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CHAPTER 1 - INTRODUCTION
BACKGROUNG OF THE STUDY
HYPOTHESIS
OBJECTIVES
METHODOLOGY
Nosocomial infection — also called “hospital acquired infection” can be defined as: An
infection acquired in hospital by a patient who was admitted for a reason other than that
infection
An infection occurring in a patient in a hospital or other health care facility in whom the
infection was not present or incubating at the time of admission. This includes infections
acquired in the hospital but appearing after discharge, and also occupational infections
among staff of the facility.
WHAT IS HYGIENE?
Hygiene is a set of practices performed for the preservation of health .According to the
world health organisation (WHO), Hygiene refers to conditions and practices that helps to
maintain health and prevent the spread of diseases.
The fundamental of hygiene control depends on the various measures, in which hierarchy
is:
There is a list of fact which emphasis the need for the study of hospital hygiene-
The Centres for Disease Control and Prevention estimates there are 1.7 million
infections resulting in approximately 99,000 deaths annually in the United States,
making healthcare-associated infections the fourth leading cause of death.
There has been a 20 percent decrease in infections related to the 10 surgical
procedures tracked in the CDC Progress Report between 2008 and 2012.
1.3 HYPOTHESIS
Hygiene can be maintained in the hospital through architectural design and detail.
1.4 OBJECTIVES
1.6 METHODOLOGY
Selection of topic
- Personal - Book
Observations
Data Collection
- Case Studies -- Online Data
Synthesis of data
Airborne transmission occurs only with microorganisms that are dispersed into the air
and that are characterized by a low minimal infective dose. Only a few bacteria and
viruses are present in expired air, and these are dispersed in large numbers only as a
result of sneezing or coughing.
Direct contact between patients does not usually occur in health-care facilities, but an
infected health-care worker can touch a patient and directly transmit a large number of
microorganisms to the new host.
The most frequent route of transmission, however, is indirect contact. The infected
patient touches—and contaminates—an object, an instrument, or a surface. Subsequent
contact between that item and another patient is likely to contaminate the second
individual who may then develop an infection.
During general care and/or medical treatment, the hands of health-care workers often
come into close contact with patients. The hands of the clinical personnel are thus the
most frequent vehicles for nosocomial infections. Transmission by this route is much
more common than vector borne or airborne transmission or other forms of direct or
indirect contact.
2.3.2 PRINCIPLE
Two basic principles govern the main measures that should be taken in order to prevent
the spread of nosocomial infections in health-care facilities:
The separation of the source has to be interpreted in a broad sense. It includes not only
the isolation of infected patients but also all “aseptic techniques”—the measures that are
intended to act as a barrier between infected or potentially contaminated tissue and the
environment, including other patients and personnel.
2.3.3 CLEANING
One of the most basic measures for the maintenance of hygiene, and one that is
particularly important in the hospital environment, is cleaning. The principal aim of
cleaning is to remove visible dirt. It is essentially a mechanical process: the dirt is
dissolved by water, diluted until it is no longer visible, and rinsed off. Soaps and
detergents act as solubility promoting agents. The microbiological effect of cleaning is
also essentially mechanical: bacteria and other microorganisms are suspended in the
cleaning fluid and removed from the surface. The efficacy of the cleaning process
depends completely on this mechanical action, since neither soap nor detergents
possess any antimicrobial activity. Thorough cleaning will remove more than 90% of
microorganisms. However, careless and superficial cleaning is much less effective; it is
even possible that it has a negative effect, by dispersing the microorganisms over a
greater surface and increasing the chance that they may contaminate other objects.
Cleaning has therefore to be carried out in a standardized manner or, better, by
automated means that will guarantee an adequate level of cleanliness.
