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醫院整建過程中之感染管制

醫院整建過程中之感染管制. 衛生署 疾病管制局 中區傳染病防治醫療網 王任賢 指揮官. 院感人員在醫院整建中之角色. 主要任務 由感染管制的角度監控整個營建及改建之進行，包括計畫之擬定、修訂、工程執行、及後續之監控. 建築過程相關之感染殺手 : Aspergillus sp. 建築過程相關之感染殺手 : Legionella sp. 微生物之來源 : I. 黴菌斑、灰塵、土壤均會受黴菌孢子與細菌污染 天花板、絕緣材質、防火材質、牆壁剝落物 黴菌孢子可由戶外飛入 ( 敞開的窗戶或未密閉的窗戶 ). 微生物之來源 : I I. 水管系統

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醫院整建過程中之感染管制

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  1. 醫院整建過程中之感染管制 衛生署 疾病管制局 中區傳染病防治醫療網 王任賢 指揮官

  2. 院感人員在醫院整建中之角色 • 主要任務 由感染管制的角度監控整個營建及改建之進行，包括計畫之擬定、修訂、工程執行、及後續之監控

  3. 建築過程相關之感染殺手: Aspergillus sp

  4. 建築過程相關之感染殺手: Legionella sp

  5. 微生物之來源: I • 黴菌斑、灰塵、土壤均會受黴菌孢子與細菌污染 • 天花板、絕緣材質、防火材質、牆壁剝落物 • 黴菌孢子可由戶外飛入(敞開的窗戶或未密閉的窗戶)

  6. 微生物之來源: II • 水管系統 • 水管漏水會造成天花板潮濕 • 灰塵與黴菌四散 • 換新水管時土壤中的Legionella sp.可以因此而進入水管系統

  7. 微生物之來源: III • 空調系統 • 空調系統若有不完整將使營建區的空氣流通至病患區域 • 空調系統並未完全密閉 • 不正確的壓力差 • 不正確之空氣交換 • HEPA filters沒有保養

  8. Risk factors of patients and environment • Exposure to construction and soil excavation

  9. Risk factors of patients • Patient characteristics • underlying medical conditions • immunosuppressive conditions • GVH disease, prolonged neutropenia / granulocytopenia,prolonged use of antibiotics, steriod therapy • dialysis and mechanical ventilation, smoking, patient age, very young and very old • diabetes, surgery, neoplastic, pulmonary, renal or cardiac disease

  10. Risk factors for infections with filamentous fungi • Exposure to construction activities • immunosuppressive conditions • AIDS, congenital immunodeficiencies • Dialysis, renal failure • Diabetic ketoacidosis • Mechanical ventilation • Smoking • Age of the patient - very young and very old

  11. Risk factors for Legionnaires’ disease • Exposure to soil excavation during construction and malfunction of plumbing systems • Immunosuppressive conditions • Advanced age • Chronic pulmonary disease • Smoking • Excessive use of alcohol • Surgery • Diabetes, neoplastic disease, renal failure, cardiac failure

  12. Risk assessment • Proactive approach • Minimise dust • Prevent dust infiltration into patient care areas adjacent to construction • Attention to plumbing system when disruptions occur • Infection control measures

  13. Contract • Preventive measures outlined clearly before start of construction or renovation project • Maintenance of measures • Clear responsibilities

  14. General guidelines • Minimise dust • Prevent migration of duct particles into adjacent areas • plastic barrier from floor to ceiling + negative pressurization • plastic barrier + high efficiency exhaust fan with HEPA filter • plastic barrier + portable exhaust fan with side-draft hood

  15. Pre-construction • Consult infection control department • Authority to stop construction? • Identify essential services that may be disrupted • ICN to identify patient population at risk and implement appropriate preventive measures • Train contractors and workers • Traffic patterns determined for construction workers

  16. Construction • Move immunosuppressed patients • Seal windows, doors, air intake and exhaust vents in areas adjacent to construction area • Dust barrier • Walk-off mat • Protective clothing • CIN to visit construction site regularly with project manager

  17. Post construction • Construction zone thoroughly cleaned • ICN to check area before patients are re-admitted • Final walk-through inspection • Evaluate preventive measures and review effectiveness for any problems and positive outcome

  18. Personnel interactions • Facility project manager,environmental services, medical and nursing staff • provide information on infection control concerns • education on importance of preventive measures • collaborate in making recommendations in cleaning • collaborate with staff to identify patients at risk

