A Nurture Brief
INFECTION CONTROL IN HEALTHCARE ENVIRONMENTS
SURFACE
CO
INTRODUCTION THE Evidence for preventing infection
Hospital-acquired infections (HAI) are the fourth largest killer in America. It has been estimated that 103,000 people die every year as a result of an HAI. That’s as many deaths as from AIDS, breast cancer, and car accidents combined.1
The healthcare industry has known since 1847 that proper hand hygiene is the most cost-effective method of preventing cross-transmission of infections among patients.2 Until the 1970s, physicians and nurses were trained not to touch doorknobs, cabinets, curtains, etc. once they scrubbed and/or gloved. When antibiotics began to be used heavily in the 1970s, that training came to be considered unnecessary.3 In addition, hospitals used to regularly test surfaces for bacteria, but the CDC and AHA advised them in 1970 to stop, claiming it was unnecessary and not cost-effective. Studies have since linked unclean hospital equipment to infections.4
Of greater concern to healthcare providers is the rise of drug-resistant strains of some well-known germs. Methicillin-resistant Staphylococcus aureus (MRSA) is the most common so-called super bug; it’s about two-and-a-half times more lethal than staph infections that respond to methicillin. While most MRSA-infected patients used to arrive at hospitals from nursing homes or other skilled nursing care facilities, it’s becoming more common for otherwise healthy patients to have acquired it from elsewhere in the community, such as locker rooms, prisons, schools and the military.5 Some experts believe this rise in community-acquired superbugs is driven by the public’s reliance on antimicrobial disinfectants in the home. The CDC recommends proactive design measures instead of products containing germicides to achieve infection control attributes.6
Costs •
In Pennsylvania, one of the states leading the way in infection control, hospitals reported the average charge for infection cases was $185,260, compared with $31,389 for noninfection cases.7
•
According to the Pennsylvania Healthcare Cost Containment Council, the 1.9 million admissions in their state in 2005 without an HAI had an average length of stay less than five days. For the 24,000 admissions that were reported with an HAI, the average length of stay was 23 days. Based on the data submitted for the first nine months of 2005, it is estimated that HAIs added 227,000 extra hospital days in Pennsylvania alone.8
INFECTION CONTROL IN HEALTHCARE ENVIRONMENTS: A NURTURE BRIEF
•
HAIs erode the bottom line, especially when reimbursement is lower. In 2006, the average payer mix for patients without infections was 37% Medicare, 28% commercial payers, 21% other and 4% Medicaid. For patients with HAIs, the mix changed to 57% Medicare, 17% commercial, 14% other and 11% Medicaid, meaning hospitals receive less reimbursement for those patients.9 However, since Medicare will no longer pay for costs incurred by a hospital’s error, including several avoidable infections, hospitals will soon face the possibility of no reimbursement at all.10
THINGS TO CONSIDER Protocols
Denmark, Holland and Finland have nearly eradicated infections that are a threat in American hospitals by employing regular screening, rigorous hand-cleansing programs and cleaning protocols for equipment and rooms.11 Staffing plays a crucial part in reducing infections, because an overworked nurse may miss the subtle early signs of an infection, and because studies have shown that overburdened healthcare workers don’t clean their hands as often as those with a reasonable case load.12
Transparency
More than a dozen states, including NY, PA, and CT, have responded to mounting alarm over such infections – especially those resistant to antibiotics – by requiring hospitals to make infection rates public.13 Public reporting motivates doctors and nurses to work for better results. In 1989, when New York state started publishing hospitals’ death rates after bypass surgery, the hospitals conducted internal reviews, hired new personnel and pushed out surgeons with the highest death figures. Statewide mortality dropped like a stone, by 41 percent in four years.14
Planning
An infection control officer needs to be involved in the planning process of a new facility or renovation of an existing one. 15
INTRODUCTION
CTION ONTROL
