Infection control in the built environment 00-09 2016.pdf · Welsh Health Building Note 00-09 -...

WHBN 00-09Welsh Health Building Note

Infection control in the built environment

Disclaimer

The contents of this document are provided by way of general guidance only at the time of its publication. Any partymaking any use thereof or placing any reliance thereon shall do so only upon exercise of that party’s own judgementas to the adequacy of the contents in the particular circumstances of its use and application. No warranty is given asto the accuracy, relevance or completeness of the contents of this document and NHS Wales Shared ServicesPartnership – Specialist Estates Services shall have no responsibility for any errors in or omissions there from, or anyuse made of, or reliance placed upon, any of the contents of this document.

Note: Heath Building Notes (HBNs) and Health Technical Memoranda (HTMs) issued by the Department ofHealth in England are being superseded by specific Welsh editions, which will be titled Welsh Heath Building Notes(WHBNs) and Welsh Health Technical Memoranda (WHTMs) and which will use the same numerical coding.Where an HBN or HTM is referred to in the text, refer to the relevant publications page on the NHS Wales SharedServices Partnership – Specialist Estates Services website for the latest approved document.

Intranet: http://howis.wales.nhs.uk/sites3/page.cfm?orgid=254&pid=39106

Internet: http://www.wales.nhs.uk/sites3/page.cfm?orgid=254&pid=6142

Published by NHS Wales Shared Services Partnership – Specialist Estates Services

This guidance is based on the Health Building Note 00-09:2013 Infection control in the build environment guidancepublished by the Department of Health

This publication can be accessed from the NHS Wales Shared Services Partnership – Specialist Estates Serviceswebsite www.wales.nhs.uk/ses

© NHS Wales Shared Services Partnership – Specialist Estates Services 2016

Cover image courtesy of James Archer, the US Centers for Disease Control and Prevention (CDC), depictsPseudomonas aeruginosa bacteria, which is a prototypical multi drug resistant pathogen associated with nosocomialinfections

Cover designed by Keith James

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Welsh Health Building Note 00-09 - Infection control in the built environment

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PreambleThis Welsh Health Building Note 00-09 supersedes andreplaces all versions of Health Facilities Note 30(HFN30).

IntroductionThe importance of a clean, safe environment for allaspects of healthcare should not be underestimated. It isimportant that healthcare buildings are designed withappropriate consultation, and the design facilitates goodinfection prevention and control (IPC) practices and hasthe quality and design of finishes and fittings that enablethorough access, cleaning and maintenance to take place.Good standards of basic hygiene, cleaning and regularplanned maintenance will assist in preventing healthcareassociated infection (HCAI). Such schedules are morelikely to be successful when undertaken on a proactiveand reactive basis, and are more likely to reducecontamination and risks to patients when the buildenvironment reflects such needs.

Research and investigation have consistently confirmedthat the healthcare environment can be a reservoir fororganisms with the potential for infecting patients. ForHCAIs to be reduced, it is imperative that IPC measuresare designed-in at the very outset of the planning anddesign stages of a healthcare facility new build orrenovation project and that input continues up to, intoand beyond the final building stage.

Designed-in IPC means that designers, architects,engineers, facilities managers and planners work incollaborative partnership with IPC teams, healthcare staffand the users to deliver facilities in which IPC needshave been anticipated, planned for and met.

Welsh Health Building Note 00-09This guidance discusses the various stages of a capitalbuild project from initial concept through to post-project evaluation and highlights the major IPC issuesand risks that need to be addressed at each particularstage to achieve designed-in IPC.

The principles of this guidance can be applied to allhealthcare facilities (guidance on mental health settings isincluded in this revision – see Appendix 1). Althoughthe specific recommendations or processes it outlinesmay not necessarily be relevant to all types of healthcare

facility or organisation, they may become moreapplicable as certain healthcare services and functions aredecentralised.

The most important points raised by the document arethe need:

• for an awareness of appropriate Welsh HealthBuilding Notes and Welsh Health TechnicalMemoranda pertinent to new build orrefurbishment projects;

• for timely, comprehensive and collaborativepartnership between all parties to achieve IPC goalsspecific to each construction project;

• for all stakeholders to understand the basicprinciples of designed-in IPC;

• to understand and assess the risks of infectionrelating to construction projects and the physicalenvironment;

• for robust project management in relation to IPCconsiderations for all new-build and refurbishmentprojects;

• for a system of signing-off plans and meeting notesto include all participating parties including theIPC team;

• for quality control throughout the duration of theconstruction project;

• to regularly consult with and update all relevantparties throughout the project;

• to continually monitor developments.

ExclusionsThis document does not deal with the operationalmanagement of IPC issues (for example, dealing withoutbreaks on a ward) or day-to-day standard IPCprecautions. These issues will be dealt with locally via thehealthcare organisation’s own policies and procedures onIPC.

This guidance does not apply to prison hospitals.

ImportantIt is essential that the IPC team is consultedthroughout every stage of a capital project and theirexpertise taken into account.

Overview

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Airborne transmission: A mechanism of transmission ofan infectious agent by aerosols – that is, microbes in verysmall particles that can travel long distances but areusually relatively inefficient at transmitting infection.This route is only relevant for a small number ofinfections, principally tuberculosis.

Cohorting: Placing patients infected or colonised withthe same infection (but with no other infection) in adiscrete clinical area where they are cared for by staff thatare restricted to these patients.

Contact: Association with an infected person or animalor a contaminated environment such that there is anopportunity to acquire the infection.

Cross-infection: An infection either due to a microbethat came from another patient, member of staff orvisitor in a healthcare establishment, or due to a microbethat originated in the inanimate environment of thepatient.

Dead-legs: In a water supply and distribution system,pipes that are capped off (blind ends) or rarely used(dead-legs) or not part of a main circulation system (forexample, a branch off the main system).

Direct contact: Refers to a mode of transmission ofinfection between a colonised/infected host and asusceptible host. Direct contact occurs when skin ormucous surfaces touch (for example, via hand contact).

En suite: A room attached to a single room or multi-bedroom that has a shower, rimless WC and wash- handbasin (with extract ventilation).

Healthcare associated infections (HCAI): Encompassesany infection by any infectious agent acquired as aconsequence of a person’s treatment or which is acquiredby a healthcare worker in the course of their duties.

Immunocompromised patient: A patient whoseimmune response is deficient because of an impairedimmune system.

Mode of transmission: See Transmission

Non-touch (taps): Includes foot-operated, knee-operated, elbow-operated and sensor taps.

Pathogen: A bacterium, virus or other microorganismthat can cause disease.

Scale: A ratio representing the relationship between aspecified distance on a sketch plan and the actualdistance on the ground. For example, at the scale of1:50, 1 unit of measurement on the plan equals 50 unitsof the same measurement on the ground.

Slop-hopper: A disposal unit used for the disposal ofliquid or solid waste.

Spore: Some species of bacteria, particularly those of thegenera Bacillus and Clostridium, which are a significantcause of infection in humans, develop highly resistantstructures called spores. They may remain viable formany years but when the environment conditionsimprove the spores germinate and the bacterial cell insidestarts to multiply again.

Thermostatic mixing valves (TMVs): Valves that mixthe hot and cold water in the system to provide water ata predetermined safe temperature.

Transmission: Any mechanism by which an infectiousagent is spread from a source or reservoir to a person.Modes of transmission of infection include directtransmission involving direct transfer of microorganismsto the skin or mucous membranes by direct contact;indirect transmission involves an intermediate stagebetween the source of infection and the individual (forexample, infected food, water or vector-bornetransmission by insects); airborne transmission involvesinhaling aerosols containing microorganisms (as is thecase with diseases such as legionnaires’ disease andtuberculosis).

Glossary of terms

Contents

Overview 3

Glossary of terms 4

Chapter 1 Context 8

Chapter 2 Understanding the planning process 9Introduction The planning processStages of IPC input

Preparation of a business case to support the viability of the projectProject fundingConcept/feasibility studyDesign stageContract Pre-handover inspectionsCommissioning the facilityPost-project evaluation

Chapter 3 Designing a healthcare facility: issues to consider 17Examples of design principlesSizing/space

Patient groupsPrivacy and dignity: same-sex accommodation

Isolation facilitiesThe role of isolation facilities in preventing cross-infectionDesignCeilingsDoorsLobbiesEngineering requirements for special ventilated isolation rooms/suites

Hand-hygiene facilitiesWash-hand basin designClinical wash-hand basin provisionWater/tapsSoap dispensersHand dryingSinks and disposal facilities

Footwear washing facilitiesAncillary areas

Dirty utility room

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Clean utility roomClean linen storeTreatment roomEquipment decontamination roomDisposal roomCleaners’ roomDay room/patient waiting areasPlay areaNappy-changing areaVisitors’ toilets

StorageStorage for patients’ possessions

Interior finishes/fixtures and fittings FlooringWallsCeilingsLightingDoorsWindowsFinishesFixtures and fittingsWork surfacesSoft furnishingsCurtains and blindsRadiators

Changing facilitiesOutpatient and day surgery changing facilitiesClinical staff changing facilitiesMaintenance staff

Laundry and linen servicesCatering/food hygieneHealthcare waste

Responsibilites under ‘duty of care’Waste segregation and storageWaste receptaclesClinical waste generated in primary care and community settingsStorage capacity

Engineering servicesPlanned preventative maintenanceHeating/temperature controlHot and cold water systemsIce for patient consumptionBedhead servicesWastewater and sanitationBedpan washer-disinfectors/maceratorsMedical gas vacuum systemsPneumatic air tube transport systems

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Appendix 1: Mental health and learning disability settings 33

Appendix 2: Example of a typical IPC checklist 34

Appendix 3: IPC risk assessment during construction/refurbishment of a healthcare facility 37

Appendix 4: Microorganisms and infections: a guide for designers 40

References 41

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Contents

1.1 High standards of environmental hygiene andclinical practice in healthcare facilities have beenidentified as being important in minimising therisk of the transmission of infection. The design,planning, construction, refurbishment andongoing maintenance of the healthcare facility alsohave an important role to play in the preventionand control of infection. The physicalenvironment has to assist, not hinder, goodpractice.

1.2 The Chief Medical Officer’s (England) report oninfections and the rise of antimicrobial resistance(Davis 2013) stated that the design, constructionand maintenance of healthcare facilities have asubstantial bearing on the risk of developing ahealthcare-associated infection.

