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| | == '''About IUSS'''<br> == | | == '''About IUSS'''<br> == |
| − | This website is the repository for documents and tools developed under the Infrastructure Unit System Support - IUSS - project, an initiative of the National Department of Health, under the leadership of Dr Massoud Shaker and Mr Ndinannyi Mphaphuli. The purpose of the documents is to provide guidance to improve healthcare infrastructure delivery. | + | This website is the repository for documents and tools developed under the Infrastructure Unit System Support - IUSS - project, an initiative of the National Department of Health, under the leadership of Dr Massoud Shaker and Mr Ndinannyi Mphaphuli. The purpose of the documents is to provide guidance and improved healthcare infrastructure delivery. |
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| | == Application <br>== | | == Application <br>== |
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| | [[File:C:\OneDrive\Vibe\My Teams\59C4025 CDC\Files\Toby's Files\IUSS Wiki\CSIR logo.jpg|frameless|CSIR]] | | [[File:C:\OneDrive\Vibe\My Teams\59C4025 CDC\Files\Toby's Files\IUSS Wiki\CSIR logo.jpg|frameless|CSIR]] |
| | </gallery> | | </gallery> |
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| − | {| class="wikitable"
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| − | ! Area !! Patient At Risk !! Staff at Risk
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| − | | Theatres|| X|| X
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| − | | Central Sterile Services Department (CSSD)|| X||
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| − | | Burns|| X|| X
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| − | | Bone marrow transplant|| X||
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| − | | ICU || X||
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| − | | Isolation – containment || || X
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| − | | Isolation – protective|| X||
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| − | | Oncology|| X||
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| − | | Dialysis|| X||
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| − | | Laboratories|| || X
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| − | | Sluice rooms|| || X
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| − | | Plant rooms (filters, wet-services and ducting)||X || X
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| − | | Indoor Waiting Areas|| X|| X
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| − | |}
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| − | An appropriate level of response in developing administrative environmental controls to mitigate the risks in these areas is important. The reader is referred to the Airborne Precaution Risk Classification Matrix proposed in the [[Building Engineering Services]] guidance article and the discussion of isolation rooms in the [[Adult Inpatient Services]] guidance article for further information
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| − | === Pest control ===
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| − | A pest control policy must be implemented to combat vector transmission. It is common practice to contract pest control services. Even when this service is outsourced, record of the number of vermin encountered and exterminated should be collected and maintained to assess the effectiveness of the pest control programme. These records must be maintained and reviewed by the ICT.
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| − | Important elements in a pest control programme include the following:
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| − | • Baiting and trapping on the facility perimeter
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| − | • Waste management practice that does not create an attraction for pests
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| − | • Screening of ventilation, window and access openings where vector and vehicle transmission presents a high transmission risk (kitchens, plant rooms, wards in high malaria-risk areas)
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| − | • Bird repellents for enclosed and semi-enclosed areas that attract birds
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| − | === Maintenance ===
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| − | Without effective planned maintenance, any IPC plan could not be truly effective. Maintenance programmes and considerations that directly affect the IPC outcomes include the following:
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| − | • Legionella control programme
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| − | • Filter maintenance
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| − | • Plant room and service space hygiene
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| − | • The in-house stock of critical spare parts (fan belts, filters, breakers etc.)
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| − | •
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| − | == Additional transmission-based controls ==
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| − | === Airborne contamination control ===
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| − | In the context of high tuberculosis (TB) burden in resource-constrained settings, an effective airborne contamination control policy is critical in healthcare facilities.
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| − | A variety of control measures are available to break the chain of TB infection. These measures can be grouped into administrative controls, environmental controls and personal protective controls.
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| − | The World Health Organization (WHO) describes the elements of a hierarchy of controls ([https://www.who.int/tb/publications/2019/guidelines-tuberculosis-infection-prevention-2019/en/ World Health Organization, 2019]). Administrative controls are awarded the greatest impact, while personal respiratory protection the least weight of the three. Figure 2 represents this hierarchy of controls.
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| − | <gallery>
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| − | HOC.jpg|Figure 2: Hierarchy of controls, weighted by effectiveness
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| − | </gallery>
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| − | === Administrative controls ===
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| − | Healthcare facilities need to develop a policy and action plan to guide their TB infection control programmes. A committee should be formed and a leader appointed in writing. Members of the committee should be appointed in writing and the terms of reference developed.
