5 Infection prevention and control considerations for healthcare facility design

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Contents

• Objectives
• Healthcare facility design
• General wards and clinics
• Isolation areas
• Specialised areas
• Support services
• Case studies

Objectives

When you have completed this chapter you should:

• Understand why IPC practitioners should be consulted when designing or renovating healthcare facilities
• Understand the role of the IPC practitioner in design/renovation projects
• Be familiar with IPC requirements for general wards and clinics
• Be familiar with IPC requirements for isolation areas
• Be familiar with IPC requirements for specialised areas
• Be familiar with IPC requirements for support services.

Healthcare facility design

5-1 What aspects should be considered when designing a new healthcare facility?

The main considerations include:

• The disease profile of the local community (burden of infectious disease)
• Location of the healthcare facility within easy access of population
• The size of the catchment area (population) that the facility will serve
• The type of services to be provided (e.g. primary care; specialised care).

5-2 Why should IPC practitioners be involved in healthcare facility design and renovation projects?

In many parts of the developed world, it is required by law that IPC practitioners are consulted before and during all healthcare facility design, building or renovation projects. The IPC practitioner’s involvement is essential to reduce healthcare-associated infection transmission (through good planning and design).

IPC practitioners should be involved in healthcare facility design and renovation to incorporate design features that reduce healthcare-associated infection.

5-3 How should IPC practitioners be involved in healthcare facility design or renovation projects?

The IPC practitioner should be involved very early in the planning phase, so that necessary design changes can be implemented before construction starts. The IPC practitioner’s role is to give input on how the design of clinical areas can support IPC practices and thereby reduce the risk of healthcare-associated infection transmission. The IPC team should attend regular construction site meetings to ensure that their recommendations have been applied. Before the new facility or renovated area is opened to patients, the IPC practitioner should inspect and approve the project’s IPC aspects.

The IPC practitioner should be involved very early in the planning phase, so that necessary design changes can be implemented before construction starts.

5-4 Which specific design areas should IPC practitioners advise on?

The IPC practitioner should advise on the following elements:

• Size of wards/clinical areas and space between beds
• Layout and position of waiting areas
• Ratio of isolation rooms to multi-bed rooms
• Toilet facility requirements
• Placement of IPC provisions (handwash basins; sluice rooms, etc.)
• Ward layout (the workflow in an area directly affects IPC practices)
• Ventilation requirements (for prevention of airborne transmission)
• Selection of fittings (surfaces, floors, doors, windows)
• Provision for sterile, clean and dirty storage
• Precautions needed for renovations (to prevent fungi and mould exposures).

The IPC practitioner should advise on isolation rooms, ventilation, layout and fittings.

General wards and clinics

5-5 What are the IPC requirements for general wards?

The basic requirements to ensure good infection control practice on general wards are:

• Sufficient space between beds to accommodate equipment/staff (at least 2.5 metres, measured from the centre of one bed to the centre of the next bed)
• Beds separated by curtains (both for privacy and for infection control during cough-generating procedures)
• Good natural ventilation or regularly maintained mechanical ventilation
• Provision of some isolation rooms, preferably with en suite bathrooms (at least 20% of all beds, and up to 40% of all beds in settings with high burden of infectious diseases)
• Sufficient toilets and bathrooms with handwashing facilities
• One dedicated handwash basin per room or per six beds
• Provision of alcohol handrub at entrances/exits and after every two beds
• Sharps containers on portable procedure trolleys or in high-care areas wall-mounted next to each bed
• Readily accessible personal protective equipment (at the entrance to rooms)
• Easy to clean and seamless surfaces (floors, walls)
• Dedicated storage spaces for sterile, clean and used equipment, sterile and clean supplies, clean and used linen, cleaning equipment, waste holding
• Sluice rooms within easy reach of clinical areas (with handwash basins)
• Space for administrative areas, staff rest rooms, consultation rooms, kitchens.

5-6 What are the IPC requirements for outpatient departments (OPD) and primary care clinics?

The main infection transmission risks encountered in the outpatient setting include:

• Respiratory infections (viruses and TB): infectious and non-infectious patients congregate, often in poorly ventilated areas.
• Inadequate decontamination of shared equipment and re-use of single-use items.

