HVAC SYSTEM & INFECTION

CONTROL

Presentation By
Dr. Raju Sivasamy
VP - Medical
www.simshospitals.com SIMS Hospital, Chennai
© 2017. SIMS Hospital.
"A functional design can promote skill,
economy, conveniences, and comforts; a non-
functional design can impede activities of all
types, detract from quality of care, and raise
costs to intolerable levels."
 Objective
• Prevention of infection from the
environment in vulnerable patient
–Transplant patient
–Surgical patients (prolonged surgery
with lot of dead tissue)
–Cancer patients
–HIV (Immuno compromised Patient)
• Prevent cross infections between patients
 HVAC NEED
• Good ambience and comfort

• Prevent excess heat or cold- helps maintain

tissue vitality

• Prevent infection

• Better space utilisation

 Infection Control
Structural Functional

No hospital is ever structurally perfect!!!!

 Ventilation Pattern
Air Flow

• Wards- Opening and closing of door

• Isolation patients- Large windows facing each

other with continuous flow

Air exchange of 12/ hr , (more than 6 at least)

• OT & Other sterile zone- Laminar flow

 Design – Specialized Planning
Consideration
It is complex and needs coordination with many team
members from outside OT
– Transport of people and equipment

– Stores

– Cleaning and Sterilization

– Bio medical, maintenance

– Records

– Disposal
 4 Zones Preferable

Disposal zone

Aseptic zone- OR and Sterile corridor area Most sterile

atmosphere
CLEAN / Semi sterile
Pre op/ service rooms/Recovery/Staff
Lounge/ICU

Protective Zone
Reception/Trolley
exchange/rooms/equipment/Change room
General Scheme
 Work Flow

Dirty exit

RECEPTION
Patient
RECOVERY

Clean supply
Change rooms
Nurse office
Autoclave
Store

Staff
 Trolley Exchange Area

Opens from protected into clean side in holding area

 Scrub Area
Elbow / Foot or Electronic
Operation Room

• Sliding door

• Electronic – 2 stop

Half and full open

Dimension and Paint

• Size 20’ x 20’ x10’

• Modular

• If glass window one side

only

• Paint - Anti bacterial

• Peroxide resistant
 Laminar Flow- Plenum
Positive Pressure

8’x8’
Minimum8’x6’

• OR must have minimum

15 pascal =1.5 mm H2O
• 10 pascal – Scrub area
and sterile corridoor
• 5 pascals – Change
room

As per ISO 14644 standard

 Filter – HEPA pore size 0.3 µ
Area should be 8’x6’ minimum

HTM Standard

Particle size 0.5 µ Class

100 at 6” below the filter

Class 1000 at table

Class 10000 at periphery

(Health Technical
Memorandum)
 Temperature and Humidity

• 21±3 C for Joint

replacement 18C

• Humidity 40-60%
Pass Box
 Disposal Area

• Dirty Corridor

• Wash area

• Disposal storage area

Ventilation Management

20
 Bed Space
• 150 – 200 square feet per open bed with 8 feet
in between beds.

• 225 – 250 square feet per bed if in a single

room.

• Single room – with an anteroom (20 feet) for

hand washing, gowning etc

• Beds - adjustable, no head board, side rails and

with wheels.
 Bed Strength in ICU

• Ideally 8 to 12 beds

• Larger areas – difficult to administer and smaller areas

not being cost effective

• 3 to 5 beds per 100 hospital beds for a level iii icu / 2

to 20% of the total number of hospital beds

• 1 Isolation bed for every 10 ICU beds

 Design to Increase Hand Washing
Conveniently located basin in single room
Alcohol-
based gel Soap
dispenser dispenser

Automatic faucet
(no touch)

Hand wash basins

and hand rub
dispensers should
be close to staff
movement paths,
visually prominent,
Easy-to-clean
near care point
basin counter
(continuous
impervious
surface)
 Positive Pressure Rooms

• Vulnerable patients- Transplant etc

• 10% more supply from dedicated AHU

• 12 air changes/ hr

To prevent infection to the vulnerable patients

 Case Scenario

• 24 yrs old sputum positive TB patient is

referred to our new hospital with coughing
out blood.

• How will you protect the patients and

yourself?
 Room Ventilation

• Negative pressure room with exhaust to

outdoor or HEPA filters

• Room in the topmost floor with at least 2

windows for cross ventilation

• Good sunlight
 Airborne Particles

• 1- 5 micron size

• Remain in air for hours

• N 95 mask when entering the room

• Negative pressure room with 12 air exchanges

and exhaust well away from other areas

TB, Chicken pox, Measles

When infections cluster….
 Causes of Ventilation Deficiencies
• Plugged Filters
• Plugged Temperature Control Coils
• Duct Leakage
• Dust on Fan Blades
• Fan Belt Slippage
• Uncalibrated Control Equipment
– Digital Controls
– Pneumatic Controls
• Plugged sensors

29
HVAC Problem

30
31
 To check

• Construction work- Filamentous fungi -

Aspergillus

• Persistent moisture- Leaky pipes, water borne

bacteria, yeast and molds

• AC unit- Water stagnation near AC drains,

Fungus near chiller pipes, blowers, exhaust etc
 Cleaning Method

• Fungus has to be scrapped

• Sun exposure

• Bleach or chlorine is the sine qua non of

treatment

Maintenance of dry environment.

