Transcript Guidelines for Prevention of TB

Guidelines for
Prevention of TB
Centers for Disease Control &
Prevention
Administrative Controls
 Infection
Control Policies and Procedures
 Risk Assessment/HCW
 Investigation
Screening
of HCW TST Conversions
TB Infection Control Policies &
Procedures 1
 High
index of suspicion for TB
 Prompt
triage
 Prompt
initiation of respiratory isolation



AII room under negative pressure (monitored)
UVGI and HEPA filtration as necessary
Limit movement of patient outside AII room
 Prompt
initiation of appropriate treatment
TB Infection Control Policies &
Procedures 2

Personal respiratory protection during exposure (N95 respirators)**fit testing req.

Limit employee and visitor exposure

Monitor clinical status by symptoms, laboratory and
CXR to ensure appropriate duration of airborne
precautions

Appropriate discharge to the community
Respiratory Protection
 The
ability to filter 1um in size with a filter
efficiency of >95%
 Fit test to insure face seal leakage of
<10%
 Making respirators available in at least
three sizes
 Reuse of Respirators
Why do we place patients in
isolation?
 Patients
who are immunocompromised
are placed in a “protective environment”
 Patients who have communicable
diseases are placed in “airborne infection
isolation”(AII)
 Patients who have both problems are put
in a room with a combination of controls
but always protect the staff, visitors and
other patients
Protective Environment
Protective Environment

Install central or point-of-use HEPA filters for
incoming air
 Maintain > 12 air changes per hour (ACH)
 Maintain positive pressure (> 2.5 Pa) in relation
to corridor
 Ensure that rooms are well sealed

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
Properly constructed windows, doors and intake and
exhaust ports
Maintain ceilings that are smooth and free of fissures,
open joints and crevices
Monitor for leakage
Airborne
Spread of
Smallpox
in the
Meschede
Hospital
Fenner. 1988.Fig. 4.9
AII Rooms
AII Rooms

Maintain continuous negative pressure (2.5 Pa)
in relation to the air pressure in the corridor and
ensure monitoring
 Ensure that rooms are well sealed
 Provide ventilation to ensure > 12 ACH for new
and renovated rooms and > 6 ACH for existing
rooms
 Direct exhaust air to the outside, away from air
intake and populated areas. If this is not
practical, air from the room can be recirculated
after passing through a HEPA filter, ?UVGI
Guidelines
2001 AIA “Guidelines for Design and Construction
of Hospital and Health Care Facilities - ????NEW
July 2006
 2003 CDC “Guidelines for Environmental Infection
Control in Health-Care Facilities”
 2004 JCAHO “Environment of Care – Essentials for
Health Care” Fourth Edition

What about an anteroom?
AIA Guidelines Section: 7.2.C Airborne Infectious
Isolation Rooms does not require anterooms. The
requirement for an anteroom was dropped in the
1996-97 edition of the Guidelines on the basis of a
study.
CDC Guideline: Does not require anteroom. For
Viral Hemorrhagic Fever and Smallpox, use AII
preferably with an anteroom – if not available use
industrial-grade HEPA filters to provide additional
ACH
JCAHO EC Standard: No reference to anterooms
ASHRAE’s Design Manual
(American Society of Heating, Refrigeration, and Air-conditioning
Engineers)
“HVAC Design Manual for
Hospitals and Clinics” 2003
Chapter 12: Room Design
On negative air pressure, as is required for Airborne Infectious
Isolation Rooms:
“…Through dilution, a 500 cubic feet anteroom (for example)
with an AVM of 50 cubic feet would experience a 90 percent
reduction in the transmission of contaminated air to and from
the isolation room. An anteroom is recommended as a means
of controlling airborne contaminant concentration via
containment and dilution of the migrating air.”
Why add an anteroom or airlock?

To provide a barrier against loss of
pressurization, and against entry/exit of
contaminated air into/out of isolation room when
the door to the airlock is opened
 To provide a controlled environment in which
protective garments can be donned without
contamination before entry into and exit out of
room
 To provide a controlled environment in which
equipment and supplies can be transferred fro
the isolation room without contaminating the
surrounding area
Anterooms
Creating Isolation Rooms
 Funding
by governmental agencies to
increase isolation capacity
 Many healthcare facilities have upgraded
or retrofitted existing negative pressure
isolation rooms
 Many healthcare facilities have purchased
“quick fixes” to increase isolation capacity
What’s out there?
Source Control – Local
Exhaust/Ventilation
What’s out there?
Source Control – Local
Exhaust/Ventilation
Disclaimer
 Following
are illustrations of actual
products available to healthcare facilities.
These are being used for educational
purposes only and are not meant to
endorse or criticize any individual
company or product. I have no financial
interest in any healthcare products.
What’s out there?
Key Points

