Hospital Environment Makalah 1
Hospital Environment Makalah 1
Hospital Environment Makalah 1
1 Introduction...................................................................................................................2
1.1 Purpose, scope and audience................................................................................2
1.2 Policy rationale....................................................................................................3
1.3 Health rationale....................................................................................................4
1.4 Health-care settings.............................................................................................5
1.4.1 Large health-care settings.......................................................................................5
1.4.2 Small health-care settings.......................................................................................6
1.4.3 Emergency or isolation settings..............................................................................6
1.5 Structure..............................................................................................................6
2 Implementation..............................................................................................................8
2.1 Positive policy environment................................................................................8
2.2 Steps in managing standards at national, district and local levels........................8
2.3 Roles and responsibilities..................................................................................11
2.4 Coordination in the health-care setting..............................................................12
2.5 Using the guidelines to create standards for specific health-care............................13
settings13
2.6 Assessing and planning minimum standards......................................................14
2.7 Phased improvements........................................................................................15
2.8 Technology choice, operation and maintenance.................................................15
2.9 Ongoing monitoring, review and correction......................................................16
2.10 Staff requirements and training..............................................................................16
2.11 Hygiene promotion................................................................................................17
3 . Guidelines for setting environmental health standards...................................................18
3.1 Guidelines and associated information..............................................................18
3.1.1 Guideline structure................................................................................................18
3.1.2 Indicators..............................................................................................................18
3.1.3 Guidance notes......................................................................................................19
3.2 Guidelines..........................................................................................................21
4 Assessment checklist....................................................................................................49
5 Glossary................................................................................................................................56
6 Further reading....................................................................................................................58
1
1 Introduction
These guidelines have been written for use by health managers and planners,
architects, urban planners, water and sanitation staff, clinical and nursing staff,
carers and other health-care providers, and health promoters. They can be used
to:
• support the application of national standards and set specific targets in health-
care settings
• assess the situation regarding environmental health in existing health-care
settings to evaluate the extent to which they may fall short of national plans
and local targets
• plan and carry out the improvements that are required
• ensure that the construction of new health-care settings is of acceptable
quality
• prepare and implement comprehensive and realistic action plans so that
acceptable conditions are achieved and maintained.
These guidelines deal specifically with water supply (water quality, quantity and
access), excreta disposal, drainage, health-care waste management, cleaning and
laundry, food storage and preparation, control of vector-borne disease, building
design (including ventilation), construction and management, and hygiene
promotion. They are designed primarily for use in health-care settings in
precarious situations, and in situations where simple and affordable measures can
improve hygiene and health significantly.
1 ‘Carers’ is used in these standards to mean family, friends or voluntary workers who care for a
patient at home or who accompany patients to a health-care setting, visit hospitalized patients and
provide basic, non-professional care. Carers may be occasional visitors, or they may stay to cook,
clean and care for patients in the health-care setting (medical structure or home).
3
In principle, standards are set at the national level and are used at district and
local levels to set and work towards specific targets. Therefore, these guidelines
provide a basis for setting standards at a national level when this is required; they
may be used in a similar way at district and local levels, where appropriate. They
are intended to be used, together with existing national standards and guidelines,
for creating targets, policies and procedures to be used in each health-care
setting. Box 1.1 contains definitions of standards and guidelines.
Standards
Standards are the requirements that must be met to achieve minimum essential
environmental health conditions in health-care settings. They must be clear,
essential and verifiable statements.
Guidelines
Guidelines are the recommended practices to achieve desirable minimum
environmental health standards in health-care settings. They are not law, but
should be used as guidance.
12
2 http://www.un.org/millenniumgoals/
5
health-care setting might even become the epicentre of outbreaks of certain
diseases, such as typhus or diarrhoea.
Table 1.1 shows the risks related to environmental health in health-care settings,
as well as the main preventive measures that are covered by these guidelines.
Some staff may be exposed to radiological or chemical hazards. These require
particular preventive measures that are beyond the scope of these guidelines.
These guidelines are intended for use in precarious health-care settings where
simple, robust and affordable solutions to infection control are required. They
apply to a range of health-care settings, from home-based care through to district
and central hospitals. Three broad types of health-care settings (discussed below)
illustrate the issues involved in environmental health:
Financial and material resources may be scarce, but there is usually a substantial
human resources capacity, with medical, nursing, pharmacy and technical
services staff potentially able to contribute to infection control.
7
1.4.2 Small health-care settings
Financial and material resources may be scarce and support from the health
authorities may be inadequate, particularly in remote rural areas and poor peri-
urban areas.
1.5 Structure
These guidelines are organized into four main sections:
• Section 1 provides an overview of the purpose, scope and rationale for the
guidelines.