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| − | An annual risk assessment should be conducted in order to understand the risk for transmission throughout a health facility. The results of the risk assessment should inform the development of risk management plans and corrective actions taken.
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| − | Essential elements of a good TB infection control programme should include the following:
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| − | • Training of healthcare workers
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| − | • Health education for patients
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| − | • Screening of patients for TB symptoms
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| − | • Triaging, separation and fast-tracking of patients
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| − | • Provision of Isoniazid Preventive Therapy (IPT) for eligible patients
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| − | • Cough etiquette and provision of surgical masks
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| − | • Screening of healthcare workers and the provision of voluntary counselling and testing (VCT)
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| − | • Provision of IPT to eligible healthcare workers
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| − | === Environmental controls ===
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| − | Essential elements of a good programme for environmental control should include the following:
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| − | • There should be outside sputum collection points or sputum collection booths for internal use.
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| − | • Overcrowded and cramped waiting areas should be avoided.
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| − | • Waiting in passages should be prohibited.
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| − | • Outside waiting areas should be created to reduce overcrowding.
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| − | • In order to optimise natural ventilation, windows with large opening parts should be installed. The opening parts should be at least 20% of the floor area.
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| − | • Where mechanical ventilation is installed in high-risk areas, air flow rates should be equal to the greater of 12 air changes per hour or 80 litres per second per person.
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| − | • These mechanical systems should be maintained on a regular basis and a maintenance log should be kept.
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| − | • Where ultraviolet germicidal irradiation is used, installation should be supervised by a competent person. The efficacy of installations should meet recognised standards and should be properly maintained and a maintenance log kept.
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| − | The reader is referred to the IUSS: GNS Building Engineering Services guidance document for additional guidance on environmental controls.
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| − | === Personal respiratory protection ===
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| − | The development of a good respiratory protection programme is very important for health facilities. This programme should include the following:
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| − | • Medical evaluation of staff to check if they are fit to use respirators.
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| − | • Choice of respirators should meet international standards.
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| − | • Training of staff in respirator use.
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| − | • Fit testing to determine which sizes of respirators to procure for staff.
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| − | The reader is referred to the [[TB Services]] article and the [http://www.tbcare1.org/publications/toolbox/tools/ic/TB_IC_Implementation_Framework.pdf Implementing the WHO Policy on TB Infection Control in Healthcare Facilities], Congregate Settings and Households guidance documents for additional guidance on PPE usage and care.
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| − | === Ultraviolet germicidal irradiation ===
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| − | Ultraviolet germicidal irradiation (UVGI) has been effective in disinfecting contaminated water, air and surfaces, but it should be considered a supplement to other infection control measures. UVGI has a number of proven case uses. However, in each case, maintenance, system design and correct protocols are significant hurdles to cross in terms of the broad adoption of the technology.
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| − | Water disinfection
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| − | UVGI is an effective localised method of disinfecting water streams. As UVGI is not dispersive, any contaminant sources or reservoirs downstream of the point of disinfection are unaffected by the system. Monitoring and maintenance of water-system UVGI installations are quite onerous and challenging.
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| − | Air distribution ducting
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| − | The disinfection of air streams in air distribution ducting can be quite effective when viewed in isolation. However, when considered a part of a larger regulated system, the application of in-duct UVGI is quite limited. In most applications that require the requisite sterility in the supply, air quality would need the additional particle filtration offered by high-efficiency filter (HEPA). Where HEPA filters are installed, in-duct UVGI offers no real additional advantage. The same argument applies to exhaust air treatment, where UVGI cannot offer the same level of confidence, redundancy, and particle and odour control as regular air filtration.
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| − | Air-handling units and cooling coils disinfection
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| − | UVGI has proven effective in reducing the cleaning maintenance required on heating, ventilation and air conditioning (HVAC) cooling coils. In these applications, UVGI should be used in association with course air filtration. (ASHRAE 2013)
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| − | 3.3. Fumigation and decontamination
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| − | Gaseous fumigation is an effective and universal method for space and surface disinfection. It is important when planning and designing healthcare spaces to consider whether an area would be subject to gaseous fumigation. Where this is a requirement, careful planning should be undertaken to ensure the correct technology could be adopted. The following aspects should be considered when selecting a fumigation technology for a considered space:
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| − | • Safety – Many fumigation solutions are highly noxious, toxic, corrosive or carcinogenic. The proximity and permeability of the considered space in relation to sensitive areas and equipment should be considered.