There needs to be a clear understanding by all
of our goals when using isolation rooms – who
are we trying to protect and why.
 There needs to be a clear understanding of how
to appropriately use the equipment/resources
available to accomplish our goals.
 There needs to be a clear understanding of how
to minimize risks and maximize benefits to
patients and health care workers by using the
equipment/resources.
Key Points

A portable HEPA device will not create a
negative pressure room unless exhaust can be
discharged directly to the outside.
 Trying to connect a HEPA unit into a return duct
to create negative pressure would pressurize the
return duct and result in blowback into adjacent
rooms.
 If the unit is vented directly to the outside, return
air grilles must be sealed off – remember to take
into account the direction of flow into the
attached bathroom.
Key Points

All personnel must understand the use of these
devices – housekeeping, nursing.
 The portable air filtration device should not be
plugged into a power strip or extension cord.
Consider using an emergency power outlet.
 The HEPA unit must not create an obstruction
that would interfere with the proper delivery of
health care.
 The placement of the device needs to be predetermined to maximize air mixing for better air
scrubbing.
Key Points
 The
intake of the device should be placed
as close to the suspected source of
contamination.
 The device should be placed so that it
does not draw contaminated air past the
breathing zone of the caregiver.
 The air flowing out of the device must not
be directed in a way that would cause
discomfort to patients, visitors and staff.
Key Points

The air flow needs to be appropriate for the size
of the room to give the desired air exchanges
per hour. Consider a locked panel to prevent a
change in the air flow controls.
 Rooms in which the devices may be utilized
should be chosen beforehand ensuring that the
noise created is not disruptive to others.
 If the unit is ducted to the outside or into the
existing ventilation system, ensure that an
appropriately fitting interface is available.
Key Points

Place HEPA filters over exhaust grilles that
cannot be blocked.
 The use of the portable filtration devices should
be guided by a written policy that is facilityspecific with appropriate reviews and approvals
from infection control, administration, clinical and
facility engineering and the departments in
which the units will be used.
 Healthcare facilities should have a checklist
establishing the proper room use.
Key Points

Based on manufacturer’s recommendation and
any additional suggested protocol from facility
maintenance, a standard routine maintenance
procedure should be developed for the unit.
This should include:

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Changing of pre-filters. Be sure to include details of
PPE and proper disposal of filters.
Operational check for proper operation.
Interior cleaning of the unit
Changing of UV lamp
General electrical and mechanical safety check
Key Points
 Clinical
and/or facility engineering should
check the machine on a daily basis while
in use and measure the degree of
negative pressure between the room in
which it is situated and adjacent/affected
areas.
Key Points
 The
HEPA device must be leak tested and
certified. This should be done initially
when the equipment is received, at least
annually thereafter, and every time the
HEPA filter is changed. The frequency of
changing the HEPA filter should be based
upon manufacturer’s recommendation.
Key Points
 Policies
and procedures should specify
recommended PPE when performing
maintenance of the unit.
 Maintenance should be performed in an
area away from patient care.
Monitoring Negative Air Pressure

Pressure-measuring
devices
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Measure pressure at
the bottom of the door
Audible warning with a
time delay
Check continuous
monitoring devices at
least monthly using
smoke tubes
Smoke Test

Checked daily
 Hold 2 inches from
bottom of door
 If room air cleaners
are used they should
be running
 Door must be closed
UV Radiation
 Used
to supplement other engineering
controls
 Duct Irradiation


To recirculate air from an isolation room back
into the room.
Used in general use areas where air is
recirculated back into general ventilation
 Upper

Room Air Irradiation
Mounted on ceiling or wall
Effectiveness of UV Systems
 Intensity
of UVGI
 Duration of contact
 Relative humidity
UV Safety Issues
 Short
Term Exposure
 Education
 Labeling
 Maintenance
 Monitoring
Operating Room
 Place


bacterial filter on
patient endotracheal tube
Expiratory side of breathing circuit of a
• Ventilator
• Anesthesia equipment
 No



anterooms
Keep doors closed
Control traffic
If possible schedule case at end of day
Postoperative recovery
 Private
room
 Negative
air pressure
Autopsy rooms
 Negative


air Pressure
12 ACH
Increase ventilation if possible using HEPA –
filtered air or UVGI recirculation systems
 Exhausted
directly to outside
 Respiratory protection