Texas Association of Healthcare Facilities Management December 12, 2014

Transcription

1 Texas Association of Healthcare Facilities Management December 12, 2014

2 Toronto, Canada Seven Oaks Home for the Aged Opened in 1989 Outbreak began 9/25/05

3 Sick: 68 residents 8 employees 3 visitors Dead: 6 Hospitalized: 30 residents

4 Sick: 70 residents 12 employees 2 visitors Dead: 10 Hospitalized: 40 residents Testing underway to determine cause we are confident this outbreak is under control, says David McKeown, Toronto s Medical Officer of Health

5 Sick: 70 residents 13 employees 5 visitors Dead: 16 Hospitalized: 34 residents 2 employees 2 visitors Autopsy specimens: Legionella pneumophila it appears that transmission of the illness has subsided, says McKeown Staff and residents: preventive antibiotics Investigation to identify source HVAC shut down

6 Sick: 70 residents 18 employees 9 visitors Dead: 17 Hospitalized: 35 residents 2 employees 5 visitors Potable water shut down

7 Sick: 71 residents 23 employees 14 visitors Dead: 17 Hospitalized: Not available Potable water system safe Exhaust returned to service

8 Sick: 127 total 71 residents 23 employees 14 visitors 2 neighbors Dead: 20 Hospitalized: Not available Source: roof cooling tower (tower shut down 10/6/05) Tower Legionella matched patient Legionella Air intake near cooling tower

9 Major Site of Infection Estimated Number of Infections (2011) Healthcare Associated Infections 721,800 (all) Pneumonia 157,500 Gastrointestinal Illness 123,100 Urinary Tract Infection 93,300 Primary Bloodstream Infections 71,900 Surgical Site Infections 157,500 Other infections 118,500

10 1 in 25 hospital patients has 1 or more HAI 75,000 patients with HAIs died Many states require hospitals to post their infection rates online

11 The Joint Commission Guidelines for the Design and Construction of Health Care Facilities CDC Guidelines on Environmental Infection Control in Healthcare Facilities Assoc. for Professionals in Infection Control and Epidemiology (APIC)

12 Standard Description 2014 Non Compliance 2013 Non Compliance EC Manage utility risks (ventilation) 53% 47% LS Means of egress (corridor clutter) 52% 52% EC Safe environment (O2 cylinders; 51% 39% ventilation) EC Maintain fire protection 50% 45% equipment IC Infection control 50% 46%

13 Breathing easy: The role of HVAC systems in preserving patient safety EC Specific concerns: Directing airflow Managing outside air Reliable filtration Keeping systems energy efficient while minimizing risk

14 Written inventory of equipment Inspection, maintenance, and testing Including infection control system components (DI) Minimizes biological agents in water systems (DI) Appropriate pressure relationships and air exchange rates (DI) Written procedures for disruptions

15 100 million 500 million 1 billion 2 billion

16 SARS Epidemic Guangdong Province, China A F,G F,G Canada 18 HCW 11 close contacts Hong Kong SAR 95 HCW A H,J H,J B A Hotel M Hong Kong C,D,E K I, L,M K Ireland 0 HCW >100 close contacts B C,D,E I,L,M U.S.A. Vietnam Singapore 1 HCW 37 HCW 34 HCW 21 close contacts 37 close contacts [

17 27 Fungal outbreaks from construction Burn, trauma, transplant, oncology, respiratory failure, renal disease, premature infants, etc. 234 total infections At least 117 deaths ( Construction related Nosocomial Infections in Patients in Healthcare Facilities, Canada Communicable Disease Report, Volume 27S2, 7/2001.)

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19 Fungi: 1 to 15 microns Aspergillus spp.: 3.5 microns Penicillium spp.: 3.3 microns Stachybotrys spp.: 5.65 microns Bacteria: 0.23 to 1.25 microns Viruses: <0.23 microns [Kowalski et al. 1999]

20 Construction Project Type Patient Risk Group A B C D Low I II II III/IV Medium I II III IV High I II III/IV IV Highest II III/IV III/IV IV Adapted from ICRA Matrix developed by J. Bartley, ECSI, Beverly Hills, MI; used with permission

21 Dust control Negative pressure of work zone Containment barriers

22 Pressure differential meter Balometer (e.g. Shortridge Flowhood) Laser particle counter Ultrafine particle counter Moisture detection instruments Microbiologic air sampling equipment Microbiologic swab sampling kit Aerosol generator and light scattering photometer Ventilation and air exchange formulas

23 Commissioning Determination of existing conditions Verification of system performance Epidemiology evaluation

24 Know what question(s) you want answered Know how to interpret the results Develop a sampling plan agreed by all involved

25 Daily Weekly Monthly Annually Right before our expected TJC survey Never

26 Isolation rooms Protective environment rooms Pharmaceutical compounding areas Building pressurization Construction work zones Laboratories More [Photo provided by The Energy Conservatory]

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28 Pressurization log for AII room missing signatures for multiple days this month Multiple entries on log show positive pressure readings Your policy says AII room pressurization checked daily Nearby nurse does not know how to operate digital pressure manometer display

29 Continuous readouts of all airborne particles Rank order comparisons among clean, dirty, and outdoor areas (CDC)

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31 Example Particle Counts Outdoors (clear, spring day) = 10,000 p/l Patient wing corridor = 1,000 p/l HEPA filtered OR = 100 p/l p/l = particles greater than 0.5 microns in diameter per liter of air

32 Concentration Total Particles Aspergillus Time

33 1. Outdoor particle counts impact indoor particle counts.

