Dr. Moustapha A. Ramadan

Head of Infection Control

Al-Adan Hospital

Definition of Healthcare Associated infections Nosocomial or Healthcare-associated infections

(HAIs) are defined as a localized or systemic condition that results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and that was not present or incubating at the time of admission to the health setting

They also include infections acquired by patients in the hospital or facility but appearing after discharge, and occupational infections among staff.

Magnitude of the problem

A prevalence survey conducted under the auspices of world health organization (WHO) in 55 hospitals of 14 countries representing four WHO Regions showed an average of 8.7% of hospital patients had nosocomial infections.

Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection.

Magnitude of the problem

At any time, over 1.4 million people worldwide suffer from infectious complications acquired in hospital.

Thousands of patient deaths around the world are reported each year from infections acquired during a hospital stay.

Transmission of Healthcare- associated Infections

Patient to patient

Patient to healthcare worker

Healthcare worker to patient

Sources of Infectious Disease Transmission in the Healthcare Setting

Endogenous source Agent is present at the time of

admission as part of patient’snormal flora

Infection develops as a result of- altered resistance or- introduction of microbes into

normally sterile areas

Sources of Infectious Disease Transmission in the Healthcare Setting

Exogenous source

Infection occurs from introduction of

microbes into or on the patient from an

outside source.

Disease Transmission Cycle in the Health Care Setting

Susceptible Host Places of exit

Modes of transmission

Places of entry

Reservoir

Modes of Infectious Disease Transmission in the Healthcare Setting Contact

Direct contact: direct contact and physical transfer. Indirect contact: through a contaminated object

Respiratory transmission Droplets generated by coughing, sneezing, or talking

or by respiratory tract procedures such as suctioning or bronchoscopy

Airborne transmissionTiny droplet nuclei (< 5 microns) that remain suspended in the air

Modes of Infectious Disease Transmission in the Healthcare Setting

Common Vehicle transmissionTransmitted indirectly by material contaminated with the infectious agent. (eg. Contaminated food, blood products, water).

Vector transmissionTransmitted through insects and other invertebrate animals (e.g., mosquitoes can transmit malaria and yellow fever; fleas can transmit plague).

Infection Control Programs Goals

Improve quality of healthcare servicesIdentify and reduce risks of infections

- patients and healthcare workers Prevent spread of HAIs Improve clinical outcomesPrevent or reduce the transmission of antimicrobial-resistant microorganismsLower the costs of health care services

Environmental infection control Construction, renovation, repair, and maintenance at health

facilities are typically different than work at most other sites.

HAIs account for approximately 1.7 million infections and 99,000 associated deaths each year in the United States; 5,000 of those deaths are infections related to construction

Construction dust and debris, and other contaminants can be a source of infection.

Environmental infection control

Healthcare environmental source of Aspergillus spores include dust from construction and renovation and water droplet

Almost half of outbreaks infection caused by Aspergillusspp were associated with construction or renovation in hospitals

Environmental infection control

The mortality rate is high for both nosocomial aspergillosis

(65%-100%) and legionnaires’ disease (24%-80%) in

hospitalized populations, even when infections are

recognized and treated.

Environmental infection control

Identifying hazards that could potentially compromise patient care

Implementing proper controls to reduce risk and minimize the impact of hazards created by demolition, renovation, and/or new construction activities

Air- Particulates Dust Microbials Gases/Fumes/Odors

Waterborne Contaminants

Noise/Vibration

Hazards of Concern

Air Bacteria and other harmful germs travel in dust and can

harm patients and workers.

Microbial “reservoirs” in flooring, wall cavities, ventilation systems, materials affected by water damage or high humidity, or spores brought in from outdoors.

Fungi can proliferate in moist environments (eg, water-damaged wood) and can cause infection when disturbed or removed.

Water Gram-negative bacteria, eg, Legionellae and

Pseudomonas spp, nontuberculous Mycobacteria, protozoa, and fungi could be present in potable water and its delivery network.

Disruption of water utility systems and changes to the water distribution network often creates dead ends where water stagnates, allowing microbes in the water to grow to very high concentration.

Environmental surfaces and patient equipment

MDROs are present on surfaces that appear relatively clean and transfer of these on hands of personnel.