SUPERBUGS Some powerful bacterial infections are developing resistance to common antibiotic treatments. The development of these resistant strains is due in part to the overuse or misuse of antibiotics, together with bacteria’s capabilities for rapid mutation. Also known as “superbugs.” these potent infections often involve longer illnesses, longer hospital stays or severe side effects from more powerful treatments, all adding up to increased costs. For children, the elderly and the immuno-compromised (e.g. onocology patients), a progressive antibiotic-resistant infection can be fatal. Below are brief descriptions of some of the drug-resistant “superbug” germs that are prevalent today and causing significant rising concern:
MRSA – Methicillin-resistant Staphylococcus aureus • • •
most common causes 102,000 hospital infections a year community-acquired strain (CA-MRSA) appearing among healthy adults and children
Pseudomonas aeruginosa • •
responsible for 18% of hospital-acquired pneumonia causes deadly lower-respiratory infections in sick patients
Clostridium difficile • •
responsible for 400,000 cases of diarrhea annually new mutation produces 20X the toxin of the old version
INFECTION CONTROL IN HEALTHCARE ENVIRONMENTS: A NURTURE BRIEF
Antibiotic Any drug or chemical that kills bacteria Antibacterial A soluble substance derived from a mold or bacterium that kills or inhibits the growth of other microorganisms Antimicrobial A drug or chemical that kills bacteria or prevents them from multiplying; antibiotics are naturally occurring antimicrobials16
Klebsiella pneumoniae • • •
infects urinary tract, gut and bloodstream resistant cases are up 50% in five years untreated, two-thirds of patients die
Acinetobacter baumannii • • •
soil-borne, infects wounds; can go deep into skin, bones, lungs & blood problem for soldiers in Iraq & Afghanistan responds to only a few drugs
VRE – Vancomycin-resistant Enterococcus faceium • •
causes 10% of hospital infections infects blood, urinary tract, wounds, especially in immunosuppressed patients17
SUPERBUGS
Antibiotic vs antibacterial vs antimicrobial
Controlling Infection Transmission in the
AIR Modes of transmission Airborne microorganisms spread via three main pathways: •
Disturbance of an environmental reservoir of a pathogen. For example, when soil, water, dust, or decaying organic matter are disturbed, fungal spores (e.g., Aspergillus) may be released into the air and make their way into the hospital environment.
•
Directly from person to person in the form of droplets in the air. When droplets are produced during a cough or sneeze, a cloud of infectious particles is released into the air, resulting in potential exposure of susceptible persons within three feet of the source person.
•
Via residuals of droplets that remain indefinitely suspended in the air and can be transported over long distances. The microorganisms in the droplet residuals persist in dry cool conditions with little or no exposure of light or direct radiation. Susceptible individuals who come in contact with high concentrations of the microorganism may get infected.18
SOURCES •
•
Construction and renovation activities. Airborne pathogens such as Aspergillus survive well in the air, dust, and moisture present in healthcare facilities and are usually released into the air during site construction and renovation.19 Ventilation system contamination and malfunction. Many incidents and outbreaks of nosocomial infection have been linked to malfunctions and contamination of the ventilation system in hospitals.20
THINGS TO CONSIDER Filters & Ventilation
HEPA filters are suggested for healthcare facilities by the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). They are required or strongly recommended in all construction and renovation areas.21 During construction or renovation, it’s important to prevent access by nonconstruction personnel (patients, visitors, medical staff ) to work areas. A complete dust control system needs to be designed before construction begins. Communication between the construction team and the medical team will make the experience smoother for all.22
INFECTION CONTROL IN HEALTHCARE ENVIRONMENTS: A NURTURE BRIEF
AIR Air contamination is lowest in laminar airflow rooms with HEPA filters; this approach is recommended for operating room suites and areas with ultra cleanroom requirements, such as those housing immunocompromised patients.23 Downward ventilation systems supply air through a slot in the ceiling with the exhaust located at the floor level; they are recommended for preventing the spread of disease because the air current moves the droplet nuclei down, protecting healthcare workers and nearby patients.24
Sick Building Syndrome (SBS) describes situations in which building occupants experience acute health and comfort effects that appear to be linked to time spent in a building, but no specific illness or cause can be identified. SBS has been linked to many causes, including low ventilation rates. Studies of SBS in the lab and in the workplace have estimated a decrease in worker productivity of 3%-5%.26 Patient rooms