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| − | • Effectivity – Fumigant effectiveness varies between fumigant and agent combinations. At the planning stage, it is helpful to understand the agents that are targeted, as well as the operational time that is required and available for fumigation activities.
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| − | • Cost – Cost becomes a significant planning factor when considering customised installations, exclusive technologies or registered trademarks. In addition, many of the newer technologies offer significant improvements in effectiveness and safety at a significant additional cost.
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| − | When selecting a fumigation technology, the confluence of safety, life cycle cost, service and pathogen-specific decontamination effectiveness needs to be taken into account.
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| − | Terminal decontamination plans need to be developed and implemented for rooms used by highly infectious patients.
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| − | Sterilisation equipment should be licensed and obtained from an approved supplier with a manual, service plan and service record as required.
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| − | 3.4. Filtration
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| − | HEPA filtration assists ventilation systems in reducing airborne transmission by preventing the recirculation of airborne contaminants. This can be achieved within the central HVAC system or through portable air cleaners (PACs).
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| − | PACs can, in theory, aid in the removal of airborne contaminants if they are sufficiently sized and appropriately designed. The reader should be warned that the majority of systems that are commercially available at a reasonable cost compared to heating ventilation and air-conditioning (HVAC) based filtration systems have not yet been proven to offer significant effectiveness against airborne transmission.
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| − | • Sizing - in order for PACs to offer adequate performance, they should reasonably be equivalently sized to regular fan-filter systems. Since these systems are seldom designed with the considered room’s ideal ventilation effectiveness in mind, they may even need to be larger than that required from a central HVAC system to achieve equivalent results.
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| − | • Efficacy studies are presently inconclusive.
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About IUSS
This website is the repository for documents and tools developed under the Infrastructure Unit System Support - IUSS - project, an initiative of the National Department of Health, under the leadership of Dr Massoud Shaker and Mr Ndinannyi Mphaphuli. The purpose of the documents is to provide guidance and improved healthcare infrastructure delivery.
Application
IUSS voluntary standard/ guidance documents have been prepared as national Guidelines, Norms and Standards for the benefit of all South Africans. They are for use by those involved in the procurement, design, management and commissioning of public healthcare infrastructure. Many have been made mandatory via gazette and are clearly marked with this status on the front cover and in footers on each page. IUSS material may also be useful information and reference to private sector healthcare providers.
Use of the guidance does not absolve professional responsibilities of the implementing parties, and it remains incumbent on the relevant authorities and professionals to ensure that these are applied with due diligence, and where appropriate, deviations processes are exercised.
Gazetted guidelines are for public reference information and for application by Provincial Departments of Health in the planning and implementation of public sector health facilities. The gazetted guidelines will be applicable to the planning, design and implementation of all new public-sector building projects (including additions and alterations to existing facilities). Any deviations from the voluntary standards are to be motivated during the Infrastructure Delivery Management Systems (IDMS) gateway approval process. The guidelines should not be seen as necessitating the alteration and upgrading of any existing healthcare facilities.
Development process
The development process initiated in 2010 was to consolidate information from a range of sources including local and international literature, expert opinion, practice and expert group workshop into a first-level discussion status document. This was then released for public comment through the project website, as well as national and provincial channels. Feedback and further development were consolidated into a second-level development status document which again was released for comment and rigorous technical review. Further feedback was incorporated into proposal status documents and formally submitted to the National Department of Health. Once signed off, the documents were gazetted.
Documents and tools have been assigned a version number and date. The National Department of Health will establish a Health Infrastructure Norms Advisory Committee, which will be responsible for the periodic review and formal update of documents and tools. Documents and tools should therefore always be retrieved from the website repository www.iussonline.co.za or Department web portal (forthcoming) to ensure that the latest version is being used.
Updating is currently limited to quarterly cost models updates only. Feedback is welcome and updates will be posted if these become available.
Acknowledgements
IUSS Norms and Standards were developed with extensive input from numerous individuals and the contributions are appreciated and noted in individual publications.