• Section 2 discusses how these guidelines may be used at national, district and
local levels, and identifies roles and responsibilities of stakeholders.
• Section 3 contains the 11 guidelines, each of which is accompanied by a set
of indicators (measures for whether the guidelines are met) and guidance
notes (advice on applying the guidelines and indicators in practice,
highlighting the most important aspects that need to be considered when
setting priorities for action).
Specific terms are explained in the glossary, and references and further reading
are provided in the reference list.
9
2 Implementation
10
Table 2.1 Steps in establishing and managing appropriate standards at
national, district and local levels
National level District level HCS or community level
1 • Review existing • Raise awareness on • Mobilize support
national policies environmental health from health workers,
and ensure that in HCSs among key local communities
there is a stakeholders at and other local
national policy district level. stakeholders to
achieve and sustain a
framework that
healthy health-care
supports
environment.
improved
• Promote a working
conditions in
climate that
HCSs.
encourages patient
and staff safety.
2 • Ensure that national • Ensure that an • Create and assign
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supports Develop and use
• will be applied.
compliance. guidelines where
national standards
do not exist.
5 • Provide and/or • Allocate funding for • Seek funding for
facilitate funding for planned planned
national improvements and improvements
programmes. new developments. and new
developments.
6 • Monitor progress at • Ensure oversight of • Oversee implementation
national level and improvements and of planned
promote consistent new developments to improvements and new
application of ensure the consistent developments.
standards in all application of
regions and at all national standards in
levels. all HCSs.
7 • Produce training and • Provide appropriate • Provide advice and
information training and training to health-care
materials information to health- workers and patients.
appropriate to a care workers.
range of health-care
settings.
• Ensure appropriate
curriculum for
health-care worker
training.
8 • Periodic review and • Inform key • Mobilize support from
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maintain adequate environmental health conditions in health-care settings. The
list is not exhaustive and can be added to in any particular context.
Table 2.2 Roles and responsibilities for implementing guidelines and
standards for environmental health in health-care settings
Stakeholder group Contribution to improved environmental health in
HCSs or home care
Patients • Comply with procedures for use and care of water
and sanitation facilities, and observe appropriate
hygiene measures.
Patients’ families and • Comply with procedures for use and care of water
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Construction and • Provide skilled services that comply with
maintenance national standards for construction,
industry, including local maintenance and repair of buildings and
contractors sanitary infrastructure.
National and • Provide funding for new HCSs, upgrading or
international Funding renovation of existing ones and ongoing
bodies maintenance of targets.
Other communities • Participate in disease control sessions through
community health organizations that might exist.
• Report on health-care waste found outside HCSs.
In smaller settings, such as basic health posts, this role may be taken on by one
staff member or volunteer, who should receive support from environmental
health officers or other infection control staff based at the district level.
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2.5 Using the guidelines to create standards for specific health-care
settings
The guidelines in Section 3 reflect general principles for providing adequate
health care and minimizing the health-care associated disease risk to patients,
staff and carers. They can be used, as follows, for creating specific targets or
standards appropriate for individual health-care settings, or different types of
health-care settings:
• Review the 11 guidelines, which are narrative statements describing the
situation to be aimed for.
15
Analysing the reasons for shortfalls, in as inclusive a way as possible, is
important because most solutions will require the participation of multiple
parties, including patients, carers, health-care workers and health managers. A
useful tool for this analysis is the problem–solution tree (see Box 2.1).
Objectives should be understandable and motivating to all those concerned by
their achievement, and progress towards achieving them should be possible to
measure and describe easily and clearly.
1. Discuss any major aspects of the current situation where water supply,
sanitation, healthcare waste management and hygiene targets defined for the
health-care setting are not met. Write each one in large letters on a small piece
of paper (e.g. A6 size) or a postcard.
2. For each major problem, discuss its causes by asking “why?” For each
of the contributing problems identified, ask “why?” again, and so on until root
causes for each problem have been revealed and agreed. Write all the
contributing problems in large letters on a piece of paper or postcard and stick
them on a wall, arranged in a way that reflects their relation to each other and to
the major problem.
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4. Once a number of feasible solutions have been agreed, they should be
phrased as objectives. For each objective, the group can then discuss and agree
on a strategy (how the objectives can be reached), responsibilities (who will do
what), timing, resources and requirements.
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2.9 Ongoing monitoring, review and correction
Maintaining acceptable conditions requires ongoing efforts at all levels. The role
of the infection control committee in ensuring regular monitoring of
environmental health conditions is critical. The local department of
environmental health should be a major partner, providing expert monitoring and
advice. For example, health-care settings should be included in regular water
quality surveillance and control programmes.