Single-bed rooms prevent the transmission of airborne pathogens by keeping infected patients separate from non-infected patients.27 Isolation rooms are designed according to several administrative and engineering controls. The philosophy, however, is straightforward: a high ventilation rate within a room is used to dilute and flush the aerosol contaminants.28 A Protective Environment (PE) is a specialized patient-care area with a positive airflow relative to the corridor (i.e. air flows from the room to the outside adjacent space). The combination of HEPA filtration, high numbers of air changes per hour (>12 ACH), and minimal leakage of air into the room creates an environment that can safely accommodate patients who are immunocompromised.29
AIR
Dampness in a building may double the risk for adverse health effects, though the exact causes of the health effects are not yet certain. Mites, molds and volatile organic compounds (VOCs) may be also associated with adverse health effects in damp buildings.25
Controlling Infection Transmission in
WATER Modes of transmission Waterborne microorganisms proliferate in moist environments and aqueous solutions, especially where the temperature is warm and a source of nutrition is readily available. Waterborne infections typically spread through direct contact (e.g., for hydrotherapy), ingestion of contaminated water, indirect contact, and inhalation of aerosols dispersed from water sources.30
SOURCES •
•
Potable water, water used for treatment (such as dialysis), lab solutions, ice, and hydrotherapy tanks may harbor gram-negative bacteria and Nontuberculous Mycobacteria (NTM) that then infect the individuals through the routes described above.31 The sources of Legionella bacteria implicated most often in outbreaks of Legionnaires’ disease worldwide include cooling towers and hot water distribution systems that have been poorly maintained, and recreational whirlpool spas operated at temperatures conducive to bacterial growth and not regularly drained and refilled.32
THINGS TO CONSIDER Water Systems
The CDC and HICPAC guidelines recommend against using tap water for medical care (e.g., in direct patient care, for diluting solutions, as a water source for medical equipment and instruments, and for disinfection of instruments) as this might directly expose patients to these pathogens.33 To prevent growth of Legionella and other bacteria in the water system, healthcare facilities are required to maintain cold water at a temperature below 68ºF and hot water at a minimum temperature of 124ºF. In addition, other methods, such as chlorine treatment or copper-silver ionization and UV light, may be used to treat water that is distributed in healthcare facilities.34 Regular maintenance and inspection of water in holding tanks is also recommended. Legionella most often enter through aerosols generated by cooling towers, showers, faucets, respiratory therapy equipment, and room-air humidifiers.35 Point-of-use fixtures, such as sinks, showers, aerators, and toilets, may serve as reservoirs for pathogens such as Legionella. The American Society of Heating, Refrigerating, and Air-conditioning Engineers (ASHRAE) recommends regular cleaning and disinfection of faucet aerators, especially in areas with high-risk patients, to prevent and control for Legionella.36
INFECTION CONTROL IN HEALTHCARE ENVIRONMENTS: A NURTURE BRIEF
WATER Decorative Fountains
Decorative fountains are commonly used in healthcare environments as landmarks for wayfinding and as a source of positive distraction, but infection control managers worry about the potential risk of waterborne infections.37 There are no documented cases of decorative fountains being the source of infection. The confusion arises from general use of the term “water fountain,” to refer to drinking fountains, decorative fountains and interactive play fountains. Each carries very different risks of harboring infectious microorganisms and spreading waterborne or airborne illnesses. Public decorative fountains that are routinely used for children’s water play pose the highest-risk, because they are not maintained to the appropriate standards for such use.38 According to the CDC, the strength of evidence that decorative fountains pose a risk of contributing to the spread of waterborne pathogens is low. The recommended prevention and control steps related to decorative fountains include performance of regular maintenance, water disinfection, and avoidance of placement in or near high-risk-patient care areas.39
Effective methods of treating water in healthcare facilities include chlorine treatment, copper-silver ionization, and UV light.41 Risk Factors
