Hygiene requirements for health-care facilities

1
Hygiene requirements for health-care facilities

• RNDr. Sylva Rödlová, Ph.D
• František Kožíšek, M.D., PhD.
• Third Faculty of Medicine, Charles University,
  Prague, D1
• 2014

2
Contents/structure
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

1. Hospital hygiene
2. Building, technical and operational requirements
   for health-care facilities
3. Infectious and non-infectious hospitalism and its
   prevention(nosocomial infections, hospitalism)

3
Part I

• Hospital hygiene

4
Factors influencing health of humans
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Internal (heredity).
• External environmental and occupational
  conditions, life style, health care.
• Health of population is influenced
• Health-care ? 20
• Environment ? 20
• Life style ? 60 .

5
Health-care facilities (HCF)
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

6
Persons x risks
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

• Patients
• Medical staff
• Other staff
• Visitors

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What is hospital hygiene ?
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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)

8
Tasks of hospital hygiene
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Preventive 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.

9
Tasks of hospital hygiene
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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.

10
Organization of hospital hygiene
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

11
Expert associations
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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.

12
Part II
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Building, technical and operational requirements
• for health-care facilities

13
Legal requirements on construction, technical and
other equipments, indoor environment, operation
etc. in the Czech Republic are set up through
dozens of acts/decrees
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Building Act
• Spatial Planning Act
• Fire safety safety rules (act decree)
• Material and technical equipment of HCF (decree)
• Occupational Safety Act
• Public Health Act
• Act on Pharmaceuticals
• Radiation Protection Act
• Waste Management Act
• Etc.

14
Construction technical requirements on HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
15
Construction technical requirements on HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Spatial (city) planning
• Architectonic aspects of construction
• Building materials and furnishings
• Water supply and sanitation
• Heating, ventilation, air-conditioning,
  microclimatic conditions, noise (coming from
  HCF), lighting etc.
• (Waste management)

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

• 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)

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Architectonic aspects of construction
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• New building x reconstruction of older building
• Structure and capacity of HCF
• Hospital 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

18
Building materials and furnishings
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Building materials should not be source of
  pollution
• Materials 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.)

19
Material and technical equipment of HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

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

• 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

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

• 3. Rooms for
• a) manipulation with biological material,
• b) surgeries, or
• c) 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.

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Other requirements on outpatient clinics
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Minimum (floor) space for doctors office (13
  m2), waiting rooms and operating rooms
• Requirements on basic equipments of doctors
  office (and specialized medical offices for all
  fields), hospital units, etc. etc.

23
Water in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
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Water in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

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Water supply in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

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Operators of HCF as customer
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

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Hot water and air-conditioning system
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

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Rehabilitation spa and pools
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Requirement on water quality, but also on
  treatment and recirculation of water
• Czech Rep. Decree No. 238/2011 Coll.
• Risks microbiological and chemical (disinfection
  by products)

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Protection from adverse effects of noise in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
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Protection from adverse effects of noise
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Public Health Act and lower regulation
• Hygienic limits of noise and vibrations (various
  protected areas and buildings day night 600
  2200 and 2200 600)
• Sound
• mechanical wave composed of frequencies within
  the range of hearing and of a level sufficiently
  strong to be heard,
• Noise
• unwanted sound.

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Protection from adverse effects of noise
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Health risks of noise specific, non specific
• Specific hearing impairment
• Non-specific hypertension, ischemic heart
  disease, annoyance and sleep disturbance (?
  disturbing of healing and recovering process),
  changes in the immune system (?)

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Protection from adverse effects of noise
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

33
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
Noise limits for indoor protected areas in HCF
Protected indoor area time Correction (in dB)
Hospital room 6.00 22.00 22.00 6.00 0 -15
Operatingl theatre While in use 0
Docors office, consulting room While in use - 5
Waiting rooms, entrance halls, restaurants, café 15
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Ventilation of HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
35
Ventilation of HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Governmental 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

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Microclimatic (indoor) conditions
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Decree of Ministry of Health 6/2003 Coll.

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Microclimatic (indoor) conditions of HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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? lt 64 /warmer season/
  ? 30 /colder season/
• Relative humidity in room of patients should be
  higher than 55

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Indoor microbiological quality HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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 !

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Clean rooms in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
40
Clean rooms in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

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Classes of cleanliness (EN ISO)
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
42
Recommended classes for some rooms in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
Room Class
Superaseptic 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
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Clean rooms in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Treated air - excess pressure

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

44
Lighting
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
45
Lighting in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

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

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

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

• A 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).

48
Epidemiology of nosocomial infections
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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.

49
Epidemiology of nosocomial infections
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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).

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Epidemiology of HAI
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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 with
• number of invasive interventions,
• duration of hospitalisation (colonization with
  multirezistant nosocomial strains),
• spectrum of medication.

51
Spectrum of HAI agents
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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.

52
Epidemiological measures
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

53
Hygienic measures
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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)

54
Disinfection and sterilization
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
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Disinfection and sterilization
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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 Tgt 90C, UV irradiation, etc.)
• Chemical methods of disinfections (agents
  registered according to Biocide Act), mostly
  substances based on chlorine, phenol, iodine,
  quaternary ammonium salts, etc.

56
Disinfection
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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.

57
Sterilization
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

58
Hygienic requirements on operation of HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

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Decree No. 306/2012
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Receiving and principles of care about patients
  in HCF and institutions of social care
• Sterilization, higher level disinfection,
  disinfection
• Handling with bedding and dress
• Cleaning
• Principles of waste management

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State supervision / enforcement
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

61
Non-infectious hospitalism
Hospital hygiene Health-care facilities
Infectious and 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

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Definition of HOSPITALISM
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 1
• a 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

63
Syndrome of hospitalism
Hospital hygiene Health-care facilities
Infectious and non-infectious 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

64
Important stressors
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• Disease (inconvenience, feeling of loss, lower
  self-confidence)
• Break in current social contacts, isolation
• Unknown surroundings (isolation, sensorial
  deprivation, impersonal sterile atmosphere,
  unpleasant lighting, noise or bad odour, loss of
  privacy)
• Change in daily (biological) rhythm
• Building new social contacts (confidence/distrust)

65
Important stressors
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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)

66
Hospitalism recognized disease
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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.

67
Prevention of hospitalism
Hospital hygiene Health-care facilities
Infectious and non-infectious 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)

68
Professional behaviour in contact with patient
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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

69
Professional behaviour in contact with patient
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism

• 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!

70
Thank you
sylva.rodlova_at_lf3.cuni.cz