Many activities that are important for infection control are performed routinely
by healthcare workers as part of their health-care tasks. Hand hygiene is one of
the most important of these activities. In smaller settings, health-care workers
may also be required to perform medical and non-medical tasks, including
operating and maintaining environmental health facilities.
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In larger settings, other staff (such as cleaners, kitchen staff and waste
technicians) are also responsible for infection control. In their training and
management, they should be made aware of the importance of their role and
should be able to apply the basic principles of infection control to their daily
work.
Where the building design and mechanical services form part of the infection
control strategy (e.g. isolation rooms, ventilation), staff training should include
the importance of following correct operational procedures to ensure that
protection is maintained.
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3 . Guidelines for setting environmental health standards
The guidelines are given in the form of a statement that describes the situation to
be aimed for and maintained. Each guideline is specified by a set of indicators
that can be used as benchmark values for the following activities:
3.1.2 Indicators
The indicators are based on WHO’s guidelines and have been compared with a
number of other indicators from documents that also guide practice in health-
care settings and other relevant settings, and are presented in the reference list.
Specialist technical terms are explained in the glossary. These indicators need to
be adapted in the light of national standards, local conditions and current
practices. They mostly concern results — for example, the quantity of water
available or the frequency of room cleaning.
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3.1.3 Guidance notes
The guidance notes provide advice on applying the guidelines and indicators in
practice and highlight the most important aspects that need to be considered
when setting priorities for action. They are numbered according to the indicators
to which they refer.
The guidelines and indicators are designed to help set targets for creating
adequate conditions for the long term. Box 3.1 shows basic measures that can be
taken to protect health as a temporary measure until adequate long-term
conditions are provided.
• Provide water for handwashing after going to the toilet and before handling
food, before and after performing health care. This may be done using
simple and economical equipment, such as a pitcher of water, a basin and
soap, or wood ash in some settings.
• Provide basic sanitation facilities that enable patients, staff and carers to go
to the toilet without contaminating the health-care setting or resources such
as water supplies. This may entail measures as basic as providing simple pit
latrines with reasonable privacy.
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• Provide cleaning facilities that enable staff to routinely clean surfaces and
fittings to ensure that the health-care environment is visibly clean and free
from dust and soil. Approximately 90% of microorganisms are present
within visible dirt; the purpose of cleaning is to eliminate this dirt.
• Ensure that eating utensils are washed immediately after use. The sooner
utensils are cleaned the easier they are to wash. Hot water and detergent,
and drying on a stand are required.
• Provide safe movement of air into buildings to ensure that indoor air is
healthy and safe for breathing. This is particularly important if health care is
being provided for people with acute respiratory diseases.
A water safety plan aimed at assessing and managing water systems, and
ensuring effective operational monitoring, should be designed, developed
and implemented to prevent microbial contamination in water and its
ongoing safety.
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2. Drinking-water meets WHO Guidelines for drinking-water quality (2006)
or national standards concerning chemical guidelines and radiological
parameters.
In France, the limit value for Legionella concentration for patients with classical
individual risk factors, such as the elderly, is < 1000 colony forming units/litre.
1. Microbial quality
Microbial quality is of overriding importance for infection control in health-care
settings. The water should not present a risk to health from pathogens and should
be protected from contamination inside the health-care setting itself. Drinking-
water supplied to health-care settings should meet national standards and follow
WHO guidelines for drinking-water quality (WHO, 2006). In practice, this
means that the water supply should be from a protected groundwater source,
such as a dug well, a borehole or a spring, or should be treated if it is from a
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surface water source (see Indicator 2). Rainwater may be acceptable with
disinfection if the rainwater catchment surface, guttering and storage tank are
correctly operated, maintained and cleaned.
Legionella spp. are common waterborne organisms, and devices such as cooling
towers, hot-water systems (showers) and spas that use mains water have been
associated with outbreaks of infections.
The local department of environmental health should work with the health-care
setting infection control committee to monitor the microbiological quality of the
water in the health-care setting, as part of a routine surveillance and control
programme (WHO, 1997).
2. Chemical constituents
Chemical constituents may be present in excess of guideline levels in water
supplies, and it may not be possible, in the short term, to remove them or to find
an alternative source of water. In circumstances where WHO guidelines for
drinking-water quality or national standards for chemical and radiological
parameters cannot be met immediately, an assessment should be made of the
risks caused to patients and staff, given the levels of contamination, the length of
exposure (longer for staff than for patients) and the degree of susceptibility of
individuals (some patients may be highly susceptible to some contaminants). It
may be necessary to provide alternative sources of drinking-water for people
most at risk. For example, where a water supply exceeds WHO guideline limits
for nitrate or nitrite, this water should not be used for infant feeding (WHO,
2006).