1.3 It is important that infection prevention andcontrol (IPC) is designed-in at the planning anddesign stages of a new-build or refurbishmentproject and that input continues up to the finalbuild stage. Designed-in IPC means that designers,architects, engineers, facilities managers andplanners work in collaborative partnership withIPC teams to deliver facilities in which IPC needshave been planned for, anticipated and met.

1.4 This guidance highlights IPC issues and risks thatneed to be addressed at each particular stage toachieve designed-in infection control. Theprinciples of this guidance can be applied to allhealthcare facilities.

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Chapter 1 Context

ImportantThe infection prevention and control (IPC) teamshould be consulted throughout every stage of a capitalproject and their views taken into account.

Introduction2.1 For IPC teams to effectively participate in the

planning process for both new-build andrefurbishment projects, it is essential for them tounderstand the process from its inception tocompletion and commissioning.

2.2 It is important that the IPC team and the chiefexecutive officer or senior responsible owner sign-off each stage of the project. This will ensure thatIPC is considered throughout. An example IPCchecklist that can be adapted for use during thedifferent stages of a capital project is shown inAppendix 2.

2.3 IPC is a fundamental imperative in the planningand design stages of a healthcare facility, yet it isoften overlooked or compromised throughout thelifecycle of the project. IPC teams should beinvolved throughout all phases of construction andrenovation projects to reduce IPC risks. Failure toassess these risks properly can lead to expensiveredesign later and expose the patient andhealthcare worker to infection hazards.

2.4 To provide and maintain a clean and appropriateenvironment in premises that facilitate theprevention and control of infections, a healthcareprovider should ensure that it has:

a. made a suitable and sufficient assessment of therisks to the person receiving care with respect toIPC;

b. identified the steps that need to be taken toreduce or control those risks;

c. recorded its findings in relation to the first twopoints;

d. implemented the steps identified; and

e. put appropriate methods in place to monitor therisks of infection to determine whether furthersteps are needed to reduce or control infection.

The planning process2.5 This section explains the planning process, which

comprises the following stages (see Figure 1):

a. Preparation of a business case to support theviability of the project.

b. Project funding.

c. Concept/feasibility study.

d. Design stage.

e. Contract.

f. Project monitoring/construction.

g. Pre-handover inspections (‘snagging’).

h. Commissioning the facility.

i. Post-project evaluation.

2.6 The aim is to prompt those with overallresponsibility for managing capital schemes toinclude IPC advice at the right time in order toprevent costly mistakes.

Stages of IPC inputPreparation of a business case to support theviability of the project

2.7 The preparation of a business case is the processthat supports a healthcare organisation’ssubmission for funding of new capital projects.

2.8 A business case should convincingly demonstratethat the project is economically sound, isfinancially viable (affordable to the providers andpurchasers) and will be well-managed. Above all, abusiness case for any investment should show thatit will benefit patients.

2.9 The involvement and support of a wide range ofmanagers and staff may be vital to the success ofthe business case, both to determine therequirement and scope of the investment and alsoto participate in subsequent stages of planning.

2.10 It is important therefore at this stage to identifyand involve key people who have a direct interestin the end product; this will include members ofthe IPC team along with other leading clinicians,nursing managers and departmental heads.

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Chapter 2 Understanding the planning process

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Figure 1 The Planning Process

PLANNING PROCESS

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ISSUES

Time period

Concept

Feasibility study

Sketch plans

Detail planning/design

Contract

Monitoring/construction

Pre-handover inspectionCommissioning/equip

Post-project evaluation

1 in 200 (some preliminary designs)

1 in 200: draft activity data sheets (equipment lists - usually wish-lists)

Trust input to equipment budget

1 in 50: fixtures & fittings(fixed items in Group 1)

• Check for any changes made to originalagreements/plans

Impact of design on:• Space/sizing• Decontamination• Specialist areas• Engineering services (eg ventilation & water

systems)

Need to assess if design can support:• Storage (linen, waste, patient & cleaners’

equipment)• Ancillary areas• Changing facilities• Location of hand hygiene facilities

Discuss finer detail of:• Location & type of fixtures and fitting• Equipment schedules• Airflows in theatres• Wastewater & sanitation• Medical gas vacuum systems

Issues to consider:• Control of legionella and aspergillus

Issues to consider:• Alterations to agreed design• IPC risk assessments & control measures

(fungal spores etc)

Areas needing inspection/testing to demonstratecompliance with IPC:

• Theatres• Special ventilated isolation rooms

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2 Understanding the planning process

2.11 Normally the input from the project team shouldbe managed by the project director, but for largerand more complex schemes a project manager,reporting to the project director, may be appointedto conduct the detailed work and manage thebusiness case team.

2.12 Specifically at this stage, the project team will:• set the strategic context,

• define objectives and benefit criteria,

• generate options,

• measure the benefits,

• identify/quantify costs,

• assess sensitivity to risk,

• identify the preferred option,

• present the outline business case.

Issues to be addressed by the IPC team2.13 Issues to be addressed by the IPC team at this

stage will include:

• storage (including waste collection points anddelivery areas) and equipment cleaning areas;

• flooring;

• dirty utilities;

• cleaners’ rooms;

• hand-washing facilities;

• furnishings and fittings;

• appropriate finishes which permit efficientcleaning methods, equipment and safechemicals to be used;

• types and numbers of isolation facilities;

• specific products with IPC implications andapplicable regulations (for example, type ofpipes, Legionella precautions).

2.14 Specifically at this stage, the IPC team will needto:

• agree the requirements for IPC in the designand planning of the project;

• assess the progress of the building/refurbishment project in relation to compliancewith IPC specifications – any unexpectedproposed deviations from the infection controlspecification needs to be agreed with the IPCteam at the earliest opportunity;

• ensure that the designers/planners recognise thebenefits of not cutting corners on IPC issues.

Project roles and responsibilities2.15 A comprehensive approach to planning will

include consultation with the appropriatespecialists from inception through to post-projectevaluation.

2.16 The project organisation (see Figure 2 ) shouldcomprise (relative to the size of the project):

a. Internal organisation of the healthcare provider:

– Healthcare provider’s project board (shouldmonitor cost and progress of all capitalinvestment projects at regular meetings. Ifproblems are identified, it needs to be satisfiedthat appropriate steps are being taken).

– Chief executive officer (given the project-specific role, title, and responsibility of projectowner).

– Project team (comprising senior staff within theprovider organisation who have an interest inthe project and whose activities will be affectedby the project, for example staff from clinicalareas such as IPC).

– Project director (responsible for projectmanagement).

– Professional adviser (experienced inconstruction and design, especially ofhealthcare facilities).

– User panel (representatives of each of therelevant service departments, in each caseauthorised to define their department’s needsand to review and agree how those needs are tobe met) along with patients and carers.

b. External resources:

– Project manager.

– Other consultants.

Project funding

Capital projects 2.17 The contract between the health board or Trust

and the supply chain or contractor is critical and itis important that the service representatives/keystakeholders and particularly in this instance theIPC team are clear about the options available andthe evidence to back up any decisions they adviseon.

2.18 The IPC team will need to make sure that certaincriteria are embedded into the contract in such away that important decisions on design or builddo not go ahead without being signed off by them.The team will need:

• access to all relevant and up-to-date plans andinformation on operational policies;

• access to any meetings deemed relevant to themor timely minutes from those meetings thatthey cannot attend;

• access to sites and departments as buildingwork progresses at the appropriate time in the

construction programme, for exampleenvironmental rounds with checklists based onproject objectives;

• regular communication between the internalproject manager and the project team;

• involvement in decision-making for anycategory of equipment the project team willpurchase;

• involvement in any contracts for supportservices (such as catering, cleaning, linen, orsterile services) that the project team may beproviding;

• access to certain areas for any microbiologicaltesting deemed necessary at commissioning andprior to handover, for example theatres,pharmacies and clean rooms in sterile servicesdepartments.

Concept/feasibility study2.19 The planning process starts with the identification

of a ‘need’ by the users. The development of thisneed will involve feasibility studies to enable adesign brief or output specification to bedeveloped.

2.20 Where existing facilities are being modified orextended, the IPC team should review alloperational policies and procedures, for example:

• the effect the number of beds or departmentswill have on current policy and practice such assterile services, catering, waste disposal andcleaning;

• contracts for support services such as catering,cleaning, linen, sterile services etc that theproject team may be providing;

• additional specialist areas that may requireadditional IPC and laboratory services

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Figure 2 Project organisation

Healthorganisation board

Chief executive

User panel

Project board

(IPC input here)

Quantity surveyor

SuppliersDesigners

Adviser Project director

Project manager

Contractors

(consideration should also be given to acquiringspecialist advice from external agencies);

• location and relationships between departments;

• the number of surgical instruments andprovision of decontamination facilities whenplanning extra theatres;

• impact of proposed design on ventilation andwater systems;

• future maintenance requirements that minimisethe potential risks to patients and allow for it tobe effectively carried out.

2.21 To assist with understanding and mitigating therisks associated with bacterial contamination ofwater distribution and supply systems, it isrecommended that organisations should develop awater safety plan (WSP), which provides a risk-management approach to the microbiologicalsafety of water and establishes good practice inlocal water distribution and supply. Thoseorganisations with existing robust watermanagement policies for Legionella will alreadyhave in place much of the integral requirementsfor developing a WSP.

For further guidance, see:

• Health Technical Memoranda 04-01 Parts A andB:2006 The control of Legionella, hygiene, “safe” hotwater, cold water and drinking water systems; and

• Welsh Health Technical Memorandum 04-01:2014Addendum: Pseudomonas aeruginosa – advice foraugmented care units.

Design stage

2.22 The design brief or output specification shouldhighlight the importance of design solutions for IPC.

2.23 At this stage, the IPC team will need to follow upany input they have had in the initial design brief.Sketch plans should be available to the team toexplain how the design brief fulfils theirrequirements at the 1:200 sketch design and 1:50scale detail design stages of the project.Suggestions for improvement in operability areimportant at this stage.

2.24 At the end of each part of the design stage, theproject team and the IPC team will be required tosign-off the information issued and reviewed. Thissignifies that the design brief requirements andchanges agreed during discussions have beenincorporated. Any subsequent changes made aftersign-off should be made via a ‘change protocol’,which can have significant cost and programmeimplications for the project.

