FGI- Types of Evidence Rational understanding/experience: The - PDF document

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists Construction and Environmental Concerns for IP Linda R. Greene, RN, MPS,CIC, FAPIC Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester . edu FGI- Types of Evidence  Rational understanding/experience: The requirements supported by this kind of evidence are practical, common sense items everyone can agree on, such as a paved road leading to an emergency department entrance.  Clinical practice, policy, or guidelines: This category includes physical environment features needed to support clinical practice and a safe environment for the provision of care. An example is the CDC guidelines for hand hygiene.  Direct evidence: This type of evidence demonstrates a direct association between a requirement and a patient or staff outcome. For example, the requirement for an airborne infection isolation room to be a single-patient room is supported by documentation showing that airborne transmission of pathogens to other patients and to staff is reduced when patients with airborne infections are isolated.  Indirect evidence: Indirect evidence shows an association between a design requirement and an outcome that does not directly affected a patient or staff outcome but can be inferred to affect that outcome. An example is air change rates for exam rooms. The current requirement is for six air changes per hour, which reduces the number of airborne particulates in the room and has been shown to provide a safe environment. However, a direct correlation has not been shown between this number of air changes and reduced infection rates for staff or patients. FGI Guidelines Examples  Vertical ED issue  Ultrasound processing,  Sterile processing (since we took out the two-room sterile processing facility in 2014 and put it back in for the 2018)  New imaging classification system  Exam/treatment, procedure, and operating room requirements (knowing when you need which room type)  Functional program purpose and how-to  Telemedicine spaces FHA Mission to Care HIIN 1

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists Trends  More health care provided at home  More access to medical care in the community  More specialized diagnosis and treatment facilities  Hospitals provide only for the sickest or those with most complicated needs  Navigators and health coaches provide assistance to patients, providers, and/or payers  Increased use of technology for health care monitoring and communication  Continued government involvement in regulating health care The Future  Health care will increasingly be provided in outpatient facilities and residential care settings of numerous types.  Acute care facilities will see slower growth and be focused on providing care to higher acuity patients with more complex treatment and care needs.  As a society the United States needs to encourage development of “high value, high engagement” models of care; how the design of health care facilities can relate to this goal should be considered. Increase in Diverse Settings FHA Mission to Care HIIN 2

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists Examples Source L Dickey 2015 APIC ICRA Definitions and elements  Definition: An ICRA is multidisciplinary, organizational, documented process that after considering the facility’s patient population and program:  Focuses on reduction of risk from infection,  Acts through phases of facility planning, design, construction, renovation, facility maintenance, and  Coordinates and weighs knowledge about infection, infectious agents, and care environment, permitting the organization to anticipate potential impact. ICRA Design  The design area requires “long-range planning” for new or renovated buildings and adds a new element “finishes and surfaces” a critical feature over the lifetime of the facility. Considerations include:  Number, location, and type of airborne infection isolation and protective environment rooms.  Location of special ventilation and filtration such as emergency department waiting and intake areas.  Air handling and ventilation needs in surgical services, airborne infection isolation and protective environment rooms, laboratories, local exhaust systems for hazardous agents, and other special areas.  Water systems to limit Legionella sp. and other waterborne opportunistic pathogens.  Finishes and surfaces. FHA Mission to Care HIIN 3

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists ICRA Construction  The building and site areas anticipated to be affected by construction shall include consideration of the following:  Impact of disrupting essential services to patients and employees.  Determination of the specific hazards and protection levels for each.  Location of patients by susceptibility to infection and definition of risks to each.  Impact of potential outages or emergencies and protection of patients during planned or unplanned outages, movement of debris, traffic flow, cleanup, and testing and certification.  Assessment of external as well as internal construction activities. ICRA Infection Control Risk Mitigation  The mitigation recommendations from the ICRA panel shall address the following:  Patient placement and relocation.  Standards for barriers and other protective measures required to protect adjacent areas and susceptible patients from airborne contaminants.  Temporary provisions or phasing for construction or modification of heating, ventilating , air conditioning and water supply systems.  Protection from demolition.  Measures taken to train hospital staff, visitors and construction personnel. FHA Mission to Care HIIN 4

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists Air Flow Examples: Negative Airflow - TB rooms Janitors Closets Triage Construction Dirty utility FHA Mission to Care HIIN 5

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists Air Flow Positive Pressure: ORs Bone Marrow, Oncology Clean Utility Clean Storage Accident Causation Model Key Issues Infection literature reflects the fact that the design of the physical environment impacts nosocomial infection rates by affecting all three major transmission routes—air, contact, and water. FHA Mission to Care HIIN 6

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists Key Points  Use effective air quality control measures during construction and renovation to prevent the outbreak of airborne infections. Measures include, for example, using portable high-efficiency particulate air (HEPA) filters, installing barriers between patient-care areas and construction/renovation areas, generating negative air pressure for construction/renovation areas relative to patient-care areas, and sealing patient windows.  Install alcohol-based hand-rub dispensers at the bedside and in other accessible locations to increase hand-washing compliance and reduce contact transmission of infection.  Select easy-to-clean floor, wall, and furniture coverings, and employ proper cleaning and disinfection procedures.  Design and maintain the water system at the proper temperature and adequate pressure; minimize stagnation and back flow; eliminate dead- end pipes; regularly clean point-of-use fixtures; and consider the location of decorative fountains and carefully maintain them to minimize the risk of waterborne infection.  Provide single-bed rooms with private toilets to enable separation or isolation of patients on admission, so that those with unrecognized infections can be tested and identified without being mixed in with uninflected individuals Problems Fungal Infections FHA Mission to Care HIIN 7

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists Outcomes Risk Factors Persons at Risk for Aspergillus/Fungal Infection:  Any patient who is immunocompromised  Bone marrow and solid organ transplant  Chemotherapy  Prolonged steroid / antibiotic therapy  Dialysis Documented Source of Spores in Construction Settings  False ceilings  Insulating material  • Fire-proofing material  • Open windows/doors  Contaminated carpeting  Dust from construction site  • Dust from excavation site FHA Mission to Care HIIN 8

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists Vibration Five patients with severe postoperative Aspergillus endophthalmitis  All five patients came from one hospital in January and February during a period of active hospital construction  All five patients were subjected to aqueous or vitreous tap  Three patients had removal of the vitreous gel from the middle of the eye  Final outcome in each patient was evisceration (removal of the eye’s contents) or enucleation (removal of eye), despite an intensive course of antifungal therapy Failure to Protect Water Risks FHA Mission to Care HIIN 9

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists Continued CDC Report Timed delivery of biocide only when system is in use FHA Mission to Care HIIN 10

Infection Prevention Boot Camp for Novice May 31, 2019 Infection Preventionists CMS Regulations Atypical Mycobacterium Contaminated rinsing water of instruments FHA Mission to Care HIIN 11