To reduce these risks, the following are required:

• Good natural ventilation (in warm climates outdoor waiting areas are preferred).
• A triage system for identifying and separating potentially infectious patients. Patients with communicable respiratory infections, diarrhoeal disease and skin rashes can be identified early, separated from non-infectious patients and moved through the clinic system as quickly as possible to minimise staff and patient exposures. Many facilities use ‘cough officers’ to identify coughing patients, direct them to a separate waiting area and provide them with information on cough etiquette and hand hygiene.
• A separate cough room where patients can go to produce sputum samples (indoors or outdoors). The area must be adequately ventilated and have provision for hand hygiene.
• Sufficient toilet facilities with proper provision for hand hygiene (soap, water, paper towels).
• Appropriate personal protective equipment for staff (where indicated) and surgical masks for patients with pulmonary TB.
• Provision for hand hygiene as close as possible to point-of-care (personal alcohol handrub, bottles of alcohol handrub and handwash basins – one per consultation room).
• A dedicated, separate area for cleaning and sterilization of instruments. This should ideally be done in the nearest hospital’s central sterile services department (CSSD). In some circumstances, instruments may be manually cleaned, disinfected or sterilized on-site (using a boiler or desk-top sterilizer).
• Written standard operating procedures for decontamination of commonly used equipment (thermometers, saturation monitors, blood pressure cuffs).

The main infection transmission risks in clinics include respiratory infections and inadequate decontamination of shared equipment.

5-7 What are the IPC requirements for dental clinics?

There is a high risk of blood-borne virus transmission in dental services. Infection transmission to healthcare workers and/or patients can occur through:

• Penetrating injuries (needle-stick injury, bites)
• Mucosal splashes and aerosols (spit, high-speed drills)
• Inadequate sterilization (instruments, equipment).

To reduce these risks, the following are required:

• Individual treatment rooms/cubicles with sufficient space to accommodate a chair, patient, dentist, assistant and equipment
• A handwash basin inside each cubicle
• Good natural ventilation
• Appropriate personal protective equipment for staff (eye protection, mask, gloves)
• A dedicated, separate area for cleaning and sterilization of instruments (at a minimum: a sink to wash instruments, cleaning cloths and brushes, separate storage for clean and used instruments, a desktop sterilizer)
• Sufficient dental syringes, needles and dental trays
• Sharps containers at the point of use
• Written standard operating procedures for decontamination and adequately trained staff
• All dental staff should be immunised against hepatitis B.

There is high risk of blood-borne virus transmission in dental services through penetrating injuries, mucosal splashes and inadequate sterilization of instruments.

Isolation areas

5-8 What is the purpose of patient isolation rooms?

Patient isolation areas or isolation rooms are designed to:

• Separate infectious patients from susceptible patients
• Protect immunocompromised patients from potential exposure to harmful pathogens
• Provide directional air flow to prevent airborne organisms from flowing into other areas (by using mechanical ventilation).

Patient isolation areas are used to separate infectious patients from susceptible patients OR to protect immunocompromised patients from potential exposure to harmful pathogens.

5-9 How many patient isolation rooms does a facility require?

This will depend on the disease profile of the community and the burden of infectious diseases, e.g. TB. For most low-resource settings (where infectious disease burden is high), at least 20% of all beds should be isolation rooms (up to 40% in settings with a high burden of infectious diseases).

5-10 What are the IPC requirements for patient isolation areas?

Many countries have laws or building recommendations that prescribe the minimum requirements for isolation rooms/cubicles. These should include:

• Adequate floor space (at least 18 m², excluding toilets, cupboards)
• Adequate ventilation (either natural or mechanical negative pressure at 6–12 air changes per hour
• A door that is kept closed at all times (preferably with a patient observation window so that the patient can be seen without the need to open the door)
• A clinical handwash basin inside the room
• An en suite toilet and bathroom (so the patient does not leave the room)
• Storage space for the patient’s personal items
• Easy to clean surfaces (no carpets, preferably no curtains)
• Space for provision of personal protective equipment at the entrance to the room
• Ideally isolation rooms should be located at the far end of a ward (this avoids heavy traffic passing the isolation room, and limits potential exposures).