The style of fountain impacts the spread of Legionella: • • • •
•
Sea Bubbler: The sea bubbler feature typically has the water totally enclosed. If the water is enclosed it will create little, if any, aerosol. Cascade: By design, the smooth peaceful flow of the water results in little aerosol generated. Water Wall: Because of the fine sheeting of water created over a large surface area, there is the additional possibility of creating a small amount of aerosol. Spray: This design will create a significantly larger amount of aerosol than any of the previously discussed units. A pulsing fountain is a type of spray fountain that pulses water into the air. Pulsing fountains can create significantly more aerosol than a standard spray type fountain. Fine mists and high sprays will create more aerosol than coarse and low sprays. However, outbreaks have been associated with coarse, low sprays. Mist: These units by design create a very high amount of aerosol in proportion to their total volume.42
WATER
Submerged light, which can add a tremendous amount of heat to decorative fountains, has been present in all ornamental fountain outbreaks reported in the US. Where submerged lighting is used in a water feature, the risk management plan needs to be modified accordingly.40
Controlling Infection Transmission by
HUMANS MODES OF TRANSMISSION Most infections are now acquired in the hospital via contact between contaminated people and/or surfaces.43 People are considered the direct contact pathway of infectious pathogens. People pick up germs by coming into contact with a contaminated surface. This section will address the people part of the equation; surfaces will be discussed in the next section. There are three ways in which people spread infectious agents: •
•
•
Patient-staff-patient contact. The primary source for hospital-spread infections is the patients themselves. Many enter the hospital already carrying the infection, but they may not display symptoms. Since the staff is unaware of the infection, they treat these patients, and unknowingly pick up an infection themselves. They then treat more patients, thereby transmitting the disease to them without realizing it. Patient-equipment-patient contact. Patients touch equipment in the patient room, or furniture in the waiting room. If they are carrying a disease, those germs could be passed to the equipment. The next patient then touches the same object, and picks up the germ. Equipment-staff-patient contact. If a nurse has unwittingly picked up an infection, then uses a piece of equipment, that infection is passed to the equipment. The next nurse use the same piece of equipment, and picks up the germs. That nurse then touches a patient, thereby transmitting the infection.44
THINGS TO CONSIDER Hand Cleansing
Plain soap is good at reducing bacterial counts, but antimicrobial soap is better, and alcohol-based handrubs are the best. Alcohol-based handrubs are less damaging to the skin than soap and water.45 Dispensers must be easy to access. The time required for nurses to leave a patient’s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent handwashing or hand antisepsis. Staff can help determine the best locations for dispensers, both in clinical areas and public areas.46
Protocols
At the University of Pittsburgh Medical Center (UPMC), Shadyside Campus in Pittsburgh, Pennsylvania, “Clinicians are expected to wash their hands every time they enter a patient’s room, and again before they leave, every time,” says
INFECTION CONTROL IN HEALTHCARE ENVIRONMENTS: A NURTURE BRIEF
HUMAN Barbara Hildebrand, RN, MBA, CIC, Clinical Resource Coordinator with UPMC’s Center for Quality Improvement and Innovation. “Our hand hygiene goal is “In and Out, No Matter What,” she says. It’s a high standard, but necessary.47 Staffing
Ideally, where infected patients are cohorted, staff should also be cohorted, but that can be difficult if a unit is understaffed. However, it may be worth the effort if all other measures have failed to contain transmission.48 In two studies, the composition of the nursing staff (“pool” or “float” vs. regular staff nurses) influenced the rate of primary bloodstream infections, with an increased infection rate occurring when the proportion of regular nurses decreased and pool nurses increased.49
Screening