Sketch plans (1:200 scale designs)2.25 At this stage, 1:200 scale outline departmental

layout drawings showing rooms outlined withindepartments will be available and discussions heldwith the design team. The IPC team needs toassess whether the facility is designed to supportthe prevention and control of infection. Examplesinclude:

• confirming operational procedures;

• establishing baseline and future staffing profiles;

• establishing baseline and future revenuebudgets;

• establishing equipment requirements;

• strategy for equipping;

• procurement and selection of furnishings andequipment;

• missing rooms/facilities;

• appropriate placing and accessibility of hand-hygiene facilities;

• single-bed rooms suitable for patient isolationand special ventilated isolation rooms;

• ventilation and air conditioning systemsincluding the level of filtration where specialisedventilation is required;

• water supply, heating and plumbing;

• storage for:

– personal protective equipment (PPE)

– movable equipment

– clean patient items

– clean linen

– healthcare waste, including sharps, and usedlinen;

• surfaces: ceilings, walls, work surfaces, floorcoverings and furnishings;

• utility rooms: dirty, clean, holding, workrooms,cleaners’ rooms;

• changing rooms;

• pneumatic delivery systems.

Detail planning/design (1:50 scale designs) – earlyperiod2.26 At this point the 1:50 scale designs indicating

equipment and furniture layouts and room datasheets will be available. There may be two or morestages to the consultation process.

Detail planning/design (1:50 scale designs) – laterperiod2.27 The IPC team will need to discuss finer details such

as location and type of fixtures and fittings (for

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example, type and size of wash-hand basins andairflows in theatres). Room elevations of selectedtypical generic rooms should also be made available.

2.28 Equipment schedules for groups 1, 2 and 3 (seenext page) based on room data sheets/layouts areprepared at this stage. It is important that there isactive involvement of the IPC team at this point,as it may have significant design implications. Thiswill ensure that this equipment is compatible withIPC needs and also that proper inspection andtesting can be agreed.

2.29 A final review of room layouts, equipment, fittingsand room data sheets should be carried out at theend of this stage, as this is where the final sign-offby the project team and the IPC team occurs.

2.30 Any changes made during construction or aftercompletion could have a significant adverse impacton costs and the building project.

2.31 Items available for transfer from an existing facilityshould also be identified, which will allowschedules for new equipment to be prepared andcosts identified.

Group 1

Items that are supplied and fixed under the terms of abuilding/engineering contract and funded within theworks cost. These are generally large items of plant/equipment that are permanently wired/installed, forexample:

• specialist equipment best suited to central purchasingarrangements;

• taps, sinks and wash-hand basins. Excluded from thisgroup will be items subject to late selection due toconsiderations of technical change, for exampleradiodiagnostic equipment. Group 1 items arespecified at the design stage.

Group 2

Items that have implications in respect of space/construction/engineering services and are installedunder the terms of building engineering contracts, butare purchased by the healthcare provider under aseparate equipment budget, for example:

• paper towel dispensers;

• soap/scrub dispensers;

• cupboards;

• shelving;

• washer-disinfectors, including bedpan washer-disinfectors or macerators

• washing machines;

• worktops.

Group 3

Items that have implications in respect of space and/orconstruction/engineering services and are purchasedand delivered/installed directly by the healthcareprovider, for example:

• small refrigerators;

• furniture;

• ventilators;

• monitors;

• trolleys.

Group 4

Items that may have storage implications but otherwisehave no impact on space or engineering services, forexample surgical instruments.

Contract2.32 Tender documents sent to potential companies

should include any statements the healthcareprovider/project team may have about IPC thatmay affect any successful contractor’s employees. Itshould also comprise IPC requirements such as thecontrol of Legionella and other microorganisms(for example, aspergillus).

Construction2.33 Monitoring will not normally be required by the

IPC team until the works are at a stage when sitevisits can be arranged. At this point, the IPC teamshould visit the site so that that they can make asuitable ongoing assessment of the layout of thedepartments. This will facilitate the team toidentify any differences/problems from the agreeddesign.

Surveillance and monitoring during renovation orconstruction work adjacent to an existing facility2.34 Where patients with increased susceptibility to

infection may be placed at risk, it is importantthat an appropriate risk assessment is carried at anearly stage in advance of any building works,including disturbance/alterations to the watersystem/building fabric/ventilation systems (seeAppendix 3 ).

2.35 Quality assurance of IPC interventions duringbuilding work should be based on a suitable andsufficient risk assessment of the precautionsneeded and frequent audit of the control measuresin the risk assessment.

2.36 Since airborne fungal spores can travel significantdistances, this will apply generally to all works inthe immediate vicinity or within the boundary of

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the healthcare facility. It is strongly advised thatany recommendations informed by the riskassessment should be incorporated into thebuilding (see Appendix 3) or engineering projectso as to minimise risk both during constructionand in future use.

2.37 Where water systems are closed down, a Legionellarisk assessment should be undertaken. This shouldinclude the risk posed to adjacent water systems bybacterial overgrowth in dead-legs. Flushing andhyperchlorination should also be considered whenthe water system is reinstated.

See Health Technical Memoranda 04-01 and WelshHealth Technical Memorandum 04-01Addendum:2014 Pseudomonas aeruginosa – advice foraugmented care units.

Pre-handover inspections2.38 The IPC team should conduct periodic walk-round

inspections (commonly referred to as ‘snagging’visits) during the construction works and also atthe completion of the construction works prior toformal handover. They should raise any concernsand outstanding items with the project managerresponsible for the capital scheme, with issues thatconstitute a high risk being appropriatelyprioritised. The project manager should thenaddress these issues with the contractor and ensurethe necessary works are completed prior to formalhandover of the construction project.

Commissioning the facility2.39 Upon completion of construction, the facility

should be brought into use; depending on thecomplexity of the task involved, a commissioningmanager and team may be needed. Seniormanagers, specialist teams and users should befully involved in the process.

2.40 Technical commissioning of the building, servicesand equipment should include any areas thatrequire inspection and testing to demonstratecompliance with IPC standards (for example,theatres, hydrotherapy pools, special ventilatedisolation rooms/suites and clean rooms inpharmacies and sterile services departments).Sufficient time should be built into thecommissioning schedule to enable this and anyrectification of identified problems.

2.41 The commissioning team should establish smallerworking groups that:

• identify policy issues for referral to thecommissioning team or the construction projectteam;

• identify staff training and orientation needs;

• establish the occupation programme for thatuser function, for inclusion into the overallcommissioning master plan.

2.42 By understanding the commissioning process, theIPC team should ensure that they are fullyconsulted and engaged in any working groups inwhich their expertise will have an impact or inwhich requirements to modify services may haverepercussions on other aspects of IPC.

2.43 The IPC team should also be involved in processesfor:

• analysis of commissioning data;

• transfer of facilities;

• phased or staged occupation;

• storage and subsequent cleaning/disinfection ofany furniture or equipment;

• approval of engineering commissioning data foroperating theatres;

• commissioning tests (for example,microbiological air-sampling for operatingtheatres, water testing);

• approval of engineering commissioning data forspecial ventilated isolation room(s);

• site visits;

• staff orientation and training;

• post-handover period;

• decommissioning of redundant facilities;

• period of handover to operational management;

• confirming communication of procedures withinternal and external agencies/users (forexample, ambulance service and patientinformation leaflets).

Post-project evaluation2.44 The purpose of the post-project evaluation is to

improve project appraisal, design, managementand implementation. It typically takes place 12months post-handover and is a learning processthat should not be seen as a means of allocatingblame. There are three stages:

a. project appraisal;

b. monitoring and evaluation of project;

c. review of project operations.

2.45 It is at the third stage when it is useful for the IPCteam to be included in the evaluation teams thatare reviewing project objectives. The outcomes(activity and its consequences) of the project willnot be amenable to evaluation until the facility hasbeen in use for some time. However, if the project

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is part of a phased refurbishment or new build,valuable lessons can be learned and implementedduring ongoing project work.

2.46 It is important that the project is evaluated interms of its original objectives, not in the light ofany new legislation or development. Performanceindicators may be used if these can be measuredretrospectively. Measurable objectives may include:

• activity data;

• patient satisfaction surveys etc;

• compliance with Legionella risk assessments.

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Examples of design principlesDesign to facilitate cleanliness & cleaning

• Use finishes that are impervious, smooth andseamless, as far as practicable.

• Run hard flooring up the walls for a short distanceto provide an easy-to-clean coving.

• Eliminate dead-legs and blind ends in water systems,both in the original design and as the systems aremodified.

• Consider hands-free operation of utilities (forexample, sensor taps, automatic lights, movementsensors for toilet flushes etc).

• Consider hands-free operation of other facilities (forexample, automatic doors, proximity-sensors etc).

• Consider integral blinds as an alternative to curtainsat internal windows.

Encourage desired behaviour (for example,tidiness, hand hygiene)

• Provide sufficient space for activities to take placeand to avoid cross-contamination between adjacentbed spaces.

• Provide sufficient storage for patients’ possessionsand for all supplies to discourage clutter.

• Ensure proper segregation and management ofwaste, including clinical waste and linen.

• Provide sufficient domestic waste receptacles.

• Provide bedside waste disposal facilities for patientuse.

• Design out unnecessary horizontal surfaces (forexample, window sills) in order to discourage clutter.

• Provide enough wash-hand basins and antimicrobialhand-rub dispensers.

• Plan for and deliver good separation of clean anddirty activities.

• Provide sufficient space for storage and preparationof cleaning equipment and materials.

• Provide suitable facilities for cleaning of equipment.

Design for easy cleaning

• It is always best practice to maintain a visibly cleanenvironment that is free from dust and soilage, andacceptable to patients, their visitors and staff.

• Good design can make cleaning immeasurablyeasier, for example:

– Use finishes that are easy to clean.

– In clinical areas, flooring should be seamless andsmooth, slip-resistant, easily cleaned andappropriately wear-resistant.

– Use threshold matting on all external entrances.The type should allow for expected through trafficand easy cleaning.

– Supply pipework should always be concealed.

• There may be pressure to choose the cheapestproducts/design. Attention to whole-life costs,including the cost of cleaning and maintenance, isimportant. Consult with the IPC team beforepurchase/on planning.

ImportantThe IPC team should be consulted throughout abuilding or renovation project and their advice andrecommendations taken account of and documented.

3.1 The recommendations in this section should beapplied to the planning, design and maintenance ofall healthcare buildings – both new build andrefurbishments. They offer a planning checklist thatcan be used throughout the design and planningprocess. Not all items will need to be included inevery project, but using the checklist will ensureareas with IPC implications are not missed. Timingwill vary from project to project but refer toChapter 2 for the sequence of the project process.