34 2. Outdoor particle counts should be measured when indoor particle counts are measured.

35 3. Indoor particle counts should generally be less than outdoor particle counts.

36 4. Particle counts measured during construction should generally be less than or equivalent to preconstruction (background) particle counts. (Must also consider outdoor particle counts).

37 5. Post-construction (clearance) particle counts should generally be less than or equivalent to preconstruction (background) particle counts. (Must also consider outdoor particle counts).

38 Inpatient and outpatient care Built stories plus basement 235,000 square feet AHUs: MERV 8 (35%) + HEPA (99.99%)

39 Mean Median Min Max Std Dev Outdoors (n=2) 11,930 7,531 1,716 78,537 14,935 1st floor (Ambulatory Care; n=18) , nd floor (Inpatient; n= 21) , rd floor (Surgery and ICU; n=15) , th floor (BMT; n=12) , [Reference: Old LT, Air Quality Challenges Unique to Healthcare: Perspectives from the Safety Office. ASHE 2010 Annual Conference]

40 Mean Median Min Max Std Dev Outdoors (n=2) 11,930 7,531 1,716 78,537 14,935 Corridors, lobbies, nurses stations (n=43) Patient treatment and inpatient rooms (n=12) , Surgery (n=4) BMT patient rooms (terminal HEPA; n=3) [Reference: Old LT, Air Quality Challenges Unique to Healthcare: Perspectives from the Safety Office. ASHE 2010 Annual Conference]

41 Particle counters may be used to evaluate barrier integrity. [CDC Environmental Infection Control Guidelines]

42 Location / Air Handling Unit Day 1 Day 2 Day 3 AHU P before filters 5,670 14,600 AHU P after HEPA filters 0 0 AHU 2 before filters 2,490 4,180 AHU 2 after HEPA filters 0 0 AHU 5 before filters 10,200 4,020 AHU 5 after HEPA filters 0 0 AHU 6 before filters 9,000 7,540 AHU 6 after HEPA filters 0 0 Outdoors 44,000 25,400 16,300 [ m particles per cubic centimeter of air]

43 100 2,000 cfm 2 3 filters (including 1 HEPA filter) Proper filter installation/performance Use particle counter for quick assessment of filtration performance

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45 Day ΔP Sign. Day ΔP Sign. 6/ LO 6/ LO 6/ LO 6/ PM 6/ LO 6/ LO 6/ LO 6/ LO 6/ MH 6/ LO 6/6 6/13 6/7 6/14

46 Use an ultrafine particle counter Significant increases in particle counts during use of cauterizing equipment

47 Situation Room Location Particle Count Range Average Particle Count Patient prep OR perimeter Surgery w/o cautery Surgery w/ cautery Behind surgeon OR perimeter Behind surgeon OR perimeter 67-5, Behind surgeon 46-7,

48 ACH = (CFM * 60) / (Work zone volume) For example: 10,000 cubic feet work zone 1,000 cfm exhaust fan ACH = (1000 cfm * 60) / (10,000 cf) = 6 ACH

49 C 2 = (C 1 ) e [ Q(t2 t1)/v] C 2 = Concentration at time t 2 C 1 = Concentration at time t 1 Q = Room ventilation rate (cfm) t 1 = time (minutes) t 2 = time (minutes) V = room volume (cubic feet) [Industrial Ventilation Manual, 21 st ed.]

50 % of Original Time (minutes) Concentration

51 Thermal imaging cameras and moisture meters help detect hidden moisture damage

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53 Fungi: 1 to 15 microns Aspergillus spp.: 3.5 microns Penicillium spp.: 3.3 microns Stachybotrys spp.: 5.65 microns Bacteria: 0.23 to 1.25 microns Viruses: <0.23 microns [Kowalski et al. 1999]

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55 [Kowalski et al. 1999]

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57 Based on Institute of Environmental Sciences and Technology Standard IEST RP CC034.2: HEPA and ULPA Filter Leak Tests PAO aerosol generator Aerosol photometer Passing rate = no greater than 0.01% leakage

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61 Outbreak investigation Research Monitor potentially hazardous condition Bioterrorism Validate successful abatement Evaluate change in IC practices

62 Type and concentration of microorganism Type of sampler Number of samples Sampling time Analytical methods Shipping samples Timeframe

63 Lack of exposure standards Lack of standard sampling protocols Variable disease susceptibility High risk patient issues Unknown incubation period for Aspergillus Variations in sampling equipment

64 Remove wet absorbent items (e.g., furniture, wallboard, carpeting, etc.) if they cannot be cleaned and dried within 72 hours (i.e., moisture content <20% as determined by moisture meter readings).

65 You receive a call from a nursing unit that an isolation room is in alarm. There is a TB patient in the room with active TB disease (coughing continually). You are a small hospital and only have a limited number of isolation rooms. All other rooms have potentially infectious patients in them. You discover the roof top exhaust fan serving the room has failed. It will take 48 hours to receive parts and repair the fan.

66 Leo Old EnSafe Inc (office) (cell)

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