European countries have protocols requiring active surveillance (screening) of all patients, or at least all patients admitted to high-risk units, such as ICU, cardiothoracic, orthopedic and burn units. Where similar policies have been adopted in the US, the results have been dramatic.50 Hand cleansing is only part of the solution. In one study, researchers found that installing dispensers of alcohol-based hand cleaners inside and outside each patient’s room had no significant impact on MRSA infection rates…But initiating routine surveillance cultures for all ICU patients and contact precautions for patients testing positive for MRSA resulted in an impressive 75% drop in MRSA bacteremia in intensive care units and a 67% drop hospital wide.51
Design
Private rooms make the spread of infection less likely because patients and visitors do not share space and equipment with other patients.53 Planning for adequate space for cleaning and access to equipment and patients can help control transmission of infectious agents. If a space is too small, curtains separating patients can contaminate clinical carts, other equipment, staff and patients. Appropriate storage for waste and dirty linens and equipment is also important.54 It’s important to evaluate traffic patterns and human behavior in choosing the right place for hand cleanser dispensers. When dispensers are moved to locations more likely to be seen, usage increases.55
HUMANS
Identifying colonized patients is a key component of reducing the spread of MRSA….Culturing all admitted patients is costly and labor-intensive, but some hospitals that follow these procedures claim significantly reduced MRSA rates that pay off financially as well as clinically.52
Controlling Infection Transmission on
SURFACES MODES OF TRANSMISSION The previous section reviewed the importance of hand cleansing in limiting the transmission of infections. But what about the equipment in the hospital? As long as facilities are inadequately cleaned, doctors’ and nurses’ hands will be recontaminated seconds after they are washed—when they touch a keyboard, open a supply closet, pull open a privacy curtain, or contact other bacteria–laden surfaces.56 Environmental surfaces are indirect contact pathways of infectious pathogens. Those most likely to be contaminated can be divided into two groups: • those with frequent hand contact (door knobs, bedrails, medical equipment, light switches, edges of curtains) • those with minimal hand contact (floors and ceilings)57
COMMON SITES OF CONTAMINATION • •
•
•
Clothing worn by physicians and nurses picks up bacteria 65% of the time when the clinician leans over a patient during an exam.58 Medical equipment such as stethoscopes, blood pressure cuffs, pulse oximeters, wheelchairs and other equipment frequently carry live bacteria. The American Medical Association recommends cleaning the stethoscope before listening to a patient’s chest, but this doesn’t usually happen.59 Chairs and other furniture are potential reservoirs of pathogens in hospitals. In one hospital, Vancomycin-resistant enterococci (VRE) was found on 30% of the chairs tested, only one of which came from a room occupied by a patient known to have VRE.60 Keyboards are such reservoirs of deadly bacteria that a few hospitals are installing washable keyboards, including one that sounds an alarm if it isn’t disinfected periodically.61
CLEANING & STERILIZATION •
•
Denmark, Holland, and Finland brought their infection rates down to under 1% using meticulous cleaning of equipment and rooms in between patient use, along with screening and hand-washing programs. Wheelchairs and other equipment used to transport patients who test positive for MRSA are not used for other patients, and hospital staff must change their uniforms and footwear after entering the rooms of MRSA patients before they are permitted in other areas of the hospital.62 High-touch surfaces in patient-care areas, such as doorknobs, bedrails, light switches, walls around the toilet, blinds, shelves, and curtains, should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact.63
INFECTION CONTROL IN HEALTHCARE ENVIRONMENTS: A NURTURE BRIEF
SURFAC THINGS TO CONSIDER Cleaning Protocols
Impervious-backed paper, aluminum foil, and plastic or fluid-resistant covers are suitable for use as barrier protection on equipment that may be difficult to clean, or comes into frequent contact with workers’ hands. Coverings should be removed and discarded while the health-care worker is still gloved, and recovered before the worker puts on new gloves.64 Proper medical waste disposal requires puncture-resistant containers located at the point of use, for discarded sharps, tubes, scalpel blades, and small amounts of blood.65 Manufacturers must educate users on product choices and techniques to avoid breakdowns in the antimicrobial features of their products.66 Vaporized hydrogen peroxide is a safe cleaner that has been used for years to sterilize equipment and packaging in the pharmaceutical, biological and medical device industries. In healthcare environments, it decontaminates surfaces and has been shown to reduce the occurrence of HAIs.67