Minimum IPC requirements for isolation areas are a single room, a door that can be closed, a hand washbasin inside the room or alcohol-based hand rub available and a window that can open.

Specialised areas

5-11 What infection transmission risks are encountered in operating theatres?

The following factors in operating theatres increase the risk of surgical site infections:

• Inadequate ventilation: skin scales and aerosols from both the operating staff and patient (containing micro-organisms) may contaminate the surgical field.
• Inadequate temperature control: in hot climates, sweat from the surgical staff may contaminate the surgical field.
• Inadequate decontamination of surgical equipment: poorly processed equipment poses a serious risk of infection transmission (including blood-borne viruses).
• Inadequate surgical site antisepsis or poor aseptic technique.
• Inadequate hand hygiene or surgical handscrub.

Inadequate ventilation, temperature control, equipment decontamination and antisepsis are the main risk factors for infections arising in the operating theatre.

5-12 What are the IPC requirements for operating theatres (OT)?

The design of an operating theatre complex should minimise the risk of surgical site infections (factors listed above).

• Ventilation: The operating theatre should be mechanically ventilated under positive pressure (all windows should remain closed). Air handling units should achieve at least 20 air changes per hour. The air supply should pass through a series of filters (to remove particles) before being delivered into the theatre. Certain types of surgery, e.g. implants or orthopaedics, require specialised ventilation (ultra-clean).
• Air-conditioning: For both patient safety and staff comfort, the temperature in the operating theatre should be kept between 18–24 °C.
• Decontamination: All surgical devices should be sterilized in a sterile services department with validated processes and controlled procedures in place.
• Zoning: the design and layout of the operating theatre complex should provide for easy access to hand hygiene in all areas and provide sufficient space to create a partial barrier between well-demarcated ‘clean’ and ‘sterile’ zones.

5-13 What are the IPC requirements for intensive care units (ICU)?

Intensive care units (ICU) admit patients requiring extensive medical or surgical supportive care. ICU’s usually record the highest rates of healthcare-associated infection (HAI) rates in a facility. This is because they care for immunocompromised patients, with many indwelling devices and invasive procedures and also use antibiotics extensively.

To reduce these risks, the following are required:

• Sufficient space between beds to accommodate equipment/staff (at least 3.5 metres, measured from the centre of one bed to the centre of the next bed).
• Good natural ventilation is preferred. Where available, mechanical ventilation with negative pressure or wall-mounted extractor fans may be used for isolation areas, neutral pressure for other areas).
• Provision of some isolation rooms (at least 10% of all ICU beds, more in settings with high infectious disease burden).
• One dedicated handwash basin per ICU bed (or at maximum one per four beds).
• Provision of alcohol handrub at entrances/exits and every bed.
• Sharps containers near each bed (within easy reach).
• Readily accessible personal protective equipment (at the entrance to rooms).
• Regular training of clinical staff on infection control techniques (hand hygiene, aseptic procedures).
• Proper decontamination of shared equipment.

ICUs have high healthcare-associated infection rates because they care for immunocompromised patients, with many indwelling devices, invasive procedures and high antibiotic usage.

5-14 What are the IPC requirements for emergency and trauma departments?

Most emergency units are very busy places, with frequent admission of patients requiring resuscitation:

• Provision of sufficient space around each bed (bay) is essential. Ward design or layout is also critical to ensure easy workflow.
• Easy access to handwash basins, alcohol handrub (preferred as it saves time), sharps containers and personal protective equipment is important.
• It is useful to have some dedicated isolation spaces (bays) for patients with suspected respiratory-transmissible illness.
• Negative pressure (mechanical) ventilation is ideal, but good natural ventilation is acceptable.

5-15 What are the IPC requirements for burns wards?

Burns patients are at extremely high risk of wound colonisation and/or infection, owing to the disruption of skin integrity and transient immune-suppression. They are also at high risk of invasive infections, e.g. bloodstream infections or device-associated infections. Most burns infections are caused by direct or indirect contact with healthcare staff (hands), equipment and the environment.

