pressure at the fixture shall be regulated. Sink Design Features [Pressure should be adjusted to reduce forceful discharge into the sink at maximum flow.] Design of sinks shall not permit storage beneath the sink basin. Faucets should not discharge directly above the drain as this causes splashing (i.e., water should be angled away from the drain). Design of sinks should accommodate ADA requirements for clearance under the sink basin. Sink size and depth - ANSI standards should be considered for sink design. Note: Features using shall are requirements; features using should are appendix language.best practice Top IC Topics - Pt 1 Other Panels interface with ICRA Patient Safety Risk Assessment (PSRA) Handwashing and hand sanitation dispenser terminology No removal from patient room or toilet room if a private room During the functional programming phase Identify the specific physical hazards Likelihood of occurrence based on historic data Degree of potential harm to patients PSRA Panel Interdisciplinary panel, representatives from clinical departments; Produce a report on design features 7

8 Top IC Topics - Pt 2 Toilets in ICU: Privacy; HP Exposure Critical Care Units Handwashing and hand sanitation dispenser terminology No removal from patient room or toilet room if a private room Added one foot at the head of the bed Private rooms sized to permit two seated visitors Toilets- Bottom line Access to a separate toilet or soiled utility room for disposal of bodily waste (between rooms) [100% consensus to reject a toilet in the room - 6 ft from the bed location, or separated by an alcove to prevent splashing; No pullman types in pt. room.] ICU Waste Management Problem: Where dispose of human waste from ICU pt & maintain pt dignity?; provide privacy & still protect HCW? (MICU/SICU less likely to use attached toilet room than CCU) Options: Attached toilet or utility room (flush sink) per each room or between ICU rooms Fixed toilet /swivette/ pullman in room Issues: Dispersal of droplets with flushing, leakage, not practical for patient use; Maintenance headache; No permits in 2010 Unit s flush sink/soiled utility room or corridor bathroom Issues: personnel risk exposure transporting waste to unit utility room In-room bedpan cleaner/disinfection system (2010 OK but no toilet in patient room) Meiko Waste Removal & Bedpan Washers ICU Toilet 2010 Summary No removal from patient room or toilet room if a private room No toilet, (swivet/pullman type) in ICU patient room o Protects the patients privacy o Protects the caregiver handling waste Provide a toilet or utility room (flushing rim sink) between patient rooms Airborne infection isolation rooms in the ICU must have a dedicated toilet room not shared with adjacent room Disclaimer: BP washer Only company for which I have knowledge in U.S. Meiko- 8

9 Top IC Topics - Pt 2 Surfaces - Antimicrobials Critical Care Units cleanable surfaces Clean storage readily accessible within each unit Staff room cannot be the multipurpose room Newborn Intensive Care Units New Requirements for: Sound/Noise Lighting Flooring-no antimicrobial claims for reduced HAI Top IC Topics - Pt 2 Antimicrobials; Metals New section on Medical Oncology Units o General Requirements Architectural New section on furnishings o Casework, millwork and built-ins o Furniture and equipment o Window treatments and cubicle curtains o No antimicrobial impregnated materials and metals: fabrics; copper; silver See handout #2 for next slide for readability Top IC Topics - Pt 2 Antimicrobials Construction standards-medical oncology *(4) Architectural hardware. Frequently touched surfaces in the patient s environment of care shall be planned and designed to facilitate cleaning and disinfection A (4) Architectural hardware. Surface treatments or polymers making health claims based on antimicrobial properties should not be selected for environmental surfaces or furnishings. ( Handout #2 9

10 Top IC Topics - Pt 2 Flooring -NICU Newborn Intensive Care Units New Requirements for: Sound/Noise Lighting Floor covering- carpeting proposal originally not supported by IC group but later withdrew objections. Acoustical control for carpet cleaning was addressed; Exceptions in NICU guidelines. See NICU guidelines for more information White RD. Recommended standards for the newborn ICU Journal of Perinatology (2007) 27, S4 S19 Top IC Topics Pt 2 Flooring -NICU Floor surfaces shall be easily cleanable and shall minimize the growth of microorganisms Floors shall be highly durable to withstand frequent cleaning/ heavy traffic. Materials should permit cleaning c/o use of hazardous chemicals Transition surfaces that do not obstruct mobility, are durable, and minimize noise & jarring of equipment should be provided See handout #2 for readability Top IC Topics - Pt 2 Flooring - NICU Materials suitable: Resilient sheet flooring (medical grade rubber or linoleum) & carpeting with an impermeable backing, heat- or chemically-welded seams. Floor covering acceptable in the hospital & NICU and has obvious aesthetic/noise reduction appeal, but it is not suitable in all areas (eg around sinks or in isolation or soiling utility/holding areas). IC group agreeable; consider for NICU only. See handout #2 for readability 10