Design
Single-bed rooms help reduce the spread of infection by limiting contact between patients and are easier to decontaminate after the patient leaves.68, 69 High quality, durable, easy wipe/clean surfaces and fittings and fixtures with sealed joints minimize the risk of infection. Curtains which can be washed at disinfection temperatures, and low dust retention fixtures and integral blinds (within double glazing systems) aid cleaning.70 Smoother surfaces (except for vinyl) were less effectively cleaned than textiles with rougher surfaces.71
Materials
Copper is a natural antimicrobial material, and has been shown to eliminate the presence of MRSA and other bacteria.72 However, it must be cleaned consistently to maintain its effectiveness; even a thin film of dust can reduce its antimicrobial properties.73 Silver is a natural antimicrobial and is already common in medical settings. There is some concern about its toxicity to humans, but it is generally considered safe in limited uses.74 Not all surface materials promoted as anti-microbial were shown to be effective when tested in one independent study.75
SURFACES
Carpets have not been shown to affect the infection rates of hospitals, however, carpeting should be avoided in areas where spills are likely to occur.76
Citations INTRODUCTION 1
McCaughey, B. (2006). Unnecessary deaths: The human and financial costs of hospital infections, 2nd edition, p3. Committee to Reduce Infection Deaths. Retrieved June 2, 2007 from http://www. hospitalinfection.org/ridbooklet.pdf 2 Hugonnet, S. & Pittet, D. (2000). Hand hygiene – beliefs or science? Clinical Microbiology and Infection, 2000: 6: 348354 3 Greider, K. (January 2007). Dirty hospitals: Two million patients are infected in hospitals each year and 90,000 of those Americans die. AARP Bulletin. Retrieved August 8, 2007 from http://www.aarp.org/ bulletin/yourhealth/dirty_hospitals.html 4 McCaughey, B. (July 23-30, 2007). Why aren’t hospitals cleaner? US News & World Report. Retrieved August 9, 2007 from http://www.hospitalinfection.org/press/us_ news_and_world_report_7-16-07.html 5 Reducing MRSA infections: Staying one step ahead. (July 26, 2007). Institute for Healthcare Improvement. Retrieved August 8, 2007 from http://www. ihi.org/IHI/Topics/PatientSafety/ SafetyGeneral/ImprovementStories/ FSReducingMRSAInfectionsStay ingOneStepAhead.htm 6 Maine, B. (July 1, 2006). Infection control or greenwashing? Unintended consequences of overdesign (Part II). Retrieved April 10, 2007 from http:// www.greenbiz.com/sites/greenerbuildings/ news_detail.cfm?NewsID=31259 7 Greider, K. (2007). 8 Murphy, D. and Whiting, J. (2007). Dispelling the myths: The true cost of healthcare-acquired infections, p 8. Association for Professionals in Infection Control and Epidemiology, Inc. Retrieved August 13, 2007 from http://www. apic.org/Content/NavigationMenu/ PracticeGuidance/Reports/hai_whitepaper. pdf 9 Murphy, D. and Whiting, J. (2007). 10 Lubell, J. (August 20, 2007). CMS: Your mistake, your problem. Eight hospitalacquired conditions won’t be paid for.
Modern Healthcare. Retrieved August 21, 2007 from http://modernhealthcare.com/ apps/pbcs.dll/article?AID=/20070820/ SUB/70817007 11 McCaughey, B. (2006), p1. 12 Smith, S. (August 9, 2007). Hospital infection may cost $473m: Report recommends public release of data. The Boston Globe. Retrieved August 9, 2007 from http://www.boston.com/news/ local/massachusetts/articles/2007/08/09/ hospital_infection_may_cost_473m/ 13 Campbell, C. (May 13, 2007). The hidden danger at hospitals: State conceals which had potentially lethal infectious outbreaks. The Star Ledger. Retrieved August 9, 2007 from http://www.hospitalinfection. org/press/051307starledger.htm 14 Greider, K. (2007). 15 Guidelines for environmental infection control in health-care facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), p24. (2003) The Centers for Disease Control and Prevention. Available from http://www.cdc.gov/ncidod/dhqp/gl_ environinfection.html
SUPERBUGS 16 17
Definitions pulled from www.webmd.com Langreth, R. and Herper, M. (June 19, 2006). Germ warfare. Forbes. Retrieved August 1, 2007 from http://www.forbes. com/free_forbes/2006/0619/060.html
AIR 18
Joseph, A., PhD. (July 2006). The Impact of the environment on infections in healthcare facilities. The Center for Health Design. Retrieved January 6, 2007 from http://cool.coa.gatech.edu:8000/ patientroom/uploads/1/Joseph,2006.pdf 19 Joseph, A. (July 2006). 20 Joseph, A. (July 2006). 21 Joseph, A. (July 2006). 22 Hoyng, M. (November 2005).