2.3.4 STERILIZATION
2.3.5 DISINFECTION
The term disinfection is difficult to define, as the activity of a disinfectant process can vary
widely. The guidelines of the Canters for Disease Control (Garner & Favero, 1986) allow
the following distinction to be made: • High-level disinfection: can be expected to destroy
all microorganisms, with the exception of large numbers of bacterial spores. •
Intermediate disinfection: inactivates Mycobacterium tuberculosis, vegetative bacteria,
most viruses, and most fungi; does not necessarily kill bacterial spores. • Low-level
disinfection: can kill most bacteria, some viruses, and some fungi; cannot be relied on to
kill resistant microorganisms such as tubercle bacilli or bacterial spores. There is no ideal
disinfectant and the best compromise should be chosen according to the situation. A
disinfectant solution is considered appropriate when the compromise between the
antimicrobial activity and the toxicity of the product is satisfactory for the given
application. Another consideration may well be the cost. The more active disinfectants
are automatically the more toxic ones; potentially toxic products can be applied to
inanimate objects or surfaces, whereas for disinfection of human tissues only the less
toxic disinfectants can be considered. For antisepsis, different disinfectants are used for
application to the intact skin (e.g. alcoholic solutions) and to mucous membranes or
wounds (only aqueous solutions of non-toxic substances). Cost is a less important
consideration for an antiseptic than for a disinfectant. The principal requirements for a
good antiseptic are absence of toxicity and rapid and adequate activity on both the
natural flora and, especially, pathogenic bacteria and other microorganisms after a very
short exposure time. Essential requirements for a disinfectant are somewhat different:
there must be adequate activity against bacteria, fungi, and viruses that may be present
in large numbers and protected by dirt or organic matter. In addition, since disinfectants
are applied in large quantities, they should be of low ecotoxicity. In general, use of the
chosen disinfectant, at the appropriate concentration and for the appropriate time, should
kill pathogenic microorganisms, rendering an object safe for use in a patient, or human
tissue free of pathogens to exclude cross-contamination.
CHAPTOR 3 - INTRODUCTION TO
HOSPITAL DESIGN
Hospital is the most complex of building types. Each hospital is comprised of a wide
range of services and functional units. These include diagnostics, treatment rooms and
surgical areas, hospitals functions such as food services and housekeeping and
fundamentals impatient care or bed related functions.
The health services - including public and private hospital services- must meet quality
standards (ISO 9000 and ISO 14000 series). So in order to meet the needs for a well
maintained hygiene controlled environment for a hospital building one need to follow
these standards.
Some considerations which will usually be included in order to plan a hygienic
environment for hospitals are –
Traffic flow to minimize exposure of high risk patients and facilitate patient
transport.
Materials that can be adequately cleaned.
Adequate spatial separation of patients. Adequate number and type of isolation
rooms.
Appropriate access to handwashing facilities.
Appropriate ventilation for isolation rooms and special patient care areas
(operating theatres, transplant units).
Preventing patient exposures to fungal spores with renovations.
Zone Functions
Main Entrance
o Entrance lobby
Trolley park
General waiting
Public utilities
o Reception
o pharmacy
OPD/Emergency Entrance
o Entrance Lobby( Trolley bay,General waiting, Public utilities
Entrance o Reception
Zone Enquiry counter
Admission/discharge
Cash counter
Queuing track
Staff accommodation
o Arcade ( Gift, book shop, Snack counter)
o Security & Ambulance station
Service/Staff Entrance
o Central receipt/inspection
o Staff Utilities
Lockers
Change rooms
Time keeping
o Consultation rooms (general clinics-2, medical-2, surgical-2,
ophthalmic, ENT, dental, OBS and gynac-2, paediatric,
orthopaedics, dermatologist)
o (consultation room with attached Toilets and examination room,
sub waiting)
Ambulatory o Nursing station
care area o (Nurses desk, clean utility, dirty utility)
o Treatment rooms, injection & dressing room, emergency O.T.
