ARCHITECTURE DESIGN CONSIDERATIONS OF INFECTION CONTROL IN HEALTHCARE FACILITIES (ISOLATION ROOMS)

Dr. Zeyad Bin Abdullah Al Swaidan CEO of Medical Cities Projects Ministry of Health, Saudi Arabia Chairman of Saudi Healthcare Architects The saudi Umran, Saudi Arabia Member in the Executive Committee and the Official Representative of KSA to the (UIA/PHG) The Saudi Umran Society Saudi HealthCare Architects (SHCA)

Preamble The good design and planning in hospitals and health facilities has significant role in reducing infection, through many architectural strategies in hospitals various departments like operations, central sterilization, and ICU etc, that will be explained in detail later.

A C C E S S T O H O S P I TA L S B E C O M E D A N G E R O U S A N D W E S H O U L D H AV E P R E V E N T I O N. In 2002 as per (Healthcare Associated Infections HAIS ) the infections in the US estimated with 1.7 million And the deaths were estimated with 98.987 in US hospitals R. Monina Klevens, al (2002), Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, Public Health Reports / March - April 2007 / Volume-122

A C Q U I R I N G I N F E C T I O N I N H E A LT H C A R E B U I L D I N G MEDICAL STAFF TO PATIENTS PATIENTS TO MEDICAL STAFF PATIENTS TO PATIENTS

A C Q U I R I N G I N F E C T I O N I N H E A LT H C A R E B U I L D I N G AIR WATER CONTACT

ARCHITECTURAL SOLUTIONS TO REDUCE INFECTION AT HOSPITALS AND HEALTH FACILITIES

SEPARATION BETWEEN OUT PATIENTS (OP) AND INPATIENTS (IP)

I N PAT I E N T F L O O R D E S I G N Inpatients Outpatients مدينة الملك فيصل الطبية

PLANNING AND DESIGN OF INPATIENTS FLOORS

I N PAT I E N T F L O O R D E S I G N» The floor is designed to be penetrated to access another floor using the dead end concept.

I N PAT I E N T F L O O R D E S I G N King Faisal Medical City

I N PAT I E N T F L O O R D E S I G N King Abdullah Medical City

I N PAT I E N T F L O O R D E S I G N Al Iman Hospital

I N PAT I E N T F L O O R D E S I G N» Hygiene rooms should be decentralized distributed, as each department has its own hygiene room, in order to infection control from department to another through hygiene tools

I N PAT I E N T F L O O R D E S I G N King Faisal Medical City

FUNCTIONAL INTERRELATIONSHIP BETWEEN DEPARTMENTS

F U N C T I O N A L I N T E R R E L AT I O N S H I P B E T W E E N D E PA R T M E N T S - As shown in the figure there is no necessary functional interrelationship between laboratory, and the various hospital departments, that it deals with infectious materials (clinical samples, bacteria, viruses, and fungi) which may be dangerous concerning patients samples, sharp instruments, and examination tools - So it has to be totally separated, and make the critical departments like operation, ICUs, away from the laboratory in order to avoid infection through air. HEALTHCARE FACILITIES

F U N C T I O N A L I N T E R R E L AT I O N S H I P B E T W E E N D E PA R T M E N T S Reduce walking distances and performance speed from and to laboratory through pneumatic tube system

F U N C T I O N A L I N T E R R E L AT I O N S H I P B E T W E E N D E PA R T M E N T S ICU Operation Lab King Faisal Medical City

F U N C T I O N A L I N T E R R E L AT I O N S H I P B E T W E E N D E PA R T M E N T S ICU ICU ICU ICU LAB Operations King Abdullah Medical City

F U N C T I O N A L I N T E R R E L AT I O N S H I P B E T W E E N D E PA R T M E N T S ICU LAB Operations King Khaled Medical City

SEPARATION BETWEEN CLEAN AND NON CLEAN CORRIDORS AT HOSPITAL VARIOUS DEPARTMENTS

O P E R AT I N G D E PA R T M E N T Sterilized materials unsterilized materials King Faisal Medical City