3. Disinfection
Disinfection with chlorine is the most widely accepted and appropriate way of
providing microbial safety in most low-cost settings. Bleaching powder, liquid
bleach, chlorine tablets and other sources of chlorine may be used, depending on
local availability. To ensure adequate disinfection, a contact time of at least 30
minutes should be allowed between the moment the chlorine is added to the
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water and the moment the water is available for consumption or use. The free
chlorine residual (the free form of chlorine remaining in the water) after the
contact time should be between 0.5 and 1.0 milligrams per litre (WHO, 2006) in
all points of the system, including end-points. Residual chlorine can be measured
with simple equipment (e.g. a colour comparator and diethyl-pphenylenediamine
tablets).
Effective disinfection requires that the water has a low turbidity. Ideally, median
turbidity should be below 1 nephelometric turbidity unit (NTU) (WHO, 1997).
However, 5 NTU is the minimum turbidity measurable with simple equipment
(turbidity tube), so this level may be used in low-cost settings in practice. If
turbidity exceeds 5 NTU then the water should be treated to remove suspended
matter before disinfection, by sedimentation (with or without coagulation and
flocculation) and/or filtration.
Filtration with ceramic (e.g. candle filters), chlorination and other technologies
that can be used on a small scale may be appropriate for treating water in health-
care settings that are not connected to piped supplies, as well as those that are
connected to piped supplies whose quality is not consistently satisfactory (WHO,
2002a).
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4. Drinking-water quality
Drinking-water should be acceptable to patients and staff, or they may not drink
enough, or may drink water from other, unprotected sources, which could be
harmful to their health.
Water used for laundry and for cleaning floors and other surfaces need not be of
drinkingwater quality, as long as it is used with a disinfectant or a detergent.
Table 3.1, below, lists the minimum quantity of water that is required for
different situations in the health-care setting.
3 According to situations (e.g. for use of a flush toilet, the water requirement can be much higher).
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Table 3.1
1. Drinking-water points
Drinking-water should be provided separately from water provided for
handwashing and other purposes, even if it is from the same supply. Drinking-
water may be provided from a piped water system or via a covered container
with a tap where there is no piped supply. Drinking-water points should be
clearly marked.
2. Handwashing
Basic hygiene measures by staff, patients and carers, handwashing in particular,
should not be compromised by lack of water.
27
Waterless, alcohol-based handrubs may be used for rapid, repeated
decontamination of clean hands. Handrub dispensers can be installed at
convenient points, and can also be carried by staff as they move between
patients. However, handrubs may not be affordable, and they do not replace soap
and water for cleaning soiled hands.
3. Handwashing facilities
Water points should be sufficiently close to users to encourage them to use water
as often as required. Alternatively, a handwashing basin, soap and a jug of clean
water may be placed on a trolley used for ward rounds, to encourage
handwashing as often as needed between patient contacts.
4. Showering facilities
Although less important than handwashing in terms of reducing disease
transmission, showering (or other means of washing the body) may be important
for the recovery of certain patients, and may be required by staff and carers in
contact with infectious patients.
Separate showers may be needed for staff and patients, and for both sexes, to
ensure that all groups have adequate privacy and safety.
5. Laundry facilities
4 Specific cleaning and disinfection procedures against Pseudomonas and possibly Legionella have to
be foreseen.
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Indicators for Guideline 4
1. There are sufficient toilets available: one per 20 users for inpatient
settings; at least four toilets per outpatient setting (one for staff, and for
patients: one for females, one for males and one for children).
3. Toilets are designed to respond to local cultural and social conditions and
all age and user groups.
6. Toilets are easily accessible (that is, no more than 30 metres from all
users).
The recommended ratio of one toilet per 20 people is common and widespread,
and should be used as a planning guideline. Actual numbers required for
inpatient settings will depend on a number of factors, including the average
proportion of patients using bedpans instead of toilets. Users include patients,
staff and carers.
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2. Local technical and financial conditions
If there is sufficient and reliable piped water available and there is a connection
to a sewer system or a functioning septic tank and drainage system, flush toilets
may be appropriate, depending on materials used for anal cleansing. In other
situations, latrines (dry or pourflush types) are appropriate. Care must be taken,
when siting latrines, to avoid contaminating groundwater and risk of flooding.
Patient toilets should be equipped to make them easy to use by people with
physical handicaps, heavily pregnant women, elderly people and people who are
sick (see e.g. Jones and Reed 2005 for detailed design features).
Special children’s toilets should be provided where many children use the health-
care setting. Children’s toilets are particularly useful where latrines are used and
where the size of the drop hole and the conditions inside a normal latrine are off-
putting for children or inconvenient for carers.
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5. Handwashing points
Water points, with soap and adequate drainage, should be provided at the exit of
all toilets, and their use should be actively encouraged.
