Designing Facilities for Infection Control

1. The presentation is solely meant for
Academic purpose

3.  Why is health planning so important in designing?
• How does the built environment help support
appropriate IC practices?
• The importance of keeping a balance between the
home vs clinical environment
• Evidence Based Design – how can we use this
information to improve the built environment?

4.  OT
 ICU
 DIALYSIS
 CSSD
 LAUNDRY
 HK
 ENDOSCOPY
 ISOLATION
 AIR-CONDITION
 KITCHEN

6. It is the imbalance between
classical triad of epidemiology i.e.
agent, host and environment
which leads to the initiation of
disease process :
To which hospital acquired
infections are no exception
Surveillance, Prevention and Control of Infection, Comprehensive Accreditation Manual Volume 5.
Joint Commission of Accreditation for Hospital Organisations, USA 2000;2-6.

7. Etoh at al, AJA;2006; 203-206;42

8.  Most of the hospitals are not scientifically designed, physical
facilities are most inadequate and are overcrowded
 No segregation facilities for septic and clean cases, especially
in surgical and maternity wards
 Patient placement is generally found to be faulty
 Requirements of air conditioning and ventilation are not met
properly
 Overcrowding in nurseries and ward units
It is of paramount importance to
plan infrastructure for
IC requirements

12. Myth Reality
 Sampling will  Has no effect on
reduce HAI Antibiotic Prescription
(Except outbreaks)
 Good IC Practices &
Design
Guidelines for Environmental Infection Control in Health-Care Facilities;
HICPAC, June, 2003

19. DISPOSAL
STERILE
CLEAN
PROTECTIVE
19

20.  Protective zone  Sterile zone
◦ Reception ◦ Operating suite
◦ Waiting area ◦ Scrub room
◦ P.A.R.
◦ Anaesthesia Room
◦ Trolley bay
◦ TSSU
◦ Changing room
 Clean zone  Disposal zone
◦ Pre-op room ◦ Dirty wash room
◦ Recovery room ◦ Disposal corridor
◦ Plaster room /x-ray unit ◦ Janitor closet
◦ Staff room
◦ Store
20

21. Zoning of Operating Room (Sterile)
Super Clean
Aseptic
Ultra Clean
21

22. Vertical Laminar Flow in OT
22

23. Structural Lay out of OT
• Size of the OT: 20X20X10
• Protected Environment:
Sealed rooms & windows
• Walls: non porous,
smooth without crevics
• Floor : non porous,
smooth, anti-skid & anti-
static material.
• Drains, sewage pipes to
be avoided
• Principles of Structural
Zoning pack stores – 11
ACH
Hoffman, PN, Williams, J, Stacey, A et al. Microbiological comimssioning and monitoring of OT suites. A
report of a working party of the Hospital Infection Society/Hosp Infect, 2002:52:1-28

24. a) STERILE ZONE:
(i) Temperature: 21°C ± 3°C
(ii) Relative humidity : 40% to 60%
(iii) Fresh air allowance : 10 per hour with total air changes
20- 25 per hour
(iv) Air filters : through HEPA filters with filtration
level up to 0.3 microns and 99.97% efficiency
with pre filters & microvee filters in the system.
(v) Positive pressure = 25 Pa
(vi) Laminar Air Flow
b) OTHER AREAS:
Fresh air changes minimum 5 per hour and total 15 per hour.
HDPE washable filters with filtration level up to 5 microns.

25. Myth Reality
 HePA filters and laminar  HePA filters; in all OTs
flow should be ON only  Once the system is
when surgeries are in switched off the
progress moisture in the filters
supports growth of
fungal strains
American Institute of Architects; Retrieved 2008-03-04

26. HVAC Ducts – Out of Sight Out of
Mind!
A STORY OF A MUMBAI TERTIARY CARE HOSPITAL
•Most ductwork is concealed above false ceilings
A well respected hospital in Mumbai decided to revamp their
air conditioning system for a suite of operation theatres.
•False ceilings were torn down, ductwork dismantled but
before they were disposed of, the consulting engineer for the
new AC system decided to look inside these ducts and was
horrified to see all the dirt stuck to the walls of the ducts.
•He had all the dirt removed and weighed and found that there
was 17kgs of it, including construction debris and green
coloured lint, which could only have come from the green
cotton garments worn by the team of surgeons and their
assistants inside the operation theatres.
(Source: AC and Refrigeration Journal (ISHRAE), Oct-Dec 2005 Issue )

28.  Structure:
- Size: 22sqm / ICU bed
- Lighting 300 lux
- Separate dirty and soiled linen utility room and
janitor closet
 Ventilation:
- Positive Pressure
- 8 -10 ACPH
- Temperature: 20-25*C
- Relative Humidity: 40%-60%

30. All of them emphasize the importance of:
 Adequate isolation facilities
 At least one cubicle per eight beds
 Sufficient space around each bed- at least 22 sqm,
 WHB between every other bed / alcoholic dispensers
 Ventilation including positive and negative pressure
ventilation for high risk patients.
 Sufficient storage and utility space.
 Floors and walls should be easily cleanable and non porous.
 Dirty utility should have separate stand / shelf per bed,
bedpans, urinals, to be kept dry and hand wash solutions /
basins at each bedside.