  19. Personnel interactions • Architects, engineers, contractors, subcontractors, suppliers • ICN should be aware of existing building and professional standards that address infection control issues • communicate with them • ensure preventive measures are initiated and followed through

  20. Infection Control Risk Assessment (ICRA) 環境感染風險評估

  21. ICRA之定義 醫院整建前必須由多個單位共同評估出一個計畫，以降低整建過程對病患、訪客、及醫院工作人員造成之可能感染風險

  22. ICRA計畫 • 由醫院多個單位共同依據醫院整建計畫訂出完整的ICRA • 必須由整建團隊提供給ICRA team的資料 • 建構計畫(Floor plan) • 機械設備、水電使用、及防火計畫(MEP: mechanical, electric, plumbing, fire protection) • 周邊環境影響評估(Surrounding environmental concerns ) • 工作範圍(Scope of work) • 工作時段及時數(Work hours) • 垃圾清運計畫(Debris removal plan) • 整建過程中醫院日常活動之動線規劃(Pathway to transport patients, visitors and staff during construction)

  23. ICRA計畫 • 醫院整建團隊必須 • 充分了解並參予整個ICRA計畫之進行 • 提供ICRA所需的任何文件資料

  24. 步驟一：醫院整建過程中之感染風險評估 • TYPE A: 觀察型或非侵入型之整建 • 不牽涉任何乾燥壁面之侵入; • 移開天花板格板且只做觀察 • TYPE B: 小規模且工期小於72小時之工程，工程中只產生少量灰塵 • 牽涉切割牆壁或天花板但能有效移除灰塵之工程 • TYPE C: 較大規模且工期大於72小時之工程，工程中會產生中到大量灰塵 • 砌牆 • 長期工程且無法有效去除灰塵者 • TYPE D: 大型工程 • 大規模更動管路系統 • 新建或大規模改建工程

  25. 如果很多地方均有感染風險，必須找出最高風險區域如果很多地方均有感染風險，必須找出最高風險區域 步驟二: 找出最高風險區

  26. 醫院區域之風險分類 • 低度風險區域 • 非照顧病人之區域 • 非醫療區 (行政區域) 中度風險區 • 排除門診高風險區之外之其他門診區 • 病人聚集區 (e.g. 電梯等候區) • 醫療支援區域 (e.g. 廚房) 高度風險區 • 門診高風險區 • 腫瘤科 • 移植病人門診 • 胸腔科 • Cystic Fibrosis • 放射線科執行介入性醫療行為之處所Interventional Radiology • 導管室 • 所有住院病人區域

  27. 步驟三: 找出各區域之感染風險等級 將區域之感染風險與工程之感染風險進性綜合配對

  28. 步驟四:依風險等級之感染管制作為

  29. Proper Barrier For Dust Control

  30. Proper Barrier For Dust Control

  31. Improper Dust Barrier

  32. Improper Dust Barrier

  33. Control Cube Usage

  34. Acceptable Solid Barrier

  35. Creating Negative Pressure

  36. Creating Negative Pressure

  37. Use Of Coveralls During Demolition

  38. Improper Trash Removal

  39. Safe Debris Removal

  40. 步驟五: 工程結束後之清理工作 • 工作完畢後必須以HEPA filtered vacuum或濕拖把清理工作場所，並要經主管檢查合格才可完成 • 移除工作場所之空調系統並將之隔離處理 • 工程場所要回歸醫療使用前必須先作環境消毒，使用之消毒劑必須是醫療機構認可的

  41. 工程結束後之檢討 在整個工程結束後，整建單位、院感單位、及安全部門均必須對工程期間施工單位對於ICRA決定的落實程度進行評估，以對日後工程的進行提出建議

  42. Appropriate Signage

  43. ICRA Planning Flow Chart

  44. Air sampling • OTS • new, major renovation to ventilation system • air sampling for bacteria count • Immunosuppressed patients • Aspergillus surveillance

  45. 結論 • 乾淨的醫院環境是醫院安全很重要的一環 • 院感是每個人都該遵守的事 • 院感的達成必須要經由溝通良好的團隊共同完成 • 所有的工程案子均必須以相同手法執行評估

  46. 未來發展 • 除塵機具應標準化 • 醫院人員必須接受足夠的教育訓練 • 防塵計畫應予標準化 • 研發新的除塵機具與技術 • 充分運用新的產品與技術

  47. 懇請賜教

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