To reduce these risks, the following are required:

• Isolation rooms for patients with multi-drug-resistant infections
• Mechanical ventilation is preferred in high-care areas, otherwise good natural ventilation
• Dedicated handwash basins close to each bed
• Written standard operating procedures (SOPs) for decontamination of equipment and environmental cleaning, with regular checks on adequacy of cleaning/decontamination
• Minimal clutter, separated ‘clean’ and ‘dirty’ areas of the ward, to minimise contamination of clean supplies
• Provision for wound cleaning procedures such as special shower/bath facilities or beds
• Sufficient personal protective equipment for staff (gloves, aprons, masks as indicated).

5-16 What are the IPC requirements for dialysis units?

The major risks for infection transmission in dialysis units arise from:

• Poorly maintained dialysis machines: depending on the type of machine, may require daily rinsing and disinfection or cleaning after each use. The filter or dialysis membrane (to prevent passage of pathogens) should be verified as intact before each use.
• Poor environmental cleanliness: all surfaces with body fluid spills or leakages should be appropriately disinfected. For the rest of the dialysis unit environment, standard cleaning protocols may be followed.
• Dialysis fluid contamination: many different types of fluids are utilised and sterility checks at prescribed intervals should be included in the dialysis unit’s standard operating procedures (SOP).
• Poor aseptic technique when the patients are linked to the machines.

5-17 What are the IPC requirements for neonatal wards?

Neonatal wards are generally busy, overcrowded units providing specialised care to very vulnerable (usually premature and low-birth-weight) babies. Healthcare-associated infections and outbreaks in neonatal units often result in high mortality and serious morbidity. For these reasons, clear protocols and sufficient provisions for infection control are needed. The following aspects should be considered:

• Hand hygiene: sufficient handwash basins and alcohol handrub (placed at point of care).
• Isolation: at least one isolation room for every 10 patients, preferably en suite (to prevent the baby’s mother, who may also be colonised or infected, from leaving the room).
• Spacing: adequate space for staff and parents to move between cots or incubators. Overcrowding and staff shortages are often contributing factors in neonatal ward outbreaks.
• Waiting area: for family members to wait in before being informed of the ward protocol.
• Protocols: clear explanations and training of staff on procedures such as decontamination of equipment, incubators/cots, milk feed preparation and management of expressed breast milk.
• Maternal screening protocols: in Kangaroo Mother Care (KMC) wards, where mothers remain in hospital with their babies, all mothers should be symptom screened for TB, diarrhoea/vomiting and flu-like illnesses.

Infections and outbreaks in neonatal units result in high mortality. Clear protocols and sufficient provisions for infection control are needed.

5-18 What are the IPC requirements for milk preparation areas (milk kitchens)?

In neonatal and paediatric wards, infant formula is often prepared on the ward or in a designated ‘milk kitchen’ nearby. This should be considered a high-risk area for microbial contamination during feed preparation, storage and sterilization of bottles. To reduce these risks, the following are required:

• Handwash basin with soap, water and paper towels
• Facilities to wash bottles and formula preparation equipment
• Provision for high-level disinfection and drying of bottles and teats (using either heat, microwave or chemical disinfection with hypochlorite at 125 parts per million available chlorine)
• Plastic aprons for staff preparing batches of formula
• Facilities to boil water
• Storage area for feed supplements, measures and mixing containers
• A dedicated, functional refrigerator for prepared formula feeds (stored at 4–6 °C and used within 24 hours of preparation)
• Facilities for waste disposal
• A register to document the patients receiving formula feeds.

Milk kitchens are considered high-risk areas for microbial contamination during feed preparation, storage and sterilization of bottles.

5-19 What are the IPC requirements for handling of expressed breast milk (EBM)?

In babies mistakenly fed EBM from an HIV-, hepatitis-B/C-infected mother, there is significant risk of blood-borne virus transmission. To avoid this unfortunate occurrence, strict procedures are needed for the management of EBM:

• The importance of hand hygiene should be emphasised and the correct hand hygiene technique should be demonstrated to new mothers
• Ideally a quiet, private room should be provided for mothers to express in
• A sterile plastic container or jar in which to express breast milk should be provided
• After EBM is produced, the jar should be labelled (by a staff member in the presence of the mother) with the mother’s name, infant’s name and hospital number, the date and time EBM was produced
• EBM should be stored at 4–6 °C in a dedicated milk refrigerator and used within 24 hours (alternatively EBM can be stored frozen for up to one month)
• In the case of HIV-infected mothers who wish to give EBM or where pooled breast milk is used, facilities for pasteurisation should be provided (pasteurisation involves exposing EBM to 75 °C for 3 minutes or 90 °C for 1 minute).