6. Accessibility
Time and effort required to reach the toilets need to be taken into account. In
multi-storey buildings, there should be toilets available on all floors, and routes
used to reach toilets should be smooth and flat, for easy access for people in
wheelchairs.
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3. Rainwater and surface run-off is safely disposed of and does not carry
contamination from the health-care setting to the outside surrounding
environment.
Wastewater is produced from washbasins, showers, sinks, etc. (grey water) and
from flushing toilets (black water). It should be removed in standard waste
drainage systems to off-site sewer or on-site disposal systems. All open
wastewater drainage systems should be covered, to avoid the risks of disease
vector breeding and contamination from direct exposure.
Small quantities of infectious liquid wastes (e.g. blood or body fluids) may be
poured into sinks or toilets. Most pathogens are inactivated by a combination of
time, dilution and the presence of disinfectants in the wastewater. Toxic wastes
(e.g. reagents from a laboratory) should be treated as health-care waste (see
Guideline 6). They should not be poured into sinks or toilets that drain into the
wastewater system.
If the sewer does not lead to a treatment facility, an on-site retention system with
treatment will be necessary before wastewater is discharged.
In other situations, on-site disposal is needed. For grey water, soakaway pits or
infiltration trenches should be used. These should be equipped with grease traps,
which should be checked weekly and cleaned, if needed, to ensure the systems
operate correctly. Pits or trenches should not overflow into the health-care
setting grounds or surroundings and create insect or rodent breeding sites. Black
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water should be disposed of in a septic tank, with the effluent discharged into a
soakaway pit or infiltration trench. Grey and black water may be treated in the
same septic tank and soakaway system, although this requires a larger septic tank
than one used for black water alone. All systems that infiltrate wastewater into
the ground should be sited so as to avoid contaminating groundwater. There
should be at least 1.5 metres between the bottom of the infiltration system and
the groundwater table (more in coarse sands, gravels and fissured formations),
and the system should be at least 30 metres from any groundwater source.
If the health-care setting has a septic tank, the sludge from the tank should not be
used for agricultural purposes, but should be buried following safe procedures.
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collected from all healthcare services and stored safely before treatment
and/or disposal.
1. Segregation
The four major categories of health-care waste recommended for organizing
segregation and separate storage, collection and disposal are:
34
For the above categories of waste, it is recommended that waste containers are a
maximum of 5 metres from the point of waste generation, in two sets for each
location, for a minimum of three types of waste. At least one set of waste
containers should be provided per 20 beds in a ward.
Non-sharps infectious waste should be buried in a pit fitted with a sealed cover
and ventilation pipe for on-site treatment in small health-care settings or, should
be hightemperature incinerated or steam sterilized on-site or off-site. Special
arrangements may be needed for disposing of placentas, according to local
custom.
The preferred option for specific infectious waste (such as blood samples, plastic
syringes and laboratory tests) is steam sterilization before disposal, if available.
This avoids environmental pollution from incineration. One autoclave should be
dedicated for waste sterilization, different from the autoclave used for sterilizing
medical devices within the laboratory (see e.g. Diaz and Savage (2003) for
details on a range of processes for treating infectious wastes).
35
There are several kinds of hazardous waste and each requires specific treatment
and disposal methods, which include encapsulation, sterilization, burial,
incineration and long-term storage. Some wastes, such as pharmaceutical wastes,
cannot be disposed of in low-cost settings and should be sent to a large centre for
destruction or returned to the supplier. In all cases, national legislation should be
followed.
4. Waste-disposal zone
The waste-disposal zone should be fenced off; it should have a water point with
soap or detergent and disinfectant for handwashing or to clean and disinfect
containers, with facilities for wastewater disposal into a soakaway system or
sewer. The waste-disposal zone should also be located at least 30 metres from
groundwater sources. Where an incinerator is used, it should be located to allow
effective operation with minimal local air pollution in the health centre, nearby
housing and crops, and it should be large enough for extension if new pits or
other facilities have to be built.
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Guideline 7 Cleaning and laundry
Laundry and surfaces in the health-care environment are kept clean.
3. Any areas contaminated with blood or body fluids are cleaned and
disinfected immediately.
5. Clean and soiled linen are transported and stored separately, in different
(marked) bags.
6. Beds, mattresses and pillows are cleaned between patients and whenever
soiled with body fluids.
1. Routine cleaning
Ninety per cent of microorganisms are present within visible dirt, which should
be eliminated by routine cleaning. Neither ordinary soap nor detergents have
antimicrobial activity, and the cleaning process depends essentially on
mechanical action. Wet mopping with hot water and detergent, if available, is
recommended, rather than sweeping (WHO, 2002b). If hot water is not available,
a 0.2 % chlorine solution, or other suitable disinfectant in cold water should be
used. However, detergent is sufficient for normal, domestic cleaning of floors
and other surfaces that are not in contact with hands and medical instruments.