3.2 The IPC team should have an integral role inensuring other members of the project team areappropriately informed of any prevention andcontrol-of-infection issues that may arise when:

• an initial site is being considered fordevelopment;

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Chapter 3 Designing a healthcare facility:issues to consider

• the healthcare facility is being designed;

• the healthcare facility is being constructed orundergoing refurbishment;

• the healthcare facility is operational.

3.3 The participation of the IPC team in all phases ofplanning and construction and renovation isessential.

3.4 For the purposes of this document, the followingterminology is used:

a. Multi-bed room – this is a room that containsmore than one bed. It is best practice for multi-bed rooms to have an en suite WC/shower andalso doors to the main ward area.

b. Single bed room – this is a room with space forone patient and usually contains as aminimum: a bed; locker/wardrobe; and clinicalwash-hand basin plus a small cupboard withworktop. (Note: single-bed rooms without ensuite sanitary facilities are not recommended).

c. En suite single-bed room – as (b) but with ensuite shower, WC and wash-hand basin.

d. Special ventilated isolation room – this is as (c)but with a ventilation system that preventsuncontrolled escape of infectious aerosols fromthe room to adjacent areas. It can also provide adegree of dilution of infectious aerosols in theroom for the safety of staff and visitors. Theroom should have extract ventilation thatexceeds its supply, such that gaps in its fabricleak inwards not outwards.

e. Special ventilated isolation suite – as (d) butwith a lobby.

f. Isolation facilities – an umbrella term used inthis document for room types (b)–(e).

Design guidance on critical care areas will be covered inWelsh Health Building Note 04-02 Critical care units,which is in production at time of publication. Pleaseview the Publications page of the NWSSP – SpecialistEstates Services website to check if has been published.

For guidance on mental health units, see Appendix 1.

Sizing/space3.5 The provision of sufficient space in clinical areas,

particularly for each bed space, is one of the mostimportant considerations in the planning anddesign of inpatient accommodation. A risk-basedapproach should be taken to ensure that theenvironment is appropriate for carrying outclinical activities and undertaking manualhandling operations while maintaining a goodstandard of infection control.

3.6 Spacing should take into account the amount of,and ease of access to, equipment around the bedarea and access for staff to clinical wash-handbasins. The principle should be to maintainsufficient space for activities to take place and toavoid cross-contamination between adjacent bedspaces. The exact space needed will vary accordingto numbers and activity of staff and type ofpatient (see ‘Recommendations’ after paragraph3.12).

3.7 Mode of transmission of infection should also betaken into account. This includes:

• direct transmission;

• indirect transmission via fomites (for example,articles such as hoists, mobile X-ray units etc);and

• splash, droplet and airborne transmission.

3.8 The route of spread of infection is a basic conceptin preventing cross-infection, and spacing hasdirect implications for the prevention of infection.

Patient groups

3.9 Floor/bed space is influenced by the type ofhealthcare facility and the type of patient care.There are four distinct patient groups:

• patients requiring acute care, which includestrauma, multi-organ failure, medicalemergencies, planned major surgery and otherlife-threatening emergencies, plus obstetric andneonatal care;

• patients with chronic conditions or sub-acuteconditions;

• patients using mental health or learningdisability inpatient services (note: this guidancedoes not apply to domiciliary care services thatprovide support in people’s own homes);

• patients requiring ambulatory care, whichincludes diagnostic services, day surgery, minorinjuries and attendance at primary care facilitiesand walk-in centres.

3.10 The first three patient groups will require inpatientcare. The volume of care and the degree ofintervention, diagnostic equipment and movementof staff around the patient dictates the bed spaceneeded.

Privacy and dignity: same-sex accommodation

3.11 The need to deliver the highest standards ofprivacy and dignity applies equally to all areas of ahealthcare facility. Achieving these high standardswill usually mean ensuring that men and womendo not have to sleep in the same room or sharetoilet and washing facilities. Patients should not

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http://www.wales.nhs.uk/sites3/page.cfm?orgid=254&pid=6142

have to pass through areas used by the opposite sexto reach their own facilities.

3.12 Same-sex accommodation can be provided in:

• same-sex wards, where the whole ward isoccupied by men or women only;

• single rooms;

• mixed wards, where men and women are inseparate bays or rooms.

Recommendations

• The provision of sufficient space in clinical areas,particularly for each bed space, is one of the mostimportant considerations in the planning and designof inpatient accommodation. A risk-based approachshould be taken to ensure that the environment isappropriate for carrying out clinical activities andundertaking manual handling operations whilemaintaining a good standard of infection control.Welsh Health Building Note 04-01:2014 Adult in-patient facilities states:

• For IPC reasons, it is imperative that staff membersare able to attend to one patient without impingingon the bed space or equipment of a neighbouringpatient. In the majority of cases, the dimensions inWHBN 04-01:2014 should be adequate (althoughbed spaces for critical care areas need to be greater forreasons of circulation space and the equipment usedin these areas).

• It is also important that the physical environmentcomplies with disability access requirements and doesnot compromise the privacy and dignity of patients.

• Spacing should take into account the amount of, andease of access to, equipment around the bed area andaccess for staff to clinical wash-hand basins.

Isolation facilities

See paragraph 3.4 for definitions.

The role of isolation facilities in preventing cross-infection

3.13 The primary aim of IPC is to prevent the spreadof infection between patients, visitors and staff bycontrol or containment of potentially pathogenicorganisms. Many of these organisms can becontrolled by basic IPC practices such as handhygiene and environmental cleanliness, and thiscan be facilitated by single-bed room isolation. Asmall proportion of patients requiring isolationwill require special ventilated isolation facilities.

3.14 The key to effective isolation on general wards isthe provision of sufficient en suite single-bed

rooms to prevent patients known to be a risk forspreading infections being cared for in open wardareas. Single rooms reduce the risk of cross-infection for non-airborne diseases. Most patientsneeding segregation/isolation on general wards canbe isolated effectively in en suite single rooms.

3.15 A risk assessment should be used to informdecisions regarding which patients to nurse insingle-bed rooms. Healthcare providers shouldaudit the use of en suite single-bed rooms todetermine where further local requirements andadaptations are greatest.

3.16 Multi-bed rooms can also be used to cohortinfectious patients if they have an en suite WCand shower, and a door to the main ward area.The possible need for this should be considered atthe design stage.

3.17 Clinical wash-hand basins should be provided inaddition to the general wash-hand basin providedfor patients.

3.18 Storage of, and ready access to, clean PPE isimportant to encourage its use, as well asappropriate waste receptacles for its disposal onceworn.

3.19 Gloves and aprons should be sited outside single-bed rooms, ideally in lobbies.

3.20 Additional storage facilities will be required for thecare and treatment of patients in isolationfacilities, especially if the isolation is likely to lastfor some time:

• the storage of supplies, such as PPE, retained inthe room;

• personal clothing and possessions (see alsoAppendix 1 on mental health settings).

3.21 In accident & emergency departments, a dedicatedroom should be provided for patients with aknown or suspected infectious disease. If airborneisolation is required, this room should be atnegative pressure to the corridor; a lobby is notrequired. This room should also be suitable forgeneral use when not required for isolation.

NoteIt may be necessary to cohort-nurse a group ofinfectious patients in a multi-bed room if insufficientsingle-bed rooms are available. This can be more easilyachieved where wards are divided into two- or four-bedded rooms with en suite sanitary facilities, whichcan be isolated further by closure of doors to the areas.When IPC guidelines are adhered to, research hasdemonstrated that cohort-nursing can successfullycontrol and contain infection in hospital facilities.

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3 Designing a healthcare facility: issues to consider

Design

3.22 WHBN 04-01:2014 Adult in-patient facilitiesprovides guidance on en suite single rooms.

3.23 WHBN 04-01 Supplement 1:2014 Isolationfacilities for infectious patients in acute settingsprovides guidance on the facilities required forisolating infectious patients on acute general wards(source isolation). It also provides guidance on theventilation parameters for a special ventilatedisolation room/suite.

Ceilings

3.24 Removable ceiling tiles are not advised for specialventilated isolation rooms/suites.

Doors

3.25 Doors are critical to the design of a specialventilated isolation room/suite. For specificguidance on source isolation, refer to WHBN 04-01 Supplement 1:2014 Isolation facilities forinfectious patients in acute settings.

Lobbies

3.26 Lobbies facilitate staff compliance with handwashing and use of PPE. They may also beessential with some types of special ventilatedisolation rooms.

Engineering requirements for special ventilatedisolation rooms/suites

3.27 Planned maintenance and revalidation –maintenance and revalidation programmes shouldbe established for special ventilated isolation roomsto ensure the design criteria are maintained andmet at all times. Although it is impossible to givespecific maintenance frequencies, each unit shouldbe included in a planned preventative maintenancethat includes pressure/air flow monitoringequipment at least annually.

Recommendations

• Single-bed rooms with en suite sanitary facilities areoptimum for infection prevention.

• There should be sufficient en suite single-bed roomsto prevent patients known to be a risk for spreadinginfections being cared for in open ward areas.Healthcare providers should audit the use of en suitesingle-bed rooms to determine where further localrequirements and adaptations are greatest.

• The provision of additional isolation facilities shouldbe considered when designing new healthcarebuildings and renovating existing buildings.

Hand-hygiene facilitiesThis section should be read in conjunction withparagraphs 3.178–3.190 on safe hot and cold watersystems.

3.28 Compliance with hand-hygiene guidelines can beimproved by conveniently placed and well-designed hand-hygiene facilities. The importanceof facilities to encourage and facilitate good hand-hygiene practices should be high on the list ofpriorities when designing and planning newhealthcare premises or refurbishment of existingpremises is being undertaken.

Wash-hand basin design

See also Welsh Health Building Note 00-10Part C:2014 Sanitary assemblies and WHBN 00-02:2013 Sanitary spaces.

Clinical wash-hand basins

3.29 The dimensions of a clinical wash-hand basinshould be large enough to contain most splashesand therefore enable the correct hand washtechnique to be performed without excessivesplashing of the user. This can also occur if thewater outlet is placed too high above the basin.

3.30 Clinical wash-hand basins should be wall-mounted using concealed brackets and fixings.They should also be sealed to a waterproof splash-back to allow effective cleaning of all surfaces.

3.31 They should not have a plug or a recess capable oftaking a plug. A plug allows the basin to be usedto soak and reprocess equipment that should notbe reprocessed in such an uncontrolled way.

3.32 Clinical wash-hand basins should not haveoverflows, as these are difficult to clean andbecome contaminated.

3.33 Taps should not be aligned to run directly into thedrain aperture, as contamination from the wasteoutlet could be mobilised (see WHBN 00-10 PartC:2014).

