Healthcare-Associated Infections _ ______________________________________________________________
10 patient safety tips for hospitals [100]. When the American Institute of Architects and the Facility Guidelines Institute (FGI) updated its Guidelines for Design and Construction of Hospi- tal and Health Care Facilities in 2006, they set single-bed private rooms as the minimum standard for new hospital construction [21]. This new standard was based on a literature review that showed, in part, that private rooms have been associated with lower rates of HAIs [101]. Among the benefits of single-patient rooms compared with multibed rooms are decreased risk of infection through contaminated surfaces (e.g., blood pres- sure cuffs, privacy curtains); availability of private bathrooms; greater ease of cleaning and decontamination; increased like- lihood of appropriate hand hygiene between rooms (rather than between beds within a single room); and decreased risk of prolonged hospital stays and patient transfers, all of which are risk factors for HAIs [101]. 2022 FGI guidelines maintain the single-bed per room standard, but allow for two beds when the necessity of this arrangement has been demonstrated and approved by the authority having jurisdiction [21]. The WHO guidelines on infection control refer to “archi- tectural segregation” according to risk [18]. Four areas of a healthcare facility are defined, with administrative sections con- sidered as low-risk areas; regular patient wards as moderate-risk areas; ICUs, burn units, or isolation units as high-risk areas; and operating rooms as very high-risk areas. The WHO and others have recommended that traffic flow should be limited in higher risk areas [18]. The type of sink and the placement of sinks throughout a healthcare facility have been of critical concern because of the substantial role of handwashing in reducing the transmission of infection. As a result, sinks have been placed within easy access in each patient room. However, it is unclear that such placement promotes better hand hygiene, with no long-term clinically significant improvement in handwashing found when sinks are placed near points of clinical activity [102]. With the advent of alcohol-based handrub solutions as more effective hand hygiene, the placement of handrub dispensers has become more important than the placement of sinks [29]. The CDC guidelines on hand hygiene recommend placing dispensers in convenient locations, such as at the entrance of each patient room or at the bedside. PATIENT-RELATED FACTORS Patient-related risk factors for HAIs include age, general health status, and the type of procedure to be carried out, and risk can be classified as minimal, medium, or high [18]. Patients are at minimal risk if they have no significant underlying dis- ease, have an intact immune system, and will not undergo an invasive procedure. Medium risk is assigned to older patients who are susceptible to disease for a variety of reasons, including decreased immune function, comorbid conditions, and low nutritional status. Medium risk also refers to patients who are to have a nonsurgical invasive procedure, such as a peripheral venous catheter or a urinary catheter.
Water Water is a reservoir for several types of micro-organisms, includ- ing bacteria, fungi, and viruses, with viruses accounting for only a small percentage [87; 97]. The quality of water within a healthcare setting must meet standards that vary according to use. Tap water must be safe to drink and use for baths (for hygiene and therapy) according to criteria dictated by local regulations and public health standards. The water supply to the healthcare facility can be disinfected by several methods, including chlorination, thermal eradication, ultraviolet light, and metal ionization [91]. The most common pathogen identified in tap water is P. aeruginosa [78]. In one study, researchers evaluated the asso- ciation between tap water from faucets in a surgical ICU and patients with colonization or infection with P. aeruginosa [98]. The pathogen was found in 58% of water samples taken from individual faucets but was not identified in the main water supply. The genotypes of the micro-organism in 21 of the 45 patients were identical to those found in the tap water from the sink in the patient’s room (15 patients) or in the adjacent room (6 patients). According to epidemiologic analysis, trans- mission of the pathogen had occurred from faucet to patient as well as from patient to faucet. P. aeruginosa is also the pri- mary bacterial pathogen found in bath water [99]. The effect of infection with P. aeruginosa may be mild, as in folliculitis and external otitis, but wound infection may be more severe. Greater morbidity is associated with infection in individuals who have a compromised immune system or who have another health condition, such as diabetes [18]. Legionella , which causes infection of the respiratory tract, is another micro-organism commonly found in tap water and bath water. The highest concentrations of Legionella are found in areas of water distribution systems (hot water storage, cool- ing towers, condensers), where it colonizes [91]. Infection with Legionella is transmitted only through water, not through person-to-person contact. Inhalation of contaminated water droplets from shower heads or faucet aerators may cause disease [87]. In addition, high humidity levels in a room (through mists produced by respiratory equipment, for example) may promote the growth of Legionella and molds [93]. The WHO suggests that there is potential risk for HAIs if tap water is used for such purposes as ice machines or devices for washing eyes or ears, or for cleaning equipment [18]. Point-of- use filtration may help to reduce the risk of HAIs related to water [97]. Ducts, humidifiers, dehumidifiers, and other areas of a ventilation system should be kept clean and dry, as micro- organisms can colonize in water that accumulates in these areas [93]. Patients at high risk for infection should not be exposed to hospital water and sterile water should be used instead [88]. Architectural Design Another factor in the transmission of infection in the health- care setting is the architectural design of the facility, and the AHRQ lists “use good hospital design principles” as one of its
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