o Casualty/ Emergency
o (reception and record, emergency lab, nurses desk, emergency
beds-3, observation beds-3)
o Public utilities
o Pathology laboratory
(sample collection, record, pathologist room, bleeding room,
Diagnostic storage, sub waiting,)
Zone o Imaging
(radiology, ultrasound),
Preparation room ,change room, toilet, control, dark room,
o Sub waiting, public utilities
o Blood bank( sub waiting, bleeding room, refreshment / donor’s
rest room)
Zone Functions
o Nursing station
Intermediate o (Nurse desk, clean utility, dirty utility, pantry, store, trolly bay)
Zone o General ward-3, maternity ward-1, paediatric ward-1, 10
(inpatient private rooms
Nursing units) o Ancillary rooms (Doctor’s rest room, Nurses duty room)
o Visitors rest room
Architectural segregation
Circulation
Architectural details
Figure 4. 1: Parameters
4.1.1 ARCHITECTURAL ZONING Source : WHO
It is useful to stratify patient care areas by risk of the patient population for acquisition of
infection for some unit, including oncology neonatology, intensive care unit special
ventilation and other facilities is required. Accordingly each area shares its own hygiene
level and that is needed to be maintained according to its requirement.
There are five degree of risk according to which hygiene level can be distributed –
A room or space, whatever its purpose, is never completely separate. A distinction can
be made between high traffic and low traffic areas. One ca consider general services (
food and laundry , sterile equipment , and pharmaceutical distribution ), specialized
services and other areas .a hospital with well-defined areas for specific activities can be
described using flowcharts depicting the flow of in - and out patients ,visitors , health care
workers , supplies , as well as the flow of air , liquid and waste . Some other traffic
patterns can also be identified.
Incineration plants for the waste
disposal (to dispose of the infected organs
and body part generated after surgeries and
operation.)
1. ARCHITECTURAL SEGREGATION
The OPD includes three zones that is public zone, joint use zones and staff
zones–
Public zones are basically includes the main entrance ,foyer ,bays ,public
conveniences ,cash counter , registration counter and other spaces where
the relation with public is set by the hospital staff.
Joint use zones are the areas which are jointly used by the staff and the
patients such as consultation and examination rooms. A set of minimum
time is prepared for the contact between the staff and the patient, in order
to avoid any kind of infection in the hospital, adopted by the visitor from
outside environment.
3. ARCHITECTURAL DETAILS
Floor tile should and stain proof and resistant to any disinfectant applied to
its surface.
The pressure built inside the toilets is high, so to avoid the flow of air into
other zone.
4.3.2 DIAGNOSTICS
1. ARCHITECTURAL SEGREGATION
The diagnostic zone should be in connection with all three major zones which are
OPD, IPD and critical zone.
Areas for public waiting and diagnosis should be properly segregated with barriers
to control the hygiene levels .
3. ARCHITECTURAL DETAILS
The laboratory and diagnostic area should be air lock.
Chemical resistant and stain resistant material should be used for laboratory
worktops and work station.
Mechanical ventilation system is required with 10 -15 air changes per hour in
areas where fumes is expected , and 8-10 in other areas.
Intensive care unit is a dedicated facility for critically ill patients who require invasive life
support, high levels of medical and nursing care and complex treatment . These
speciality units are designed, equipped and staffed to treat critically ill patients those
requiring specialized care and equipment .it has capability of continuous observations of
vital functions of patients and can support these functions more promptly and efficiently.
1. ARCHITECTURAL SEGREGATION
Proper isolation wards should be provided with ICU for the patients suffering
from any infection.
IPD area should be placed in minimum distance with the CSSD unit for successful
transferring of sterile equipment to ICU.
1. ARCHITECTURAL SEGREGATION
The critical zones and OT are the most sterile zone of the hospitals, as it is
functioned with surgical activities .the OT should be in connection with the CSSD
ICU, and have a dirty corridor in order to transfer the waste and dirty equipment
without contaminating the outside environment of hospital corridor.
3. ARCHITECTURAL DETAIL
Conventional operating rooms are ventilated with 20 to 25 changes per hour of
high efficiency filtered air delivered in a vertical flow.
The operating rooms are usually under positive pressure relative to the
surrounding corridors, to minimize inflow of air into the room.
Doors should be sliding in OT as they area more user friendly and prevent air
turbulences.
Walls and ceiling should be non-porous, stain proof and easy to clean, with round
off corners and joints.