 Incidence of Healthcare Associated
Infections (HAI)
•1 in every 25 inpatients has at least 1 HAI

•Most common: Pneumonia and surgical site infection

Direct costs associated with HAI: $28.4-$45 Billion (Scott, CDC Paper, 2012)

Incidence associated with construction unknown; multiple outbreak papers published

Major site of Infection

• Pneumonia
• Gastrointestinal Illness
• Urine track infection
• Surgical site infection

34
 Factors Involved in the Spread of
Infectious Diseases

• Droplet nuclei transmission dynamics

• Nature of dust levels

• Health & condition of individual’s

nasopharyngeal mucosal lining

• Population density in a particular location

• Ventilation of the location

 Standard Precautions Against
Disease Transmission
• Early identification of microbes
• Development of appropriate SOPs
• Use of PPE including:
– Masks & gloves
– Disinfection strategies
– Vaccination
– Appropriate ventilation design

36
 Organisms Associated with Airborne
Transmission
Fungi Bacteria Viruses
Numerous Aspergillus spp. M. Tuberculosis Measles virus
reports in Mucorales Varicella-zoster
HCF virus
Atypical, Acremonium Acinetobacter Smallpox virus
occasional spp. spp. Influenza
reports Fusarium spp Bacillus spp. viruses
Pseudoallesche Brucella spp. Respiratory
ria boydii Staphylococcus syncytial
Scedosprorium aureus virus
spp. Group A. Adenoviruses
Sporothrix Streptococcus Norwalk-like
cyanescens virus
Airborne Coccidioides Coxiella burnetti Hantaviruses
in nature; immitis (Q Lassa virus
airborne Cryptococcus fever) Marburg virus
transmissi spp. Ebola virus
on in HCF Histoplasma
not Crimean-Congo
capsulatum Virus
described

CDC Guideline for Environmental Infection Control Guidelines 2003 37

 How far can Airborne Bacteria & Viruses Travel?
Large/Small Droplets

Droplet Nuclei
1. Coughing 1-5 feet
160+ feet
2. Sneezing 8-15 feet
160+ feet
3. Singing, Talking 1-3 feet
160+ feet
4. Mouth Breathing 1-3 feet
160+ feet
5. *Diarrhea 5 feet+
160+ feet

*As a Result of Toilet Water Aerosolization and

Mechanical Fan Dispersion into outdoor air

38
 Stages of Infectious Droplets & Droplet Nuclei

1. Mucus/water 2. Mucus/water 3. Mucus/water

encased by the coating starts to coating has totally
infector or by toilet evaporate. These evaporated coating
water. These will travel 3-5 feet the viron particles.
quickly fall to the before falling to the These are Droplet
ground after ground. These Nuclei which are so
traveling up to 1-3 droplets can microscopic they
feet. become droplet can float in the air.
nuclei. 39
Infectious Droplets & Droplet
Nuclei Travel Lengths

40
 Droplet Nuclei Travel Within Buildings

In hospitals re-circulated air is filtered > 90% 41

 Low Indoor Humidity Increases Droplet
Nuclei Levels (winter)

Viruses Evaporate faster in Low Humidity levels thus creating More

Droplet Nuclei.

Low humidity allows droplet nuclei to stay airborne longer as the

droplets do not absorb water weight which would cause them to
fall to the ground.

Indoor Air currents both created by HVAC systems and people

movement assure that droplet nuclei will remain airborne
Indefinitely.

This allows HVAC systems to remove and redistribute droplet

nuclei throughout the building to infect more occupants.
42
 Ventilation Specifications
Protective Environment
Airborne Infection
Specifications (PE) (Neutropenic
Isolation (AII) (TB pts)
patients)

Air pressure Negative Positive

> 6 ACH for existing

areas; > 12 ACH for new
Room air changes > 12 ACH
construction or
renovation
Sealed Yes Yes

Filtration on supply air 90% (dust-spot testing) 99.97% (HEPA)

Recirculation No Yes
 Ultraviolet Germicidal Irradiation (UVGI)

• Used as supplement or back-up to dilution

ventilation
• Does NOT provide negative pressure
• Requires maintenance, esp. cleaning bulbs
• Not effective at high humidity (>70%)
• Occupational exposure limits: eye & skin

44
TB Outpatient Unit

45
OT Cleaning Protocol
 VIRKON

Oxone (Potassium Peroxymonosulphate)

Sodium Dodecyl benzene sulfonate
Sulphamic acid

Less effective against spores and Fungi

 MIKROBAC
Product properties

• broad spectrum of effect

• aldehyde-free

Composition Active ingredients:

Benzyl-C12-18- alkyl dimethyl ammonium chlorides 199 mg/g,
N-(3-aminopropyl)-N dodecylpropane-1,3-diamine 50 mg/g.
• bactericidal
• yeasticidal
• tuberculocidal
• virucidal against enveloped viruses (incl. HBV, HIV, HCV) MNV adeno-, polyoma- and Rota
virus

Mikrobac forte is supplied as a concentrate. Completely wet the parts of medical devices and other
washable surfaces (e.g. floors) to be disinfected with a sufficient amount of solution.

maintenance disinfection of hard surfaces: 0.5% 1 hour exposure time

 Not suitable for the disinfection of invasive medical devices. Use disinfectants safely. Always read the
label and product information before use.
 BACILLOL

– PROPAN-1-OL
– PROPAN-2-OL
– ETHANOL
Cleaning by….Spray and wipe
• Bactericidal
• Yeasticidal
• Tuberculocidal
• Virucidal against enveloped viruses (incl. HBV, HIV, HCV) MNV adeno-,
polyoma- and Rota virus
 Theatre hygiene
What we should not do in OT
THANK YOU

www.simshospitals.com

© 2017. SIMS Hospitals. 51