3.34 Healthcare providers should have policies in placeensuring that clinical wash-hand basins are notused for other purposes such as emptying ofpatient bathing water, as this may transfer strainsto the water supply system where they can coloniseexisting biofilms.

See also Appendix 1 on mental health settings.

General wash-hand basins

3.35 All en suite facilities should have a wash-handbasin for use by patients and their visitors.

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3.36 All toilet facilities should have a wash-hand basin.

3.37 Overflows should not be provided as these aredifficult to clean and become contaminated.

3.38 Taps should not be aligned to run directly into thedrain aperture.

3.39 All general wash-hand basins should be sealed to awaterproof splash-back.


Clinical wash-hand basin provision

3.40 All clinical wash-hand basins should be accessibleand should not be situated behind curtain rails.Inconveniently located or insufficient clinicalwash-hand basins are two of the main reasons thathealthcare staff do not comply with hand-hygieneprotocols. There is a need to review the numbersand placement of clinical wash-hand basins as wellas their dimensions (see WHBN 00-10 PartC:2014; WHBN 00-02:2013; and WHTM 04-01Addendum:2014).

3.41 Hand-hygiene facilities should be readily availablein all clinical areas. There should be sufficientnumbers and appropriate sizes of clinical wash-hand basins to encourage and assist staff to readilyconform to hand-hygiene protocols.

3.42 The location and provision of clinical wash-handbasins should ensure that they are all readilyavailable and convenient for use. Having a clinicalwash-hand basin easily available at all times ismore important than compliance to a precise bed-to-basin ratio. For example, in a multi-bed room,if two clinical wash-hand basins are placed side-by-side, both on the same side of the entrance, onlythe one closest to the entrance will get significantuse – the other will form a dead-leg in the waterdistribution system. While it may be marginallymore complex in terms of plumbing, there shouldbe one clinical wash-hand basin on each side ofthe entrance or at opposite sides of the room.

3.43 Guidelines for the appropriate numbers of clinicalwash-hand basins in clinical areas are given inWHBN 04-01:2014 Adult in-patient. Toencourage good practice and to give reasonableaccess, it is recommended that:

• A minimum of one clinical wash-hand basin ineach single-bed room is required. En suitesingle-bed rooms should have a general wash-hand basin for personal hygiene in the en suitefacility in addition to the clinical wash-handbasin in the patient’s bedroom.

• In intensive care and high dependency units(critical care areas), a clinical wash-hand basin

should be available by each bed space. It shouldbe noted, however, that under-usage of basinsencourages colonisation with Legionella andother microorganisms. Designers should beaware of this and, accordingly, should balanceease of staff hand washing with the avoidance ofunder-used wash-hand basins (see also WHTM04-01 Addendum:2014 Pseudomonas aeruginosa– advice for augmented care units ).

• Two clinical wash-hand basins in multi-bedrooms (note that there should be no more thanfour beds in a multi-bed room in line withWHBN 04-01:2014 ).

For guidance on mental health settings, see Appendix 1.

3.44 In primary care and outpatient settings, whereclinical procedures or examination of patients/clients is undertaken, a clinical wash-hand basinshould be close to where the procedure is carriedout (see WHBN 00-03:2013 Clinical and clinicalsupport spaces ).

3.45 WHBN 00-10 Part C:2014 also gives details ofsanitary assemblies for other areas such as kitchensand patient wash areas.

Water/taps

3.46 Health and safety regulations (Workplace (Health,Safety and Welfare) Regulations 1992 ) require thatboth hot and cold running water should beavailable in areas where employees are expected towash their hands.

3.47 Hands should always be washed under runningwater; mixer taps allow this to be practised insafety in healthcare settings where hot watertemperatures may be high to control Legionella(see Health Technical Memoranda 04-01).

3.48 Taps can be lever- or sensor-operated and shouldbe easy to turn on and off without contaminatingthe hands.

3.49 Taps discharging directly into a drain hole cancause splashing, which could dispersecontaminated droplets. The tap outlet flow shouldnot discharge directly into the waste aperture.

3.50 Non-TMV taps (commonly used in kitchens andon sinks in cleaners’ rooms/dirty utilities) allowthe user free rein to determine the temperature ofthe water delivered at the point of use; however, arisk assessment should be undertaken first.

3.51 Swan-neck tap outlets are not recommended, asthey do not empty after use. Similarly, strainers,aerators and flow restrictors should not be used asthey become colonised with bacteria.

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Taps in augmented care settings

3.52 For the augmented care setting, the choice andtype of water outlets is important and should bebased on a risk assessment of infection control andscalding issues. There is some evidence that themore complex the design of the outlet assembly(for example, some sensor operated taps), the moreprone to P. aeruginosa colonisation the outlet maybe (Berthelot et al 2006).

3.53 In intensive care and other critical care areas,where patients are unlikely to be able to use thewash-hand basins, the installation of non-TMVmixing taps may be the preferred control optionfollowing a risk assessment (see WHTM 04-01Addendum:2014 Pseudomonas aeruginosa – advicefor augmented care units ).

Soap dispensers

3.54 Liquid soap dispensers should be wall-mounted atall wash-hand basins and be designed to beoperated without contamination from the user’shands coming into direct contact with thedispensing mechanism.

3.55 Dispensers should not be refillable but be of adisposable single-cartridge design (see alsoAppendix 1 for guidance on mental health units).

3.56 Antimicrobial hand-rub dispensers should beavailable at the point of patient care, subject tolocal risk assessment. Users and IPC teams shouldliaise and advise on the position of these units inclinical areas.

Hand drying

3.57 Paper hand-towel dispensers should beconveniently placed by all wash-hand basins(clinical and non-clinical).

3.58 The use of paper towels in rolls should bediscouraged; they are difficult to tear off withoutcontaminating the remaining roll.

3.59 Fabric towels are a source of cross-contaminationand are not recommended in clinical areas.

3.60 Hot-air hand dryers reduce paper waste and maybe considered for use in public areas of healthcarefacilities, but should not be installed in clinicalareas as they are noisy and could disturb patients.

3.61 Hands-free waste bins, with appropriate colour-coded waste bags, should be provided by eachwash-hand basin.

Sinks and disposal facilities

3.62 Using sinks for both hand washing and thecleaning of equipment should be discouraged asthis will significantly increase the risk of hand and

environmental contamination. Dirty utility roomsshould contain a:

• sluice for disposing of body fluids and patients’wash-water;

• separate sink for cleaning equipment;

• clinical wash-hand basin.

3.63 Contaminated fluids such as patients’ wash-watershould not be emptied down clinical wash-handbasins in adjacent ward areas.

3.64 Disposal facilities should be provided in areaswhere dirty wastewater is disposed (for example,dirty utility rooms and cleaners’ rooms/areas forcleaning equipment). See WHBN 00-10 PartC:2014 Sanitary assemblies for further guidance.

Recommendations

• In each single-bed room, a minimum of one clinicalwash-hand basin should be available. En suite single-bed rooms should have a separate general wash-handbasin for patients and visitors in the en suite facility.

• In critical care areas, one clinical wash-hand basinshould be available by each bed space.

• In multi-bed rooms, two clinical wash-hand basinsshould be provided.

• In primary care and outpatient settings, where clinicalprocedures or examination of patients/clients isundertaken, a clinical wash-hand basin should beclose to where the procedure is carried out.

• All clinical wash-hand basins should be accessible andshould not be situated behind curtain rails.

• All en suite facilities should have a wash-hand basinfor use by patients and their visitors.

• Clinical wash-hand basins should not have anoverflow or be capable of taking a plug.

• All wash-hand basins should be sealed to a waterproofsplash-back.

• Wall mounted liquid soap and paper-towel dispensersshould be available at each wash-hand basin.

• Antimicrobial hand-rub dispensers should be availableat the point of patient care.

• Space should be allowed at the design stage for theplacement of hands-free waste bins next to each wash-hand basin.

• Hands-free operated taps are recommended forclinical wash-hand basins.

• Taps should not be aligned to discharge directly intothe waste aperture.

• The alignment of tap and basin should be such thatstaff can wash their hands without excessive splashingto their bodies.

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• For decontamination, two sinks will be needed – onefor decontamination/washing and one for rinsing,plus a clinical wash-hand basin for staff use.

For guidance on mental health units, see Appendix 1.

Footwear washing facilities3.65 Where specialist footwear, such as clogs within

theatres, is required specific guidance on cleaningis covered in HBN 26:2004 Facilities for surgicalprocedures, paragraphs 5.21-5.23.

Ancillary areas3.66 It is important that ancillary areas are of an

acceptable standard to support effective infectionprevention. Clean and dirty areas should be keptseparate and the workflow patterns of each areashould be clearly defined.

3.67 The design and finish of ancillary areas shouldfacilitate good cleaning. These areas should havefacilities for hand hygiene and sufficient storagefor supplies and equipment.

3.68 IPC issues are determined on:

• the use of the ancillary area;

• who will have access; and

• what type of activity will be carried out there.

3.69 Ancillary areas include:

• dirty utility;

• clean utility;

• clean linen store;

• decontamination room;

• disposal room;

• day room/patient waiting areas;

• play areas;

• nappy-changing area;

• visitors’ toilets;

• personal laundries in mental health andlearning disability settings (but not domiciliarycare settings);

• treatment room.

Dirty utility room

3.70 A dirty utility room should include facilities for:

• cleaning items of equipment;

• testing urine;

• the disposal of body fluids including watercontaminated with body fluids, exudate etc;

• the decontamination of commodes;

• temporarily holding items requiringreprocessing;

• clinical washing of hands after activity in thedirty utility room.

3.71 Space and facilities for the holding, reprocessing ordisposing of bedpans, urinals and vomit bowls arerequired. Unused bedpans and linen-bag carrierscan also be stored in this area. Apron and glovedispensers should be provided for ease of access toPPE.

3.72 Where commodes are to be used, there should besufficient space allowed for their decontaminationand storage.

3.73 A clinical wash-hand basin is necessary plus a slop-hopper for disposal of body fluids and a separatesink for decontaminating equipment.

3.74 There needs to be a clear demarcation betweenclean/unused equipment and soiled/dirtyequipment. Clean and dirty areas should be keptseparate and the workflow patterns of each areashould be clearly defined.

Clean utility room

3.75 A clean utility room is required where drugs andlotions may be stored and prepared, a supply ofclean and sterile supplies may be held and dressingtrolleys prepared. Clinical hand-hygiene facilitiesare required.