Floors should be smooth, non-slip either inset mosaic with the least possible
number of joints.
PARAMETERS OF STUDY
LOCATION
3A, Near Jawahar circle, Jagatpura road,
Jaipur ,Rajasthan, 302020
Patients inside the IPD wards are kept in closed environment. There is no source
of natural light provided inside the wards.
Walls of IPD are coated with plastic paint (bacteria resistant), which is stain proof
and easy to clean.
IPD have uniform and smooth tile flooring which is easy to clean and resistant to
any disinfectant.
Dustbins were placed for any kind of waste disposal inside the ward
WASTE DISPOSAL
Dustbin were placed in the public zones(cafeteria and waiting areas) .In OPD ,OT , and
IPD a set of three dustbins are placed with three different colours which represents
biological waste , surgical waste ,and dry waste .To maintain the hygiene level in OT the
waste generated after the surgery is transferred through the dirty corridor to the back
station of the hospital where the waste is kept in the separate room according to their
category , and later they are taken to the incineration plant to dispose off.
AIR CIRCULATION
The floor for the OT was antiskid mating which was resistant to dust
and the liquid compound generated during the surgery process ,and was
resistant to any disinfectants and chemicals .
The walls are cladded with the aluminium panels which are non-porous
and also we can easily provide the rounded corners along the edge of the
rooms using aluminium.
A constant laminar flow ensures that the air above the protection area,
which has been 'contaminated' by the patient and the surgical team, is
displaced. Operating theatres must only be accessed via airlocks; positive
pressure must be maintained such that no pathogens from adjoining areas can
enter. The way to maintain the pressure conditions in the operating theatre is a
laminar flow that causes very little turbulence.
LOCATION
ANALYSIS
ANALYSIS
Operation theatre are placed in direct connection with the IPD ,hence there is direct
movement of patients from OT to IPD after surgery ,without having a movement from a
unhygienic environment and this helps to prevent nosocomial infection in users.
AIR CIRCULATION
Fresh air unit are set up for OPD and IPD department to have a faster system of
air exchange in the zones. It is not a continuous process, this cycle of air
exchange is practice at a regular interval of time.
In operation theatre the three layered laminar flow hepo filter system is used for
cleaner and filtered air to maintain the level of hygiene. A constant laminar flow
ensures that the air above the protection area, which has been 'contaminated' by
the patient and the surgical team, is displaced. Operating theatres must only be
accessed via airlocks; positive pressure must be maintained such that no
pathogens from adjoining areas can enter. The way to maintain the pressure
conditions in the operating theatre is a laminar flow that causes very little
turbulence.
OPERATION THEATRE
OT have uniform and smooth tile flooring which was easy to clean .Outer zones of
critical care have marble flooring.
OT has a lower skirting, due to which there is the possibility of settlement of
bacteria and dust particles.
OT was provided with the provision to source of natural light as a window which is
generally not required.
LOCATION
Opposite Sanganeri Gate, Jaipur,
Rajasthan 302004.
BLOCK 2 – EMERGENCY
On the second floor operation theatre is set up which created the direct connectivity with
the IPD zone which is present on the same floor.
On the third floor separate IPD wards for other patients and private rooms are provided.
ANALYSIS
CHAPTOR 6 – ANALYSIS
AIR CIRCULATION
7.1 CONCLUSION
On the basis of the parameters derived for the maintenance of hygiene in the hospital,
each parameters provides us with the following conclusion -
PARAMETERS CONCLUSION
Hence, all these parameters are required to be taken into the consideration, as they
affect and helps to maintain the level of hygiene in the hospital.
.2 RECOMMENDATIONS
At the stage of planning one should consider the placement of zones and the
circulation of users for the maintenance of the quality of hygiene levels.
At the time of planning a particular zone different architectural detail should be
taken into the consideration as per the zone requirement to maintain the quality of
hygiene.
Proper provision for the system of waste disposal should be proposed.
In order to maintain the quality of air ,the provision for a air filtration system should
be given as it is a more adaptable method for a clean and germ free air in a
building .