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2. Intensity of cleaning routine
Floors and other washed surfaces should be made of a suitable, non-porous
material that is resistant to repeated cleaning with hot water and detergents or
disinfectants. This may be achieved by classifying areas of the health-care
setting into three areas, each with a specific cleaning routine (WHO, 2002b):
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cleaned and autoclaved before being supplied to operating rooms or theatres.
Woollen blankets should be washed in warm water (WHO, 2004b).
If woven mats are used instead of, or on top of, mattresses, they should be
destroyed (burned) and replaced between patients.
The information in these indicators and guidance notes is drawn from WHO
(2001) and WHO (2004c).
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3. Food is cooked thoroughly.
Food handlers should wash their hands after using the toilet and whenever they
start work, change tasks, or return after an interruption. Soap and water should
be available at all times during food preparation and handling, to ensure that
handwashing can be done conveniently (see Guidance note 3).
Kitchen staff and carers with colds, influenza, diarrhoea, vomiting and throat and
skin infections, or those who have suffered from diarrhoea and vomiting within
the past 48 hours, should not handle food unless it is packaged. All infections
should be reported and sick staff should not be penalised.
Eating utensils should be washed immediately after each use with hot water and
detergent, and air-dried. The sooner utensils are cleaned the easier they are to
wash. Drying cloths should not be used, as they can spread contamination.
In many inpatient settings, carers may bring food to patients, or may prepare
food at the health-care setting. In these cases, staff should seek to ensure that
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food is prepared hygienically and that cooked food is consumed immediately.
Cooking facilities may need to be provided.
Food should be stored in containers to avoid contact between raw and prepared
foods.
Raw meat, poultry and seafood should be separated from other foods.
Cooked food must be reheated thoroughly to steaming hot all the way through.
Cooked food to be served should be kept hot (more than 60°C) before serving.
4. Storage
Cooked or perishable food should not be left at room temperature for more than
two hours, and should be prepared or supplied fresh each day. All food should be
kept covered to protect it from flies and dust.
Food should be protected from insects, rodents and other animals, which
frequently carry pathogenic organisms and are a potential source of
contamination of food (see Guideline 10).
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5. Washing and use of water
Only safe water should be used for food preparation, handwashing and cleaning.
For specification of safe water, see Guideline 1.
Fruit and vegetables should be washed with safe water. If there is any doubt
about the cleanliness of raw fruit and vegetables, they should be peeled.
5 WHO recommends that infants are exclusively breastfed for the first six months of life to achieve
optimal growth, development and health. There are instances where breast milk is not available; where
the mother is unable to breastfeed; where she has made an informed decision not to breastfeed; or —
for example — where the mother is taking medication that is contraindicated for breastfeeding, or the
mother is HIV-positive. Similarly, some very low-birth-weight babies may not be able to breastfeed
directly, and in some cases, expressed breast milk may not be available at all or available in
insufficient quantities. Infants who are not breastfed require a suitable breast-milk substitute, for
example, infant formula.
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3. Sufficient lighting is provided during all working hours to allow safe
movement of staff, patients and carers, and normal undertaking of
medical activities.
5. Health-care settings are built, furnished and equipped with materials that
minimize infectious disease transmission and facilitate cleaning.
1. Ventilation
The effective use of blinds, opening and closing of doors and windows, planting
of suitable vegetation around the building and other operational measures can
help optimize indoor conditions.
43
they dispense dust around the room (especially over the sterile field and
equipment in an operating theatre).
Operating theatres and rooms for isolating particularly vulnerable patients (e.g.
severely immunocompromised patients) may require positive air pressure
conditions, where clean air is drawn into the room, thus avoiding contaminated
air entering from other parts of the health-care setting.
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ventilation (Escombe et al. 2007), and where the climate allows, large opening
windows, skylights and other vents can be used to optimize natural ventilation.
Where possible, air should flow into rooms from the top and out of the room
from the bottom (near the floor, which is generally the most likely contaminated
part of the room), and natural ventilation should be optimized wherever feasible.
3. Lighting
Natural light may be sufficient in outpatient settings that operate only during the
day.
However, some form of lighting should be available for night-time emergencies.
5. Cleaning
All surfaces should be easy to clean by wet mopping and should be able to
withstand repeated exposure to hot water, detergents and disinfectants.
Walls, floors and ceiling surfaces should be smooth and made of non-porous
materials that are easy to clean and that do not provide a suitable environment
45
for pathogen survival or development. The same is true for furniture and
equipment used for patient care.