About 35% of methicillin-resistant Staphylococcus aureus(MRSA) isolates recovered from the environment matches genetically to the strain recovered from patients.

Noise/ vibration Drilling and other sources of vibration have potential to

dislodge dust collected above suspended or false ceilings.

Vibrations loosen corrosion within water pipes.

Infection Control Measures during Construction, Renovation, Repair and Maintenance

Know the Infection Control Risk Assessment (ICRA) results.

Establish dust and debris control.

Maintain ventilation and environmental controls.

Implement pedestrian and equipment traffic control.

Schedule continuous work site clean up.

Infection Control Risk Assessment (ICRA)

These are strict guidelines to keep patients safe.

The ICRA is a process to determine: the risk of patient exposure to dust and debris contamination; and the classification of the work involved; Impact on areas above, below and adjacent to the work site.

Results of the ICRA determine the safest methods to be used in completing the work.

Identify the Type of Construction Project Activity (Type A-D) Type A: Inspection and Non-Invasive Activities.

Type B: Small scale, short duration activities which create minimal dust

Type C: Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies

Type D: Major demolition and construction projects

Identify the Patient Risk Groups that will be affected.

Low Risk Medium Risk High Risk Highest Risk

Office

areas

Cardiology

Echocardiography

Endoscopy

Nuclear Medicine

Physical Therapy

Radiology/MRI

Respiratory

Therapy

CCU

Emergency Room

Labor & Delivery

Laboratories

(specimen)

Newborn Nursery

Outpatient Surgery

Pediatrics

Pharmacy

Post Anesthesia Care

Unit

Surgical Units

Any area caring for

immunocompromised

patients

Burn Unit

Cardiac Cath Lab

Central Sterile Supply

Intensive Care Units

Medical Unit

Negative pressure

isolation rooms

Oncology

Operating rooms

including C-section

rooms

Match the Patient Risk Group Construction Project Type

Patient Risk Group TYPE A TYPE B TYPE C TYPE D

LOW Risk Group I II II III/IV

MEDIUM Risk Group I II III IV

HIGH Risk Group I II III/IV IV

HIGHEST Risk Group II III/IV III/IV IV

Dust and Debris Containment

If a job, (regardless of scope), includes disturbing existing dust, or creating new dust, containment must be used.

Doors should be closed and sealed with duct tape to prevent the dust and debris from escaping.

If the work area cannot be contained by walls and doors, use a plastic, fire rated barrier and seal all seams with duct tape.

Dust and Debris Containment

If working in high risk area( 3 or 4) Hepa filter will be needed in the containment area

Cleaning is required at completion of the barrier construction; plans should also describe a terminal barrier removal process that minimizes dust dispersal

Traffic Control

Entry and exit routes must be limited to those openings that result in the least amount of exposure to patients, staff, and visitors.

Only authorized personnel should be allowed to enter the construction zone.

When possible use dedicated doors, elevators, and stairways.

Traffic Control

All debris must be completely covered when being removed from the work site.

Signage should direct pedestrian traffic away from the construction area and materials.

Ventilation and Environmental Control

If mandated by the ICRA, negative air pressure must be maintained in the construction area.

Use of a Hepa Filter System, will help maintain negative air pressure.

Supply ducts should be blocked off and return air ducts should be covered with pleated air filters.

Exhaust fans may be used in conjunction with a Hepa Filter System and must run continuously.

Clean up of Work Site

Walk off or tacky mats must be used at the entrance and exit of each site.

Any dust outside of the work site area must be vacuumed/damp mopped immediately.

Vacuum cleaners must be equipped with a Hepa filtration system

Clean up of Work Site

When leaving the worksite on breaks or for meals, be sure to remove dust from clothes and shoes AT THE WORK SITE.

Dust can very easily be transferred from your clothes to a patient care environment

All debris removed from construction site must be covered.

Follow path with least patient/visitor involvement

Take home message

Infection prevention and control during construction is the role of multidisciplinary team of architects, engineers,

infection prevention and control professionals (ICPs), and

representatives from environmental services, administration, medicine, and nursing.

The built environment has a profound affect on health and the natural environment and require that health care facilities be designed to ‘‘first, do no harm.’’