O P E R AT I N G D E PA R T M E N T / C S S D Unsterilized Operation Sterilized Central Sterilization King Faisal Medical City

O P E R AT I N G D E PA R T M E N T الموادالغير النظيفة الموادالمعقمة King Abdullah Medical City

O P E R AT I N G D E PA R T M E N T / C S S D Unsterilize d operation Central Sterilization Sterilized King Abdullah Medical City

O P E R AT I N G D E PA R T M E N T O P E R AT I O N Unsterilized materials sterilized materials King Khaled Medical City

O P E R AT I N G D E PA R T M E N T / C S S D Unsterilized operation Sterilized Central Sterilization King Khaled Medical City

I N PAT I E N T / ICU Specific Corridors for Services King Faisal Medical City

I N PAT I E N T / ICU Non clean clean Service Corridor King Faisal Medical City

CENTRAL STERILIZATION DEPARTMENT.

C S S D In order to ensure infection control through air or by touch, materials have to pass three different stages

C S S D Non clean area Clean Area Sterilized area King Faisal Medical City

C S S D Non clean area Sterilized area Clean Area King Abdullah Medical City

PROVIDING HAND WASHING SINKS FOR INFECTION CONTROL THROUGH THE MEDICAL STAFF

I N PAT I E N T

R A D I O L O G Y D E PA R T M E N T» All the radiology rooms like general rooms, fluoroscopy, ultrasound, mammography, CT Scan etc must be provided with washing hands sinks for the staff for infection control

O U T PAT I E N T C L I N I C S» All outpatients clinics (dental general specific) should be provided with hand washing sinks for infection control

E M E R G E N C Y» All monitoring, examination, and recovery rooms should be provided with hand washing sinks for infection control through medical staff

TYPES OF ISOLATION ROOMS.

T Y P E S O F I S O L AT I O N R O O M S. 1 Airborne infection isolation (AII) Tuberculosis Smallpox,varicella Measles 2 Protective environment (PE) Cell transplant Undergoing an allogeneic or autologous bone marrow

T Y P E S O F I S O L AT I O N R O O M S. 3 Combination Airborne infection isolation/protective environment (AII/PE) (patients undergoing allogeneic or autologous bone marrow/stem cell transplants) who require a protective environment and have an airborne infectious disease. Convertible isolation rooms 4 Not allowed Room can converted from AII to PE by ASHRAE standard 170

AIRBORNE INFECTION ISOLATION(AII)

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I ) Number» for general hospital at least one AII room shall be provided in the hospital and in any other specific areas requiring AII room.» As HADD standard should at least 20% of patient rooms to be isolation rooms.

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Location» AII rooms shall be located in individual nursing unit or grouped as a separate isolation nursing unit.

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Requirements each patient room shall contain only one bed

EVIDENCE-BASED DESIGN Large, Single Bed & Universal Room: SINGLE OCCUPANCY PATIENT ROOM WITH FAMILY AREA Lowers hospital acquired infections (HAIs) Decreases noise and stress Improves patient privacy/ confidentiality Facilitates family support Improves staff to patient communications Improves patient satisfaction Universal Room: Flexibility for future changes in room type Decreases length of stay

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Requirements (a) Patient rooms shall have a minimum clear floor area of 11.15 square meters (b) The dimensions and arrangement of rooms shall be such that there is a minimum clear dimension of 3 feet (91.44 centimeters) between the sides and foot of the bed and any wall or any other fixed obstruction. bed size space is 2.43 m

PATIENT ROOM DESIGN ZONING 1 Caregiver Zone 2 Decentralized Workstations Patient Zone Visual Access to Healthcare Team 3 3 One on One Connectivity Daylight Family Zone 4 1 2 4 Designated space in the room Sleep accommodations Hygiene Zone Location of bathroom Accessibility Wet Room

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I ) D E S I G N» Caregiver Zone Decentralized Workstations» Patient Zone Visual Access to Healthcare Team One on One Connectivity Daylight» Family Zone Designated space in the room Sleep accommodations» Hygiene Zone Location of bathroom Accessibility Wet Room