31. Isolation cubicles with self closing door and airlock. Air
lock is supposed to have following functions:
a) They provide a barrier against loss of pressurization and
against entry / exit of contaminated air into / out of the
isolation room.
b) They provide a controlled environment in which
protective garments can be donned without
contamination before entry into the room.
c) They also provide a physical and psychological barrier to
control behavior of staff in adopting infection control
practices. ICU is planned with 15 air changes per hour (5
fresh + 10 re-circulation) as per minimum ASHRAE
standards. Positive pressure gradient of 15 Pa is
recommended between isolation cubicle and main ICU.

34.  S - Standard isolation : for patients who require contact or droplet isolation; N - Negative isolation : for
patients who require air borne droplet nuclei isolation e.g. Tuberculosis; P - Positive isolation : for
patients who are profoundly immunocompromised e.g. transplant and oncology patients
•S - Standard isolation: for patients who require contact or droplet isolation;
•N - Negative isolation: for patients who require air borne droplet nuclei isolation e.g.
Tuberculosis;
•P - Positive isolation: for patients who are profoundly immuno-compromised

35. Infectious Disease Isolation Room
Special Ventilation Requirements
• Ante Room
• Air Pressure – Negative
• Clean to Dirty
• ACPH - > 6
• > 12 during new construction
• No recirculation
• Direct Exhaust to outside
• HEPA at exhaust

36.  Separated entries and exits:
for soiled, clean and sterile
goods
 Strict separation of the staff
working in the 3 different
areas
 Room ventilation separated
- for good production
conditions
 Straight workflows - for
simple, reliable working
routines to have an
economic and ergonomic
production
 Patient related utensils -
washed and disinfected at
the user area – as soon as
possible!

37.  Ventilation –
◦ Min. 6-10 ACH, Clean to Soiled
◦ Temp: 18-22 deg C + 5
◦ RH – 35-50%
◦ Exhausted to outside/ Exhausted to a filtered partial re-
circulation system
 Configuration of systems that provide steam, hot/cold
water, purified water, compressed air, electrical power, air
exhausts and drainage of sewage are important
considerations while installing equip.
 Adequate Hand Washing facilities in or near all
decontamination, preparation, sterilization and sterile
storage
 Storage facility for sterile items areas.

39. Bubble Diagram

40.  Storage Safety
 Autoclave
 Bio-Safety Cabinets
 Clean – Soiled
 PPE
 Drains
 Disposals

41. Private rooms make the spread of infection less likely because patients
and visitors do not share space and equipment with other patients

42.  Considerations for Design, Equipment
and Ventilation
 Though nursing of single pt. is ideal, 2-
4 single rooms/30 bed unit is sufficient Not only
 Centers of beds 8ft apart in pavilion principles of
ward
asepsis and
 1 Wash Hand Basin (WHB) /4-6 beds in
Rig’s ward hygiene
 Floor space area/bed – 7 sq m
excluding corridor of 2.4 m
 Single bed rooms- 14 sq m

45. ◦ Stringent criteria for preparation (Risk levels I, II, III)
◦ Differences in intervals between preparation and use
(depending on how materials are stored)
◦ Traffic Control: segregation of aseptic area
◦ Risk Level II: Environmental control, positive pressure,
environmental and end product testing
◦ Risk Level III: (including material prepared from unsterile
components): monitoring physical env,
env. Micorbial sampling, terminal sterilization

54. Item Standard
Distribution Piping System
Material (Copper Pipe) ASTMB 819.00; 2002
Fittings BS EN 1254-1: 1998 Part 1
Copper to copper joints silver BS 1845 / BS 1044
copper-phosphorous brazing
alloy
pipeline isolation and lockable HTM 2022 / EN737 / NFPA 99
line valve
Rigid retractable pendant HTM 2022 / EN 737 / NFPA 99
Terminal outlets (PB Type NFPA 99 compliant. Imported
compatible) products to be CE marked / UL
Listed 54

55.  Water Treatment
 Drinking Water
 Flush Water
 RO Water
 Microbial Analysis
 Endotoxin Analysis
 Effluent Treatment

56.  Give her a cup of coffee
 Organise an immediate consult
 And let her know that her daughter-in law was also
concerned

57.  Take leave
 Be by her bed side
 Get the best doctor
 Get the best hospital; from treatment & HAI point of
view (designed)
 Show her; son-in-law is in total control

58.  Health Care Design publication Vol 10,no 10 – The Centre For
Health Design
 Evidence Based Health Care Design – Rosalyn Cama 2009
 A Visual Reference for Evidence Based Design – Jain Malkin 2008
 Healing By Design – building for health Care in the 21st Century-
Roger Ulrich
 The role of the Physical Environment in the Hospital of the 21st
Century : A Once-in-a-Lifetime opportunity.
 Healing spaces – The science of place and well-being – Esther M
Sternberg MD 2009
 Future opportunities for learning - Healthcare facilities: The
environment and users‟ behavior, and how these relate to the
acquisition of hospital acquired infection. A pilot study to be
presented in Manchester in the UK in September 2011