3.76 The room should be located adjacent to thetreatment area.

3.77 It is important that planners/design teams thinkabout the type of storage facilities provided. Thereshould be enough storage area for sterile suppliesequipment and other clean supplies to keepsupplies off the floor with sufficient space underthe lowest shelf to permit cleaning the floorunderneath.

3.78 It is important that sufficient worktop area isprovided to enable aseptic preparation to becarried out (for example, preparation ofintravenous infusion).

3.79 Storage facilities should be able to be cleaned easilyand quickly while protecting clean stores andequipment from dust and contamination.

Clean linen store

3.80 Clinical areas should have designated areas for thestorage of clean linen to maintain the cleanlinessof the linen and allow easy access. Storage shouldbe on slatted shelving or racking and be off thefloor, with sufficient space under the lowest shelfto permit cleaning the floor underneath.

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Treatment room

3.81 A treatment room may be required for inpatientexamination or investigations. In primary caresettings, it will require different design featuresaccording to its planned use, for exampleimmunisation or wound dressing.

3.82 A clinical wash-hand basin should be provided (seeWHBN 00-03:2013 Clinical and clinical supportspaces ).

3.83 Carpets should not be used as this area has a highprobability of body fluid contamination.

3.84 Space should be available to allow for the storageof equipment and sterile supplies.

Equipment decontamination room

3.85 Local decontamination (that is, thedecontamination of reusable medical devicesundertaken at the point of use) is associated withlarge items of equipment that are not amenable tosteam sterilization such as infant incubators inneonatal intensive care units. This room shouldfacilitate a defined dirty-to-clean flow throughoutthe decontamination process and have sufficientwork surfaces and sinks to allow effectivereprocessing.

Disposal room

3.86 The disposal room is for temporary storage ofsupplies and equipment that have to be removed forcleaning, reprocessing or disposal (for example, usedlinen, items to be returned to the sterile servicesdepartment (SSD), waste bags and sharps bins).

3.87 The sizing of disposal rooms should be consideredat the design stage, taking into account thepredicted levels and types of waste to be generatedand the planned operational policies relating tofrequency of waste and linen collection.

3.88 This area should be secure and not accessible tothe public.

Cleaners’ room

3.89 This room is used to deliver day-to-day cleaningservices for a defined area. Cleaning materials andequipment in daily use should be stored in thisroom.

3.90 The room should be provided with a sink andslop-hopper or janitorial unit as well as a wash-hand basin. There should be unrestricted access tothe sink and slop-hopper/janitorial unit (seeWHBN 00-10 Part C:2014 for more informationon these sanitary assemblies).

3.91 Space should be provided for mops, buckets, avacuum cleaner, scrubbing/polishing machine (for

hard floors) and other appropriate cleaningequipment.

Day room/patient waiting areas

3.92 There is often conflict between the aesthetics ofthese areas and the prevention of contamination ofthe environment or furnishings and ease ofcleaning/disinfection. This is especially the case inwaiting areas such as in accident and emergencydepartments, primary care and minor injury units.

3.93 It is important that where blood and body-fluidspillages may occur, the environment should beable to be cleaned effectively. Carpets should notbe used in areas where body fluid spillage isanticipated.

Play area

3.94 All equipment, finishes and furnishings should befluid-resistant and be able to withstand cleaningand disinfection. This is particularly important forplay mats and soft floor coverings.

Nappy-changing area

3.95 Facilities for the disposal of soiled nappies and forhand washing in the immediate environment arerequired along with a regular cleaning programmeof equipment used.

3.96 The area used for nappy changing should have asurface that can be easily cleaned and disinfected.

Visitors’ toilets

3.97 Visitors’ toilets are heavily used and shouldprovide enough space and have a high grade offinish to maintain a high standard of cleanliness.

3.98 There should be provision of disposal facilities forsanitary waste in women’s, accessible and unisextoilets.

3.99 The number of toilets, wash-hand basins and handdrying facilities provided should be sufficient forthe size of the facility (see WHBN 00-02:2013).

3.100 Hand drying should be by single-use paper handtowels or hot-air hand dryers. If a facility is in, orclosely adjacent to, areas where patients may besleeping, hot-air hand dryers should be avoideddue to the noise they create.

Recommendations

• Clean and dirty areas should be kept separate and theworkflow patterns of each area should be clearlydefined.

• The design and finish of ancillary areas shouldfacilitate good cleaning. They should have facilities forhand hygiene and sufficient storage for supplies andequipment.

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Storage3.101 Storage areas need to be appropriate for the

operational requirements of each clinical area.

3.102 The need for sufficient secure storage should notbe underestimated. Many plans start withsufficient storage, but this space is often lost toother areas during the design process. This canhave implications for both clinical practice andinfection control.

3.103 Storage away from areas of clinical activity isrequired for both small and bulky items ofequipment to minimise clutter, enabling efficientenvironmental cleaning.

3.104 All healthcare premises need a storage area forlarge pieces of equipment such as beds, mattresses,hoists, wheelchairs and trolleys that are notcurrently in use. The use of equipment librariescan be an effective way of storing, maintaining anddecontaminating large or electrical equipment.

3.105 Cleaning equipment, laundry and clinical wasteneed to be stored in separate purpose-built areas toprevent cross-contamination.

3.106 Sufficient and appropriate storage will protectequipment from damage, contamination and dust(which may potentially carry microorganisms), butshould also allow free access to floors and shelvesfor cleaning.

Storage for patients’ possessions

3.107 Adequate space should be allocated for the storageof patients’ possessions. Wardrobes and lockersused for storage of patients’ possessions should beselected to be easily and efficiently cleaned. Louvredoors should not be fitted, as they are difficult tokeep clean.

3.108 In mental health settings, risk assessment shouldinform the choice of furniture (see Appendix 1).

Recommendations

• Wardrobes and lockers used for storage of patients’possessions should be selected to be easily andefficiently cleaned.

• Cleaning equipment, laundry and clinical waste needto be stored in separate purpose-built areas to preventcross-contamination.

• All healthcare premises need a storage area for largepieces of equipment such as beds, mattresses, hoists,wheelchairs and trolleys that are not currently in use.

• Sufficient and appropriate storage will protectequipment from damage, contamination and dust(which may potentially carry microorganisms), butshould also allow free access to floors and shelves forcleaning.

Interior finishes/fixtures and fittings

NoteAlthough a range of antimicrobial-impregnatedproducts (such as surface coatings, paints and curtains)is available, there are, at present, no definitive data tosupport their efficacy in reducing HCAIs.

3.109 The quality of finishes in all clinical areas shouldbe readily cleaned and resilient. It is importantthat the healthcare environment is aestheticallypleasing but takes into account the clinical natureof the intended purpose suited to its function.

Flooring

For guidance on flooring in healthcare facilities, seeWHBN 00-10 Part A:2014 Flooring.

For guidance on flooring in mental health settings, seeAppendix 1.

Flooring in clinical areas

3.110 Flooring should be seamless and smooth, slip-resistant, easily cleaned and appropriately wear-resistant.

3.111 There should be coving between the floor and thewall to prevent accumulation of dust and dirt incorners and crevices.

3.112 Any joints should be welded or sealed to preventaccumulation of dirt and damage due to wateringress.

3.113 Wood and flooring with unsealed joints aredifficult to keep clean and should be avoided.

3.114 In areas where frequent wet cleaning methods areemployed (for example, clinical areas and theatres),floors should be of a material that is unaffected bythe agents likely to be used.

3.115 Floors that are particularly subject to traffic whenwet (bathrooms, kitchens) should have a slip-resistant surface, but be easy to clean.

Carpets

3.116 Carpets should not be used in clinical areas.This includes all areas where frequent spillage isanticipated. Spillage can occur in all clinical areas,corridors and entrances. Aesthetic considerationsand noise reduction are most often cited as thereason for using carpets; yet in areas of frequentspillage or heavy traffic, they can quickly becomeunsightly. Smell and staining have been the reasonsbehind the removal of carpets in many clinicalareas (see Appendix 1 for flooring in mentalhealth settings).

3.117 If carpets are to be considered for non-clinicalareas (for example, interview rooms, counselling

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suites, consulting rooms), it is essential that adocumented local risk assessment is carried outwith IPC involvement and a clearly defined pre-planned preventative maintenance and cleaningprogramme is put in place.

3.118 Where the care environment is also a person’shome, such as a residential setting for people witha learning disability, carpets may be acceptable.The use of carpets may be appropriate in suchfacilities but the need for frequent cleaning shouldbe considered in the design stage, both in thechoice of carpet and its continued maintenance.

3.119 Facilities should also be available for the promptand effective removal of any spillage.

Walls

3.120 Smooth cleanable impervious surfaces arerecommended in clinical areas. Design shouldensure that surfaces are easily accessed, will not bephysically affected by detergents and disinfectants,and will dry quickly. Additional protection to thewalls should be considered to guard againstgouging/impacts with bedheads and trolleys. Wallsurfaces should be maintained so that they are freefrom fissures and crevices (see also WHBN 00-10Part B:2014 Walls and ceilings ).

Ceilings

3.121 Smooth jointless impervious ceilings should beused in operating theatres and special ventilatedisolation rooms.

3.122 Suspended ceilings may be installed in generalclinical areas and other areas in the healthcarefacility (see WHBN 00-10 Part B:2014). Dust andfungal spores may accumulate on the upper surfaceof ceiling tiles over time, and their dispersal on tileremoval or manipulation may pose an inhalationrisk to highly immunocompromised patients. Arisk assessment should always be done before suchwork is carried out (see Appendix 3).

Lighting

3.123 Efficient lighting in all areas of wards ordepartments enables cleaning staff to undertakecleaning more effectively. CIBSE’s Lighting Guide2: Hospitals and healthcare buildings (SLL LG2)gives guidance on lighting levels in healthcarefacilities.

3.124 Light fittings that are easy to clean and unlikely toaccumulate dust should be chosen for clinicalareas. For example, flush ceiling fittings areacceptable, but not open up-lights.

3.125 The location and design of luminaires shouldpermit easy changing of lamps and frequentcleaning. They should be designed so that there

are no ledges or ridges and they allow ease ofaccess for cleaning. If skylights or light tubes are tobe installed, ease of cleaning and maintenanceshould be the key considerations.

Doors

3.126 Doors should be cleanable, that is, smooth, non-porous and fluid-resistant, especially wherecontamination with blood or body fluid is apossibility.