INFECTION CONTROL IN HEALTHCARE ENVIRONMENTS: A NURTURE BRIEF
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Infection control during construction is contagious. Healthcare Design. Retrieved December 14, 2006 from http://www. healthcaredesignmagazine.com/ME2/ dirmod.asp?sid=9B6FFC446FF7486981E A3C0C3CCE4943&nm=Articles&type=P ublishing&mod=Publications%3A%3AArt icle&mid=8F3A7027421841978F18BE89 5F87F791&tier=4&id=ED7CD7493A70 496F82D0C6E758EDB1F0 23 Joseph, A. (July 2006). 24 Joseph, A. (July 2006). 25 Bornehag, C.G., Sundell, J., Bonini, S., Custovic, A., Malmberg, P., Skerfving, S., Sigsgaard, T., and Verhoeff, A. (2004). Dampness in buildings as a risk factor for health effects, EUROEXPO: a multidisciplinary review of the literature (1998–2000) on dampness and mite exposure in buildings and health effects. Indoor Air, 14(4): 243-257. Available from http://www.blackwell-synergy.com/doi/ abs/10.1111/j.1600-0668.2004.00240. x?journalCode=ina&volume=14&issue=4 26 Indoor air quality, health, and productivity: Can design make a difference? (January 2002). Research Design Connections. Available from http://www. researchdesignconnections.com/issues/01_ 1/features/80-1.html 27 Qian, H., Li, Y., Nielsen, P.V., Hyldgaard, C.E., Wong, T.W. and Chwang, A.T.Y. (2006). Dispersion of exhaled droplet nuclei in a two-bed hospital ward with three different ventilation systems. Indoor Air, 2: 111-128. Available from http:// www.ncbi.nlm.nih.gov/sites/entrez?cmd=R etrieve&db=PubMed&list_uids=1650703 9&dopt=AbstractPlus 28 Phillips, D., PhD., Eng, P., Schuyler, G. Infectious Disease control issues principles of isolation room design. RWDI Technotes, Issue no.22. Retrieved September 13, 2007 from http://go.rwdi.com/technotes/t22. pdf 29 Guidelines for environmental infection control in health-care facilities (2003), p6
ONTROL WATER 30
Joseph, A. (July 2006). Guidelines for environmental infection control in health-care facilities. (2003), pp40-41. 32 Rogers, J.L. (Winter 2006). The Debate over decorative fountains in healthcare environments: How great is the infection control risk? Research Design Connections. Retrieved July 6, 2007 from http://www. researchdesignconnections.com/issues/cgibin/udt/im.display.printable?client_id=rese archdesignconnections&story_id=397 33 Joseph, A. (July 2006). 34 Joseph, A. (July 2006). 35 Joseph, A. (July 2006). 36 Joseph, A. (July 2006). 37 Rogers, J.L. (Winter 2006). 38 Rogers, J.L. (Winter 2006). 39 Rogers, J.L. (Winter 2006). 40 Guidelines for control of Legionella in ornamental water features. (2005). Legionella Risk Management, Inc. Retrieved August 16, 2007 from http:// www.legionellarm.com/guidelines/ ControlofLegionellainWaterFeatures.pdf 41 Joseph, A. (July 2006). 42 Guidelines for control of Legionella in ornamental water features. (2005). 31
Chiarello, L., and the Healthcare Infection Control Practices Advisory Committee. (June 2007). 2007 Guidelines for isolation precautions: Preventing transmission of infectious agents in healthcare settings, pp57-8. The Centers for Disease Control and Prevention. Available from http:// www.cdc.gov/ncidod/dhqp/gl_isolation. html 49 Reducing MRSA infections: Staying one step ahead. (July 26, 2007). 50 Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., and the Healthcare Infection Control Practices Advisory Committee. (June 2007), p43. 51 McCaughey, B. (2006), p2. 52 McCaughey, B. (2006), p6. 53 Reducing MRSA infections: Staying one step ahead. (July 26, 2007). 54 Van Enk, R.A. (September 2006). Modern hospital design for infection control. Healthcare Design. Retrieved from http:// www.healthcaredesignmagazine.com/ME2/ dirmod.asp?sid=&nm=&type=Publishing &mod=Publications%3A%3AArticle&mi d=8F3A7027421841978F18BE895F87F7 91&tier=4&id=0EF07759107C4E56BDB E79ABE44DA446 55 Safety. (2007). National Health Service Confederation. Retrieved January 19, 2007 from http://www.nhsconfed.org/ specialist/specialist-1644.cfm
HUMANS 43
Joseph, A. (July 2006). McCaughey, B. (2006), p3. 45 Hand hygiene in healthcare settings – Core. (2002). The Centers for Disease Control and Prevention, slides 11 & 13. Retrieved August 6, 2007 from http:// www.cdc.gov/handhygiene/download/ hand_hygiene_core.ppt 46 Hand hygiene in healthcare settings – Core. (2002), slide 14. 47 The Sound of two hands washing: improving hand hygiene. (October 4, 2006). Institute for Healthcare Improvement. Retrieved from http:// www.ihi.org/IHI/Topics/CriticalCare/ IntensiveCare/ImprovementStories/ FSSoundofTwoHandsWashing.htm 48 Siegel, J.D., Rhinehart, E., Jackson, M.,
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Infection Control in Healthcare Environments Prepared by
Steelcase WorkSpace Futures Explorations Healthcare Research Team Item # 07-0001013 Š 2007 Steelcase Inc.
s
Joyce Bromberg, Director Researchers: Caroline Kelly Melanie Redman Ritu Bajaj
printed on recycled paper