Strict protocols are needed for the management of expressed breast milk (EBM) in hospitals to avoid inadvertent blood-borne virus exposure to babies.

Support services

5-20 What are the IPC requirements for mortuaries?

Mortuary facilities should be designed to ensure the safety of mortuary staff. Exposure of mortuary staff to pathogens occurs through penetrating injuries (bone/sharp instruments), inhalation of pathogens (while cutting bone and lung tissue) and through mucosal splashes (blood and body fluids). To reduce these risks, the following are required:

• Refrigeration: for safe storage of bodies.
• Showers and change areas: for staff to remove their personal garments, dress, put on closed footwear and other protective equipment, and shower before leaving the mortuary.
• Ventilation: negative pressure ventilation is required, especially for TB-endemic settings.
• Personal protective equipment: to reduce exposure to blood and body fluids.
• Sharps containers at the point of use
• Provision for cleaning sinks to decontaminate equipment.
• Staff lockers for personal belongings.

5-21 What are the IPC requirements for ambulances?

Before transporting any patient, the ambulance staff should attempt to establish (from the patient and healthcare workers) if there is a known or suspected infection transmission hazard. In all cases, standard precautions should be used, with the addition of transmission-based precautions where needed. For example, staff transporting a patient known with pulmonary TB, should implement airborne precautions. This would include: a surgical mask on the patient, N95 respirators for the staff plus gloves and an apron (for anticipated contact with respiratory secretions). Strict adherence to the five moments for hand hygiene should be practised. Hand hygiene with alcohol handrub is sufficient unless hands are visibly contaminated. Adequate natural ventilation may be difficult to achieve in the confined space of an ambulance, but where possible side windows should be kept open. After transport of a patient with a known pathogen, e.g. TB or drug-resistant bacterial infection, surfaces and equipment should be cleaned and wiped over with an appropriate disinfectant. Spills of blood and body fluid must be cleaned up immediately and the contaminated areas washed and disinfected with sodium hypochlorite.

Ambulance staff transporting a patient with known pulmonary TB should implement airborne precautions.

5-22 What are the IPC requirements for hospital kitchens?

The following features are recommended:

• Location of kitchen near main delivery areas, but with easy access to the wards
• Adequate changing, toilet, handwash and rest facilities for staff
• Separate area for receiving and storing food produce (frozen foods between -13 and -18 °C; meat and cold products below 4 °C)
• Separate preparation areas for raw and cooked food
• Separate areas for dry and fresh (wet) food supplies
• Adequate food storage areas
• Designated areas for utensil washing
• Uninterrupted supply of hot and cold water
• Provision of personal protective equipment (aprons, boots, hairnets, disposable gloves)
• Occupational health screening of kitchen staff for carriage of known intestinal pathogens and a mechanism for staff to report and receive treatment for concurrent illness
• Provision for safe storage and disposal of all kitchen waste
• A programme for regular audits and inspection of the kitchens.

5-23 What are the IPC requirements for other support services?

Support services include laundry and linen, waste management, housekeeping and engineering services among others. All support services staff are at increased risk of exposure to pathogens, and should be trained in job-specific infection prevention skills at employment and regular intervals thereafter. Hepatitis B immunisation is recommended because of the high risk of needlestick injuries among housekeeping, laundry and waste management staff. Appropriate personal protective equipment (PPE) should be readily available to support services staff and its use should be enforced by healthcare management.

Support services staff are at increased risk of exposure to pathogens, and require job-specific IPC training and immunisation against hepatitis B.

Case study 1

Owing to population growth and a greater demand for healthcare services, the community health centre in a rural town will be expanded and renovated. Additional consultation rooms will be added to accommodate a TB clinic, an antiretroviral treatment clinic, a midwife obstetric unit (MOU), an emergency treatment area, a paediatric clinic, a clinic for curative services and a dental clinic. The IPC team forms part of the renovation committee.

1. What should be the main focus of the IPC team in this renovation project?

The IPC team should consider the main risks and route of microbial transmission in each of the clinical areas being expanded or renovated. They will then be able to advise on specific design features, layout and ventilation requirements to reduce the risk of healthcare-associated infection.