3.127 Doors should have smooth handles that can beeasily cleaned and dried. Additional protection tothe doors should be considered to guard againstgouging/impacts with bedheads and trolleys.

3.128 In mental health settings, risk assessment shouldinform the choice of door furniture (see alsoAppendix 1).

Windows

3.129 Windows should be sealed and unopenable inoperating theatres and special ventilated isolationrooms.

3.130 Internal ledges in all windows should be avoidedas this will allow dust and clutter to accumulate.Sloping ledges should be considered.

Finishes

3.131 Floors or walls penetrated by pipes, ducts andconduits should be sealed to stop entry of pests.

Fixtures and fittings

3.132 Design should ensure that surfaces are easilyaccessed, will not be physically affected bydetergents and disinfectants, and will dry quickly.

Work surfaces

3.133 All work surfaces should be impervious, designedfor easy cleaning and be free of fissures andunsealed joints. They should be able to withstandthe effects of regular cleaning with both detergentsand disinfectants.

Soft furnishings

3.134 Soft furnishings (for example, seating) usedwithin all patient areas should be chosen for easeof cleaning and compatibility with detergents anddisinfectants. They should be covered in amaterial that is impermeable, preferably seam-freeor heat-sealed.

3.135 Fabric that becomes soiled and stained cannot beadequately cleaned and will require replacement.

Curtains and blinds

3.136 Privacy curtains become contaminated withmicroorganisms, which can then be transmitted tostaff hands. Where patients may be particularly

26


susceptible to infection, curtains should havefittings that make them quick and convenient toreplace; such fittings are common in disposablecurtains.

3.137 In new-build or refurbished augmented care units,consideration should be given to having separatecurtains for each bed space, sufficiently separatedsuch that staff can easily and correctly identifywhich curtain belongs to which bed space.

3.138 Reusable curtains should be able to withstanddecontamination in healthcare launderingprocesses.

3.139 There should be a local policy on the changing ofprivacy curtains, both for routine changing whenthe curtains become soiled and after the dischargeof a patient with a known/suspected infection.

3.140 Window blinds that are not readily amenable tocleaning are not recommended. Double-glazedroom vision panels with integral blinds are easy toclean.

3.141 Impervious dividers, screens that can bemanoeuvred on wheels or retractable fixed screensbetween bed spaces can be of benefit in certainclinical areas. The use of these dividers requiresconsideration at the planning stages as extra spaceis required either for their use between beds or forstorage. It is important that they are easily cleaned,are non-fabric and can withstand the effects ofdisinfectants.

Radiators

3.142 Radiators must be accessible and cleanable. Inclinical areas, supply pipework should always beconcealed. In all cases, the objectives of design andspecification should be an installation that is neat,easy to clean and maintain, and durable.

3.143 Underfloor heating should be considered in mentalhealth and inpatient learning disability settings.

Recommendations

• The quality of finishes in all clinical areas should bereadily cleaned and resilient.

• Carpets should not be used in clinical areas.

• Flooring should be seamless and smooth, slip-resistant, easily cleaned and appropriately wear-resistant.

• Design should ensure that surfaces are easily accessed,will not be physically affected by detergents anddisinfectants, and will dry quickly.

• Avoid internal ledges in all windows as this will allowdust and clutter to accumulate. Consider the use ofsloping ledges.

• All work surfaces should be impervious, designed foreasy cleaning and be free of fissures and unsealedjoints.

• In all cases, the objectives of design and specificationshould be an installation that is neat, easy to cleanand maintain, and durable.

Changing facilitiesOutpatient and day surgery changing facilities

3.144 In areas such as outpatients, day surgery, imagingand minor injuries units, it will be necessary toprovide sufficient changing/storage facilities ifclothing has to be removed and kept safe. Thesefacilities should be included at the planning stageand should be able to be cleaned easily.

Clinical staff changing facilities

3.145 By providing staff changing facilities, sanitaryfacilities, showers and sufficient locker space foroutdoor clothing, staff will be able to change outof their uniform on site. Wash-hand basins andshower facilities for staff should be available andeasily accessible in case of substantial blood orbody fluid contamination. There needs to besufficient storage for clean scrub suits andfootwear.

Maintenance staff

3.146 Changing facilities should be provided formaintenance staff members who undertakeactivities that could expose them tocontamination. There should also be access toshowers in case of significant contamination.

Recommendations

• Appropriately sized changing facilities should beprovided for staff to encourage them to change out oftheir uniform on site.

• Wash-hand basins and sanitary facilities should beincluded, and showers should be provided in theevent of contamination by blood or body fluid.

Laundry and linen services3.147 A Welsh Health Technical Memorandum covering

laundry and linen services (WHTM 01-04) iscurrently in production. Please contact NWSSP-Specialist Estate Services at [email protected] advice on this topic.

Catering/food hygiene3.148 Hand-hygiene facilities should be provided for

staff members who prepare and serve food. Wardkitchens should have a separate staff wash-hand

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basin with non-touch taps, liquid soap and papertowels.

3.149 Hand-washing facilities should ideally be locatedbetween raw and cooked-food preparation areas.

Healthcare waste3.150 Guidance on healthcare waste management is

outlined in WHTM 07-01:2013 Safe managementof healthcare waste.

Responsibilities under ‘duty of care’

3.151 The ‘duty of care’ is a law (as set out in section 34of the Environmental Protection Act 1990 andassociated regulations) decreeing that anyone whomanages waste and/or has responsibility for themanagement of waste must take all reasonablesteps to keep that waste safe.

3.152 One of the main responsibilities under duty ofcare, which has major implications for IPC andthe built environment, is to ensure that waste isstored safely on site. Essentially:

• storage areas at ward and unit level should besecure and located away from public areas;

• storage areas should be sufficient in size to allowpackaged waste to be segregated and so as toavoid waste of different classifications beingstored together in the same area.

Waste segregation and storage

3.153 Any new capital developments should haveenough space for waste receptacles to be locatedclose to the point of waste production to avoidunnecessary handling of waste.

3.154 Waste segregation entails providing sufficient spacefor recycling, reuse and recovery to minimise wasteand reduce costs.

3.155 Space at the ward/unit level is needed for suitablewaste receptacles to segregate the waste in line withthe approach described in WHTM 07-01:2013.The storage should be sufficient for different wastestreams to be segregated pending collection; that is,domestic waste should be separate from clinicalwaste, and clinical waste with different disposalroutes should not be mixed (for example, sharpswaste not mixed with orange-bagged waste). Thereshould be no public access to this area.

3.156 Adequate secure storage areas for waste are bestlocated at entrances to wards or departments,preferably with access from both ward and hospitalcorridor to facilitate collection by authorisedpersonnel only. Waste can then be stored in theseareas – instead of taking up valuable space in dirtyutility rooms.

3.157 Storage for used linen should be in a clearlydesignated area separate from waste. This shouldminimise any risks of used linen being accidentallytaken for disposal, or of waste being taken to thelaundry.

3.158 The waste and used linen storage areas should beeasy to clean efficiently. The holding area shouldbe large enough to hold a wheeled-bin, which inturn will reduce handling and the associated risksto porters.

3.159 A designated secure area is also necessary to holdreceptacles from the whole site for collection fordisposal and should be provided with good accessroutes away from public areas. This area shouldalso be washable and animal-proof.

Waste receptacles

3.160 The size of waste receptacles required needs to bein line with the quantity of waste generated in aparticular area by waste stream (that is, clinical ordomestic waste).

3.161 Waste receptacles should be foot-operated only(that is, it should not be possible to open them byhand in normal use) and should be easy to clean.The foot pedal should be sturdy and durable. Stafftraining and awareness-raising on the risks ofcross-infection will be key to understanding theimportance of the receptacle’s hands-free operationand design.

3.162 The lids of clinical waste receptacles need to be of adesign to allow them to be cleaned and disinfected.Temporary labels should not be attached toreceptacles as they inhibit effective cleaning.

Clinical waste generated in primary care andcommunity settings

3.163 In healthcare facilities such as care homes andprimary care settings, all waste should be containedappropriately and kept secure at all times.

3.164 The system and frequency of waste collectionneeds to be taken into account when planningfacilities needed for temporary holding bays etc. Iflocated externally, the holding bay or receptacleshould be washable, secure and animal-proof.Only rigid lockable receptacles should be stored inexternal areas.

3.165 There should be a strict routine for removingwaste to ensure it does not remain uncollected forextended periods.

Storage capacity

3.166 Storage areas need to be of a sufficient size to meetthe needs of the number of different waste streamslikely to be generated.

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3.167 Storage capacity needs to match the proposedfrequency of collection by a waste disposalcontractor. The design of the facility should alsotake account of accessibility and space needed forvehicles collecting the waste.

Recommendations

• Refer to WHTM 07-01:2013 Safe management ofhealthcare waste.

• Waste receptacles should be foot-operated only (thatis, it should not be possible to open them by hand innormal use) and should be easy to clean.

• The lids of clinical waste receptacles should be of adesign to allow cleaning and disinfecting.

• Storage areas need to be of a sufficient size to meetthe needs of the number of different waste streamslikely to be generated in the healthcare facility.

Engineering services3.168 This section discusses various aspects of

engineering services and the IPC implications ofeach.

Planned preventative maintenance

3.169 Local policies should be in place for plannedpreventative maintenance to ensure safety andefficiency of the engineering services provided.

Heating/temperature controlGeneral3.170 Covered heat emitters allow dust to build up

beneath and inside the heat emitter grille. Whereheat-emitter covers are used, regular plannedcleaning should be undertaken to prevent dustaccumulation. When installing heat emitters, it isrecommended that there be sufficient spaceunderneath the heat emitter to allow cleaningmachinery to be used.

Pipework siting and access

3.171 Pipework should be contained in a smooth-surfaced box that is easy to clean; pipework sitedalong a wall can become a dust trap and beimpossible to clean.

3.172 Pipes and cables running through walls abovesuspended ceilings should be sealed as far as ispracticable.

Heating and general ventilation grilles

3.173 Ventilation grilles need to be accessed easily forinclusion in cleaning programmes by cleaning andmaintenance staff.

Ventilation ductwork

3.174 Ventilation ductwork should be installed in such away that it can be accessed for cleaning. Extractductwork accumulates large amounts of dust,particularly where heat reclamation systems areused.

See HTMs 03-01 Parts A and B Specialised ventilationfor healthcare premises (Please check the Publicationspage of NWSSP-SES website for the most recentedition of these guides as, at the time of publication,these are being re-written) for comprehensive guidanceon the design, installation and operational managementof ventilation systems in healthcare premises.

