Transcript Hospital hygiene Health-care facilities Infectious and non

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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Contents/structure
I. Hospital hygiene
II. Building, technical and operational
requirements for health-care facilities
III. Infectious and non-infectious
hospitalism and its prevention
(nosocomial infections, hospitalism)
Part I
Hospital hygiene
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Factors influencing health of humans
1) Internal (heredity).
2) External: environmental and occupational
conditions, life style, health care.
Health of population is influenced:
– Health-care
 20 %
– Environment
 20 %
– Life style
 60 %.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Health-care facilities (HCF)
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Persons x risks
 Patients
 Medical staff
 Other staff
 Visitors
 Biological factors (pathogens,
opportunistic pathogens)
 Chemical factors (pollutants)
 Physical factors (ionizing and nonionizing radiation, noise, lighting and
microclimate, injuries)
 Ergonomic factors
 Psychological and organization
factors
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
What is hospital hygiene ?
 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)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Tasks of hospital hygiene
 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.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Tasks of hospital hygiene
 Intervention and surveillance
 to control compliance of SOP
procedure)
(standard operating
 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.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Organization of hospital hygiene
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Expert associations
 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.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Part II
Building, technical and operational
requirements
for health-care facilities
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Legal requirements on construction, technical and other
equipments, indoor environment, operation etc. in the
Czech Republic are set up through dozens of acts/decrees
 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.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Construction & technical
requirements on HCF
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Construction & technical requirements
on HCF
 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)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Spatial planning
 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)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Architectonic aspects of construction
 New building x reconstruction of older building
 Structure and capacity of HCF
 Hospital pavilions x one big building (monoblock)
 Compatibility with requirements on equipment
and operation (e.g. separation of clean and
unclean operations – in place or in time)
 Economical possibilities
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Building materials and furnishings
 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.)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Material and technical equipment of HCF
 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…
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
General requirements
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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
General requirements
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.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Other requirements on outpatient clinics
 Minimum (floor) space for doctor´s office (13
m2), waiting rooms and operating rooms
 Requirements on basic equipments of doctor´s
office (and specialized medical offices – for all
fields), hospital units, etc. etc.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Water in HCF
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Water in HCF
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Water supply in HCF
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Operators of HCF as customer
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Hot water and air-conditioning system
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Rehabilitation spa and pools
 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)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Protection from adverse effects of
noise in HCF
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Protection from adverse effects of noise
 Public Health Act and lower regulation
 Hygienic limits of noise and vibrations (various
protected areas and buildings; day – night: 6:00
– 22:00 and 22:00 – 6:00)
 Sound
mechanical wave composed of frequencies within
the range of hearing and of a level sufficiently
strong to be heard,
 Noise
unwanted sound.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Protection from adverse effects of noise
 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 (?)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Protection from adverse effects of noise
 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
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
Docor´s office, consulting room
While in use
-5
Waiting rooms, entrance halls,
restaurants, café
+ 15
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Ventilation of HCF
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Ventilation of HCF
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Microclimatic (indoor) conditions
 Decree of Ministry of Health 6/2003 Coll.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Microclimatic (indoor) conditions of HCF
 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:
 < 64 % /warmer season/
 ≥ 30 % /colder season/
 Relative humidity in room of patients
should be higher than 55 %
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Indoor microbiological quality HCF
 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 !
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Clean rooms in HCF
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Clean rooms in HCF
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Classes of cleanliness (EN ISO)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Recommended classes for some rooms in
HCF
Room
Class
Superaseptic operational theatre
Background of superaseptic o.t.
5-6
7
Aseptic and septic o.t.
Background of aseptic and septic
o.t.
7
8
Surgery room
8
ICU – burns, transplantations
CU – post operational
ARU
5-6
8
7
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Clean rooms in HCF
Treated air - excess pressure
 Air-condition in supra-aseptic operating theatre (laminar air flow
above the operating table protects the patient)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Lighting
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Lighting in HCF
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Part III
Infectious and non-infectious
hospitalism and its prevention
(nosocomial infections,
hospitalism)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Nosocomial infections
 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…).
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Epidemiology of nosocomial infections
 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.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Epidemiology of nosocomial infections
 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%).
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Epidemiology of HAI
 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
1. number of invasive interventions,
2. duration of hospitalisation (colonization with
multirezistant nosocomial strains),
3. spectrum of medication.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Spectrum of HAI agents
 Spectrum of agents is changing – 1950s
mostly Staphylococcus aureus; 1970s gramnegative bacteria (e.g. Pseudomonas
aeruginosa); since 1980s mostly gram-positive
bacteria with multiple resistance – vancomycin
resistant enterococci (VRE) and methicillinresistant Staphylococcus aureus (MRSA).
 Microorganisms of low virulence x
immunocompromised patients.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Epidemiological measures
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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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Hygienic measures
 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)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Disinfection and sterilization
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Disinfection and sterilization
 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 T> 90°C, UV irradiation, etc.)
 Chemical methods of disinfections (agents
registered according to Biocide Act), mostly
substances based on chlorine, phenol, iodine,
quaternary ammonium salts, etc.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Disinfection
•
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.

Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Sterilization
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Hygienic requirements on
operation of HCF
 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
care
Prevention and surveillance of infectious diseases
Hygienic requirements on management of HCF and
social care
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Decree No. 306/2012
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
State supervision / enforcement …
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
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“
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Definition of 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Syndrome of 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Important stressors
 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)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Important stressors
 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)…
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Hospitalism = recognized disease
 Hospitalism appears under adjustment
disorders at F43.2, in the World Health
Organization's classification of diseases (ICD10).
 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.
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Prevention of 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)
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Professional behaviour in contact with patient
 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
Hospital hygiene
Health-care facilities
Infectious and non-infectious hospitalism
Professional behaviour in contact with patient
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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!
Thank you
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