6. Building design
The building of new health-care settings or the improvement of existing ones
should be in line with national building codes and standard health-care setting
building designs. For example, beds for patients should be separated by a
minimum of one metre and should be easily accessible by people with physical
handicaps or elderly people.
46
Mosquitoes and flies can effectively be excluded from buildings by covering
opening windows with fly screens and fitting self-closing doors to the outside.
Any use of chemical controls requires specialist advice, such as for residual
insecticide spraying, in and around the health-care setting. Advice should be
available from within the ministry of health.
Patients with vector-borne diseases, such as malaria, Lassa fever and typhus,
should be treated or protected to ensure that the related vectors do not transmit
the disease from them to other people in the health-care setting. This may require
removal of the vectors (e.g. insecticide dusting to remove lice from typhus
patients) or the use of a barrier (e.g. insecticide bednets to isolate yellow fever
patients from mosquitoes).
47
Indicators for Guideline 11
2. Patients and carers are informed about essential behaviours necessary for
limiting disease transmission in the health-care setting and in the home.
Infection control should be a core part of initial training, and refresher trainings
should be carried out regularly to sustain knowledge and awareness of staff.
As part of an infection control strategy, all staff, once sufficiently trained and
equipped, should be sanctioned for non-compliance with reasonable procedures.
They should be updated on any changes. In particular, senior staff should
provide role models by complying consistently with procedures.
Posters and other visual information should be used to promote disease control
among patients and carers. Visual information should be relevant to risk
practices, it should be understood by the target audience and it should provide
practical and realistic advice and information.
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Patients’ and carers’ contact with the health-care setting should be used as a
means to promote hygiene in the community. Both during normal periods and
during epidemics, health-care settings should be actively involved in preventive
health care through hygiene promotion.
3. Adequate facilities
Staff, patients and carers should not be expected to adopt behaviours that are
inconvenient, uncomfortable or impractical. For example, staff are unlikely to
comply fully with handwashing procedures if there are no handwashing facilities
close to where they care for patients (WHO, advanced draft). Refer to Guidelines
1 to 10.
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4 Assessment checklist
The following checklist provides a set of assessment questions for each of the
guidelines presented in Section 3, to measure the extent to which the guidelines
are followed and identify areas for action. The qualitative and quantitative
indicators under the relevant guideline can be used as references to help answer
the questions. Questions may be answered with a “yes”, a “no” or a “not
applicable”. A “no” answer to any question should alert the assessor that
remedial action is required, either in the design and construction of facilities or
their operation and maintenance. Guidance on action to take can be found in the
guidance notes under each guideline in Section 3.
1 Water quality
Water for drinking, cooking, personal hygiene, medical activities, cleaning and
laundry is safe for the purpose intended
Design and construction Operation and maintenance
1 • Is water from a safe source (free Is the safety of the water source
•
monitored regularly?
from faecal contamination)?
• Is the quality of the water supplied
• Is water protected from to the HCS monitored regularly?
• Are water storage, distribution and
contamination in the
use facilities in the HCS
HCS? adequately maintained to avoid
contaminating the water?
2 • If necessary, can water be treated at • If water is treated at the HCS, is
the treatment process operated
the HCS?
effectively?
• Are there sufficient supplies and
adequately trained staff to carry
out treatment?
• Is the quality of the treated water
monitored regularly?
• Are treatment processes monitored
regularly?
3 • Does the water supply meet WHO • If necessary, are measures in place
guidelines or national standards to avoid overexposure of
susceptible patients to chemical
regarding chemical or contaminants?
50
radiological parameters?
4 • Is water acceptable (smell, taste, • If the water is not acceptable is
appearance)? there a safe alternative supply of
drinking-water?
5 • Is the water supply designed and • Are procedures in place for
built so that low-quality water used keeping both water supplies
for cleaning, laundry, etc. independent and well identified,
cannot enter the drinking-water and are procedures followed
supply and is identified as non- consistently?
potable at all outlets?
51
4 • In inpatient HCSs, are there • Are showers properly used and
sufficient showers? adequately maintained?
5 • In inpatient HCSs, are there • Are laundry facilities properly used
sufficient laundry facilities? and adequately maintained?
Adequate, accessible and appropriate toilets are provided for patients, staff and
carers
Design and construction Operation and maintenance
1 • Are there sufficient toilets in the • Are there sufficient toilets actually
health-care setting? in use?
2 • Are the toilets technically adapted • Are the toilets maintained and
to local maintenance systems? repaired in a timely and effective
• Are the toilets affordable in the way?
short term and long term?
3 • Are the toilets designed to suit • Do patients, staff and carers find
local culture and social conditions? the toilets appropriate?
• Do the toilets provide privacy and • Are the toilets used according to
security? their design?
4 • Are the toilets hygienic to use and • Are the toilets clean and without
easy to clean? smell?