11 Design Solutions: In with the Good Air Heating, Ventilation, & Air-Conditioning Top IC Topics - Pt 2 Ventilation Design 1. Design Requirements 2. ASHRAE Standard 170 incorporation 3. Natural (NV) & displacement ventilation (DV) 4. Airborne Infection Isolation Rooms (AIIR) Door seals and sweeps Ante room requirements if used in AII or PE design 5. Protective Environment (PE) Top IC Topics - Pt 2 1. Ventilation Design Requirements Humidity- hot issue Range now 60-30% in special areas. Costly to have lower limit = 30% RH July 1 8 areas with RH ranges approved as lower limit = 20% (OR, C-section, procedure rooms etc) Unidirectional diffusers/low velocity similar to ORs for cardiac cath & interventional radiology (not req) Fresh air intakes 25 feet from hazardous outlets (decon, autopsy, etc.) 10 feet from exhaust fans, plumbing vents, etc. 11

12 Comparison of Operating Room Ventilation Systems in the Protection of the Surgical Site Farhad Memarzadeh, P.E., Ph.D. Director Research National Institute of Health, Bethesda, Md Andrew P. Manning, Ph.D. the director of engineering at Flomerics, Inc., Southboro, Mass Top IC Topics Pt 2: 2. Ventilation Standard 170 -What is it? Merge: FGI Guidelines Table 2 & ASHRAE Ventilation Std 170 o 170 is incorporated as separate chapter in FGI 2010 o Designers/engineers: Single table for guidance o AHJs: Single set of standards to enforce Affect Air changes/hour; Pressure relationships o Positive: Air flow out o Negative Air flows in o Dash: Neither one stipulated not neutral ICUs; Wound care or Burn units (dash)- New Laboratory name changes Top IC Topics Pt 2 2. Ventilation Standard 170 How it works ASHRAE 170 Standard Maintenance & Healthcare Guidelines Revision SubCommittee are meeting. Voting members of Std 170 maintenance are also HGRC members. (Streifel; Bartley; Erickson; HGRC engineers) Reconciling differences; clinicians get edge More opportunity for expert input; regular updating More opportunity for research The Guidelines are a 1-stop shop for HC ventilation 12

13 Top IC Topics - Pt 2 3. Ventilation - What s new? NV & DV vs. Mechanical Natural (NV) and displacement ventilation (DV) NV: (Open windows) No support... DV: Still under major review as proposed amendment to current 170 DV: Studies testing how filtered air moves up & away vs. downward /mixed as well as with people moving in the room DV data general support but proposals must receive public review may be several years 3. DV Ventilation: Low Sidewall Supply 3. Ventilation: Overhead mixing 13

14 Top IC Topics - Pt 2 4.Ventilation Airborne Infection Isolation Use of airborne infection isolation rooms for non-infectious patient care. o Negative pressure shall remain unchanged. oconstant volume for airborne infection isolation and protective environment rooms ostudies to show if safe to reduce air changes & neg pressure in real-life setting; safe to reduce if pressure relationships remain the same 5. Ventilation - Negative pressure AII bundle: Not only negative pressure but.. monitor corridor Bundle of required parameters to prevent airborne agent transmission Negative pressure greater exhaust than supply air volume Pressure 2.5 Pascal's or 0.01"w.g Airflow differential >125 cfm Sealed room, with about 0.5 sq. feet leakage Clean to dirty, airflow; Air exchanges per hour >12 per hour Directional Monitoring; Exhaust to outside or HEPA filtered if recirculated Self-closing door Top IC Topics - Pt 2 6. Protective Environment Needs full PE Bundle Protective environment rooms HEPA placed right before air enters the room. PE bundle reinforced oall elements must be in place for effectiveness not just HEPA filtration 14

15 PE Solution-Evidence-based prevention of Aspergillosis but only IF PE bundle AII plus anteroom: BMT patient (with airborne infection) Positive Ante room Immune compromised Corridor Negative Ante room Immune compromised Corridor Monitor Monitor Bathroom Bathroom Bundle of required parameters to prevent airborne agent transmission HEPA filtered; Pressure 2.5 Pascal's (0.01"wg); Air changes per hour (ACH) >12/hour; Directional monitors; Self-closing door Sealed room:~ 0.5 sq. ft leakage; Greater than 125 cfm airflow differential supply vs. exhaust Clean to dirty airflow Anteroom airflow patterns Top IC Topics - Pt 3 Same Standards Ventilation Std 170 table Gastrointestinal Endoscopy facility updated: recommendations for pre- and post op spaces Air flow positive: still 6 air changes/hour (ACH) ACH: Had been 6, 15 and back to now 6 (not an OR but clean procedure room) Bronchoscopy Procedure room Remains negative, e.g., air flow into room but 12 ACH [similar design as an AIIR] Top IC Topics - Pt 4 No AII Room(s) required in LTC Rejected proposal to go to required single bedded rooms for nursing homes Great acceptance for a series of recommendations on Nursing Homes based on research from the Univ. of Minnesota Prepared a surfaces and furnishings checklist or matrix for every facility chapter 15

16 2010 edition is here- CD or book! Official release date was January 2010: Workshops/webinars addresses major changes A handbook is being developed for 2010 edition White papers/resources: opatient Handling & Safe Movement Assessment; ocritical Access Hospitals Thank you! QUESTIONS? 16