OUTBOARD/FOOTWALL PATIENT ROOMS Creates family space near the patient head of bed Caregivers have immediate access to the patient upon entry to the room Opportunity for decentralized workstations; Distinct zones for caregiver, patient, and family Provides an opportunity for a server on the corridor wall Caregiver, patient, and family have equal access to the bathroom Room: 26 sm Toilet: 5 sm Total: 31 sm

OUTBOARD/HEADWALL PATIENT ROOMS Equipment, family, and bassinet may limit access to the bathroom Family zone is more distant from the patient Caregivers have immediate access to the patient upon entry to the room Opportunity exists for decentralized workstation and server on the corridor wall Room: 26 sm Toilet: 5 sm Total: 31 sm

INBOARD/FOOTWALL PATIENT ROOMS Inefficient space at entry to the room Opportunity for larger windows Limited opportunity for visibility of the patient unless room door is open Room size is larger to achieve 13-foot headwall for ICU level of care Family zone is compromised Room: 29 sm Toilet: 5 sm Total: 34 sm

INBOARD/HEADWALL PATIENT ROOMS No or minimal visibility of the patient from the hallway Caregiver zone next to the head of the bed is compromised To upgrade a room to ICU level of care, the family zone is compromised Non-usable space exists at the entry to the room Lost opportunity for a patient server Opportunity for larger windows Room: 29 sm Toilet: 5 sm Total: 34 sm

MIDBOARD PATIENT ROOMS Extends the length of the patient unit, so caregiver travel is increased In critical situations when the bed is pulled away from the wall to permit staff to work, the bed and bathroom door limit movement There is no opportunity for a standardized room Room: 26 sm Toilet: 5 sm Total: 31 sm

UNIVERSAL SOLUTION PATIENT ROOMS Creates family space near the patient head of bed Caregivers have immediate access to the patient upon entry to the room Opportunity for decentralized workstations; Distinct zones for caregiver, patient, and family Provides an opportunity for a server on the corridor wall Room: 29 sm Toilet: 5 sm Total: 34 sm 67

INTERNATIONAL SOLUTION PATIENT ROOMS View of patient from decentralized caregiver work station Increased privacy and minimal visibility of the patient from the hallway Opportunity for larger windows Extra space exists at the vestibule entry to the room. Lost opportunity for a pass-thru patient server Room: 32 sm Toilet: 5 sm Total: 37 sm 68

CONVENIENT LOCATION OF SUPPORT TO PATIENT EVIDENCE-BASED DESIGN Nurse views : Reduces staff walking Increase in patient care activities More staff interaction with family (patient satisfaction) Reduce HAIs Shorter response time to patient needs Supports common nursing ratios ALLOWS CONSTANT OBSERVATION OF PATIENT PATIENT VIEWS NURSE VIEWS

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Requirements Each patient room shall be provided with natural light by means of a window to the outside. A window in each patient room, the views from it, and the diurnal cycle of natural light afforded by it are important for the psychological wellbeing of all patients, as well as for meeting fire safety and building code requirements. When designed to be operable, a window in the patient room may also be important for continued use of The area in the event of mechanical ventilation system failure.

WINDOW EVIDENCE-BASED DESIGN Views to Nature Recover faster Less anxiety & stress Lessens dependency on pain medications Staff experiences less stress

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Window treatments and privacy curtains. (a) Window treatments shall be selected for ease of cleaning. Smooth surfaced, easy-to-clean, wipeable, nonpleated window treatments shall be used. (b) Fabric drapes and curtains shall not be used for window treatments. (c) Use of fabric privacy curtains shall be permitted if they are washable. wipeable fabric with a smooth surface is preferable.

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Window treatments (a) Blinds, sheers, or other patient-controlled window treatments shall be provided within patient rooms to control light levels and glare. (b) Window treatments shall not compromise patient safety and shall be easy for patients and staff to operate.