5 • Are there handwashing facilities • Is there water and soap available all
close by the toilets? the time?
6 • Are the toilets easily accessible for • Are access routes to toilets kept in
all users? good condition and well lit?
7 • Is there a cleaning and maintenance • Is there an effective cleaning and
plan? maintenance routine in operation?
5 Wastewater disposal
52
run-off drainage system avoid disposal activities prevented from
carrying contamination outside ending up in the open environment
the health-care setting? and contaminating rainwater and
run-off?
53
storage facilities for clean and and stored separately?
soiled linen?
6 • Do mattresses have waterproof Are mattresses and pillows cleaned
•
54
HCS, health-care setting
55
1 • Are HCS environments protected • Are vector-breeding sites avoided or
from vectorborne disease? controlled?
2 • Are HCS buildings designed and • Are inbuilt protective measures
built to exclude disease vectors? effectively used and maintained?
3 • Is insecticide sprayed in and • Are barriers or repellents used to
around the HCS? reduce exposure to vectors?
4 • Are HCSs equipped with bednets • Are all patients, and particularly
and window screens? patients with vector-borne
diseases, treated or protected to
prevent further transmission?
5 • Are there facilities to safely • Are infectious substances removed or
contain the waste produced? covered or disposed of immediately
and completely?
HCS, health-care setting
56
5 Glossary
57
Housekeeping Environmental surfaces that are not involved in direct
surfaces delivery of patient care in health-care settings.
58
6 Further reading
Diaz L, Savage G (2003). Risks and costs associated with the management of
infectious wastes. Manila, World Health Organization (Western Pacific
Regional Office) (available at http://www.wpro.who.int/publications)
Hazel J, Reed R (2005). Water and sanitation for disabled people and other
vulnerable groups — designing services to improve accessibility.
Loughborough, UK, Water,
Engineering and Development Centre (available at
http://wedc.lboro.ac.uk/publications)
Médecins Sans Frontières (2005). Essential water & sanitation requirements for
health structures. Unpublished document. Brussels, MSF.
59
Pittet D (2001). Improving adherence to hand hygiene practice: a
multidisciplinary approach. Emerging Infectious Diseases, 7(2):234–240
(available at http://www.cdc.gov/ncidod/eid)
Venter SN, September SM (2006). The effect of water quality on the outcome of
hand hygiene. Department of Microbiology and Plant Pathology,
University of Pretoria.
WHO (1997). Guidelines for drinking-water quality, 2nd ed. Vol. 3. Surveillance
and control of community supplies. Geneva, World Health Organization
(available at
http://www.who.int/water_sanitation_health/dwq/gdwq2v1/en/index2.htm
l)
WHO (2001). Five keys to safer food. Geneva, World Health Organization
(Poster
WHO/SDE/PHE/FOS/01) (available at
http://www.who.int/foodsafety/consumer/en)
WHO (2002a). Managing water in the home: accelerated health gains from
improved water supply. Geneva, World Health Organization
(WHO/SDE/WSH/02.07)
(available at
http://www.who.int/entity/water_sanitation_health/dwq/wsh0207/en/, see
also http://www.who.int/entity/household_water)
WHO (2004a). Safe health care waste management: policy paper. Geneva,
World Health Organization, (available at http://www.healthcarewaste.org)
WHO (2004b). Practical guidelines for infection control in health care facilities.
New Delhi/Manila, World Health Organization (South-East Asia
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Regional Office/Western Pacific Regional Office), (SEARO Regional
Publication, No.
41/WPRO Regional Publication) (available at
http://www.wpro.who.int/publications)
WHO (2004c). First adapt then act! A booklet to promote safer food in diverse
settings. New Delhi, World Health Organization (Regional office for
South-East Asia) (SEA-EH-546) (available at
http://www.who.int/foodsafety/consumer)
WHO (2005a). Health through safe health care: safe water, basic sanitation and
waste management in health care settings. Geneva, World Health
Organization (available at http://www.healthcarewaste.org)
WHO (2005b). Management of solid health care waste at primary health care
centres: a decision-making guide. Geneva, World Health Organization
(available at
http://www.who.int/water_sanitation_health/medicalwaste/decisionmguid
e_rev_o ct06.pdf)
WHO (2005c). World health report 2005. Geneva, World Health Organization
(available at http://www.who.int/whr/2005/en)
WHO and CDC (Centers for Disease Control and Prevention) (1998). Infection
control for viral haemorrhagic fevers in the African health care setting.
Geneva, World
Health Organization (available at
http://www.who.int/csr/resources/publications/en)
WHO and FAO (Food and Agriculture Organization) (2007). How to prepare
powdered infant formula in care settings, Geneva, World Health
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Organization (available at
http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf)
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