2. Which of the features in the design and layout of the clinic would be the most important to limit exposure to respiratory infections?

Well-ventilated waiting areas and consultation rooms will be needed. Ideally, separate waiting areas for each clinic should be provided. A cough room or outdoor cough booth should be included in the renovated facility, so that patients can produce sputum samples safely.

3. Why is a triage area close to reception an important design feature from an IPC perspective?

Patients with communicable respiratory infections, diarrhoeal disease and skin rashes can be identified early, separated from non-infectious patients and moved through the clinic system as quickly as possible to minimise staff and patient exposures.

4. What are the minimum requirements to facilitate proper decontamination of medical instruments used in the MOU, treatment clinic, and dental clinic?

The facility will require dedicated cleaning rooms in each of these clinical areas. Each cleaning room should have: a sink to wash instruments, cleaning cloths and brushes, separate storage for clean and used instruments, a desktop sterilizer.

Case study 2

The emergency department of a large tertiary hospital is being revamped. The hospital’s IPC team is invited to be part of the renovation team and to give input on the layout of the department.

1. Where in the emergency department would be the best place to have the sluice room?

The sluice room should be located close to the patient care areas to facilitate the prompt and safe disposal of body fluids and contaminated items.

2. Where is the best place to put sharps containers in the emergency department?

Sharps containers should be wall-mounted next to each patient bed or attached to procedure trolleys, i.e. at the point of use (within easy reach).

3. Is it necessary to have an isolation facility within the emergency department?

Yes, patients with suspected or known respiratory infections and other communicable disease must preferably be isolated.

Case study 3

A 40-bed medical ward in a resource-limited hospital has four single rooms that can be used as isolation rooms. These isolation rooms are mostly used for patients with active pulmonary tuberculosis and patients infected/colonised with multidrug-resistant organisms. Occasionally cases of meningococcal meningitis or viral respiratory infections are isolated here as well.

1. What factors will determine if the number of isolation rooms is sufficient?

The communicable disease profile of the community in which the hospital is located will determine how many isolation beds are needed. Generally 20% of the beds in each ward should be isolation beds.

2. What are the ideal requirements for each of these isolation rooms from an IPC perspective?

The isolation room should have the following features: a single room at the far end of the ward, a door that can be closed, patient observation panel in the door/wall, en suite bathroom, handwash basin inside the patient room, mechanical ventilation/window that can open and easy-to-clean surfaces.

3. What are the minimum requirements for each of these isolation rooms?

Minimum requirements are a single room, a door that can be closed, a handwash basin inside the room or alcohol-based handrub available and a window that can open.

4. If there is mechanical ventilation in the isolation rooms, what should the settings be?

Mechanical ventilation of isolation rooms requires regular maintenance (servicing) to maintain negative pressure ventilation at between six and 12 air changes per hour.

Case study 4

In a 30-bed neonatal ward for premature babies, some mothers are expressing breast milk (EBM) and others are feeding with formula milk. At the 2 am morning feed, one baby is mistakenly given EBM belonging to another baby’s mother. The EBM donor mother is known to be HIV-infected and nursing staff members have noticed that she is coughing a lot in the ward.

1. What is the risk of giving another mother’s EBM to a baby?

In this case the source milk or donor EBM comes from an HIV-infected mother. There is a risk of transmitting HIV to the baby that was mistakenly given the EBM.

2. What can be done to prevent this mistake from happening again?

After EBM is produced, the jar should be labelled (by a staff member in the presence of the mother) with the mother’s name, infant’s name and hospital number, the date and time EBM was produced. Before feeding a baby, the EBM or formula milk jar label should be checked by two staff members against the baby’s identity band.

3. What should the nursing staff do about the coughing mother?

Ideally all mothers admitted to neonatal wards with their babies should complete a symptom screening questionnaire to identify potentially transmissible infections, e.g. TB, diarrhoeal disease. In this case, they should ask the medical staff to exclude the possibility of TB or other respiratory illness in this lady. While these investigations are being completed, the staff should ask the mother to wear a surgical mask while in the ward, and ideally move her and her baby to an isolation room.