LIGHTING AND TEMPATURE CONTROL AT PATIENT BEDSIDE EVIDENCE-BASED DESIGN Ergonomics: Patient control of environment promotes self-healing Improves privacy Increase comfort during medical procedures and hospital stays

TOTAL CONTROL

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Requirements hand-washing station

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )

TOUCHLESS FAUCET WITH TEMPATURE CONTROL EVIDENCE-BASED DESIGN Improve Placement and Number of Hand-washing Sinks: Lowers HAIs Improves quality of care Sink is conveniently located in patient room Strategic locations of sinks throughout patient unit HANDWASHING COMPLIANCE INDICATOR LIGHT

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Requirements Separate room with a toilet, bathtub, or shower and handwashing station shall be provided in each airborne infection isolation room.

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Architecture details (a) AII room perimeter walls, ceiling, and floor, including penetrations, shall be sealed tightly so that air does not infiltrate the environment from the outside or from other spaces.

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Architecture details (b) Airborne infection isolation room(s) shall have self-closing devices on all room exit doors. (c) Doors shall have edge seals.

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» HVAC requirements. (1) Use of AII rooms for routine patient care during periods not requiring isolation precautions shall be permitted. Differential pressure requirements shall remain unchanged when the AII room is used for routine patient care. (2) Each AII room shall have a permanently installed visual mechanism to constantly monitor the pressure status of the room when occupied by patients with an airborne infectious disease. The mechanism shall monitor the pressure differential between the AII room and the corridor, whether or not there is an anteroom between the corridor and the AII room. (3) When an anteroom is provided, airflow shall be from the corridor into the anteroom and from the anteroom into the patient room.

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» An anteroom is not required. If an anteroom is part of the design concept it comply with the following. (a) The anteroom shall provide space for persons to don personal protective equipment before entering the patient room. (b) all doors to anteroom shall have self-closing devices.

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» Requirements area for gowning and storage shall be located either directly outside or inside the entry door to the patient room.

A I R B O R N E I N F E C T I O N I S O L AT I O N ( A I I )» When not required for patients with airborne infectious diseases, use of these rooms for normal acute care patients shall be permitted.

FINISHING MATERIALS

EVIDENCE-BASED DESIGN Finish Materials: Decreases room noise (fewer sleep disturbances) Lowes HAIs Reduces anxiety Promotes visual and acoustic privacy Calming and therapeutic A RICH AND VARIED PALETTE OF WOOD, STONE AND GLASS COMBINED WITH ELEMENTS FROM THE LOCAL VERNACULAR CREATE A WELCOMING, HEALING ENVIRONMENT AND BLUR THE LINES BETWEEN HOSPITAL AND HOSPITALTY

PROTECTIVE ENVIRONMENT(PE)

P R O T E C T I V E E N V I R O N M E N T ( P E )» Each PE room shall comply with requirements of AII rooms.» SPECIAL DESIGN ELEMENTS All service shall be cleanable Lighting shall have lenses and shall be sealed

COMBINATION AIRBORNE INFECTION ISOLATION/PROTECTIVE ENVIRONMENT (AII/PE)ROOM

C O M B I N AT I O N A I R B O R N E I N F E C T I O N I S O L AT I O N / P R O T E C T I V E E N V I R O N M E N T ( A I I / PE) R O O M» Number Hospital with PE rooms shall include at least one combination AII/PE room.

C O M B I N AT I O N A I R B O R N E I N F E C T I O N I S O L AT I O N / P R O T E C T I V E E N V I R O N M E N T ( A I I / PE) R O O M» Each combination AII/PE room shall comply with (PE) requirements.» Door from the (AII/PE) room directly to the corridor shall be permitted if the door equipped with door seals, including a door sweep seal.

C O M B I N AT I O N A I R B O R N E I N F E C T I O N I S O L AT I O N / P R O T E C T I V E E N V I R O N M E N T ( A I I / PE) R O O M» (AII/PE) room shall be equipped with anteroom that meet the following. Anteroom shall provide space for persons to done person protective equipment before entering the patient room. All doors to the anteroom shall have self closing devices.

R E F E R E N C E S