Specialised ventilation

3.175 In healthcare premises, certain activities willnecessitate the provision of ventilation equipmentwith additional special features in order to achieveand maintain specific conditions. For infectionprevention in specialist areas such as operatingtheatres, to prevent contaminated air fromentering designated clean areas, it should beensured that air flows from the cleanest tosequentially less clean areas. This direction ofairflow prevents contaminated air passing in theopposite direction.

3.176 The following areas usually have specialisedventilation requirements for infection prevention:

a. operating departments;

b. airborne infectious diseases isolation;

c. bronchoscopy and sputum induction roomswhere a risk assessment has indicated atuberculosis risk;

d. accommodation for highlyimmunocompromised patients;

e. cardiac catheterisation/interventional radiologyunits;

f. microbiology containment laboratories;

g. mortuaries.

Split and cassette air-cooling units and activechilled beam units

3.177 These types of units must not be used in clinicalareas.

Hot and cold water systems

3.178 See HTM 04-01 Parts A and B for comprehensiveguidance on the design, installation andoperational management of water systems inhealthcare premises.

3.179 The Water, England and Wales. Water Supply (WaterQuality) Regulations 2010 contain provisions to

29



ensure that the drinking water supply withinbuildings to which the public has access remainswholesome and is not adversely affected by thelocal distribution system.

3.180 Immunocompromised patients are at particularrisk from cryptosporidium. Very low numbers ofcryptosporidium cysts can occasionally occur inmains potable water. A local risk assessment couldbe used to establish the need for filtration ofdrinking water to remove these cysts. For guidanceon separate cold water services for drinking water,see HTM 04-01 Part A:2006.

Storage and distribution of water

3.181 Many organisms capable of causing disease,particularly in highly susceptible patients (such asPseudomonas aeruginosa and Legionella spp.), havebeen isolated from healthcare water systems.Preventative measures include:

• routine inspections of water storage tanks withcleaning as required;

• identifying and removing dead-legs and blindends;

• keeping cold water systems cold and hot watersystems hot; and

• ensuring rapid turnover in water storage.

3.182 Temperature control is the traditional strategy forreducing the risk from Legionella spp. in watersystems. This will require temperature monitoringon a regular basis. The recommended testfrequencies are given in HTM 04-01 Part B:2006.It is good practice to ensure that hot- and cold-water pipework is separated, insulated andpreferably not in the same ducting to avoid heattransfer to the cold water supply.

3.183 Chemical and other water treatments that havebeen shown to be capable of controlling Legionellaspp. to some extent may also be considered. Theywill only work in systems that are amenable totheir use (for example, those that do not havedead-legs and blind ends).

For guidance on control of Legionella in water systems,see the Health & Safety Executive’s (2013) Legionnaires’disease. The control of Legionella bacteria in water systems:Approved Code of Practice and guidance.

Health Technical Memorandum 04-01 Part B:2006provides guidance on the monitoring and maintenanceof water systems (including water storage).

See also Welsh Health Technical Memorandum 04-01:Addendum 2014 Pseudomonas aeruginosa. Advice foraugmented care units.

Sanitary facilities

3.184 WCs, bathrooms and showers should be designedto be easily cleaned and maintained. Wash-handbasins should be provided in or adjacent to WCs.

3.185 Showers are generally more practical than baths inconnection with clinical procedures and are easierto keep clean. Any fixture with a shower such as aseat should be readily amenable to cleaning.

3.186 To minimise the possibility of bacterialcolonisation of showerheads, they should beregularly cleaned and descaled.

3.187 Bidets may present infection risks, depending ondesign and patient group (although they are mostcommonly installed in maternity units). Theappliance should be rimless with an over-rim watersupply and conform to the specifications given inWHBN 00-10 Part C:2014.

3.188 Baths should be easy to clean. Recirculating spapools are not recommended (see WHBN 00-10Part C:2014).

3.189 In wet rooms, high quality water-resistant claddingshould be used on the walls to prevent mould.

WHBN 00-10 Part C:2014 contains guidance to assistthe design team in the selection, specification andapplication of sanitary assemblies in healthcarebuildings. It also gives guidance on the appropriatecleaning and maintenance regimes.

WHBN 00-02:2013 gives detailed guidance on thedesign of sanitary facilities.

Water fittings

3.190 Water fittings (washers etc) should not supportmicrobiological growth. All fittings should satisfythe requirements of the Water Supply (WaterFittings) Regulations 1999, SI 1999/1148. Even ifWRAS-approved, the unnecessary use of flexiblehoses should be avoided.

3.191 Where flexible hoses must be used (for example,on essential equipment such as hi-lo baths), theymust be lined with a suitable alternative to EPDM(ethylene propylene diene monomer) as well asbeing WRAS-approved. Care should be taken toavoid kinking or distorting them duringinstallation – see the Department of HealthEstates & Facilities Alert DH (2010) 03 Flexiblewater supply hoses which, although not officiallycirculated in Wales, is still pertinent.

Ice for patient consumption

3.192 Ice machines should be of a type that dispenses iceby a non-touch nozzle.

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3.193 Ice should be made directly from water that is ofdrinking quality. Ice for the immunocompromisedshould be made by putting drinking water intosingle-use ice-making bags, then into aconventional freezer.

Bedhead services

3.194 Bedhead services should be smooth, accessible andeasy to wipe clean.

3.195 Sufficient dedicated 13-amp socket outlets shouldbe provided in corridors and in individual roomsto enable cleaning appliances with 9m long leadsto operate over the whole department.

3.196 Where possible, socket outlets should be providedflush-mounted or in trunking systems to enableeasy cleaning and prevent the buildup of dust.

Patient entertainment systems

3.197 Radio and television headsets should be of adesign that may be cleaned or disinfected betweenpatient use or should be single use, whichever isthe most economical method to adopt.

See HTM 08-03: 2011 Bedhead services for furtherguidance.

Wastewater and sanitation

3.198 Wastewater is generated from a huge number oftasks carried out in healthcare buildings, whichrange from cleaning, hand washing, specialistlaundries, surgical operations and areas such as renaldialysis units. Most of this wastewater containspathogenic microorganisms and must be disposedof via a safely contained internal drainage systeminto the external wastewater sewerage system.

Internal drainage system

3.199 An internal drainage system should use theminimum amount of pipework, retain water andbe airtight at joints and connectors. It should besufficiently ventilated to retain the integrity ofwater seals.

3.200 The design should comply with the relevantBritish Standards and Codes of Practice, includingBS EN 12056:2000 and Drainage and wastedisposal. Approved document H of the BuildingRegulations (2010). Recommendations for spatialand access requirements for public healthengineering services are contained in CIBSEGuide G (2014) Public health and plumbingengineering.

3.201 Provision for inspection, rodding and maintenanceshould be located to minimise disruption orpossible contamination, and access points shouldnot be sited in clinical areas.

Bedpan washer-disinfectors/macerators

3.202 Where reusable bedpans are used, ward areasrequire adequate and suitable bedpan washer-disinfectors that comply with WHTMs 01-01Parts A-E. Decontamination of medical deviceswithin acute services.

3.203 Where fitted, bedpan washer-disinfectors should beinstalled according to the Water Supply (WaterFittings) Regulations 1999, SI 1999/1148 to preventbackflow and contamination. Easy access is essential.

3.204 When considering installation of bedpanmacerators, it should be established that internaldrains and the external sewerage system can copewith the resultant slurry.

3.205 Where reusable supports are used with maceratablebedpans, there should be adequate facilities fortheir cleaning and disinfection between uses.


Medical gas vacuum systems

3.206 Health Technical Memoranda 02-01 Parts A andB. Medical gas pipeline systems give guidanceregarding piped medical gases and vacuum systemsand includes recommendations on emergencyprocedures, power failure, access for cleaningcontaminated vacuum systems, training andcommunication, maintenance and infection risk.

Pneumatic air tube transport systems

3.207 Guidance for the design and management ofpneumatic transport systems can be found in HTM2009:1995 Pneumatic air tube transport systems.

3.208 The carrier for specimens should be transparent,able to be autoclaved and incorporate a leak-proofseal.

3.209 If leaking samples are allowed to enter the tubesystem or station, the station should be isolatedand dealt with following advice from the IPCteam. The disinfection procedure or cleaning willdepend on the nature and level of risk imposed bythe contaminant. Each incident will need to beassessed separately.

3.210 If clinical samples leak on entering or duringtransportation, the station and/or system shouldbe isolated and dealt with following advice fromthe IPC team. Each incident will need to beassessed separately.

3.211 Major policy decisions with reference to thesystem should be made through the directorresponsible for infection prevention and control(DIPC) and/or the IPC team.

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Recommendations

• Refer to HTMs 04-01 Parts A and B forcomprehensive guidance on the design, installationand operational management of water systems inhealthcare premises.

• Heat emitters should be designed and installed in amanner that prevents buildup of dust andcontaminants.

• Heat emitters, heating and general ventilation grillesshould be easily accessible for cleaning.

• WCs, bathrooms and showers should be designed tobe easily cleaned and maintained. Wash-hand basinsshould be provided in or adjacent to WCs.

• To minimise the possibility of bacterial colonisationof showerheads, they should be regularly cleaned anddescaled.

• Lighting should be planned so that units can be easilycleaned, with no ledges or ridges where dust cangather.

• Contamination of the water supply can occur due topoor design of pipework, inappropriate storage orduring renovation and refurbishment work (seeHTMs 04- 01).

• Ice-making machines should not be installed inimmunocompromised patient facilities. Ice for theimmunocompromised should be made by puttingdrinking water into single-use ice-makers, then intoa conventional freezer.

• With regard to pneumatic air tube transport systems,the carrier for specimens should be transparent, ableto be autoclaved and incorporate a leak-proof seal.

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33

Appendix 1: Mental health and learningdisability settings

Note

1. This appendix should be read in conjunction withthe rest of the document.

2. With regard to learning disability settings, thisguidance applies to inpatient units only and not todomiciliary care services that provide support inpeople’s own homes.

1. The need to minimise the risk of cross-infection isimportant in mental health settings, but other factorssuch as ligature risk and the creation of a positivetherapeutic environment will need to be taken intoconsideration when providing advice to these areas.

2. The IPC requirements for those using all types ofmental health and learning disability environmentsmust be made in conjunction with health and safetyteams, risk management teams and clinicians whenadvising on the built environment.

Recommendations

• Creating/maintaining a non-clinical feel can beachieved by using furnishings/fittings that aremanufactured especially for this setting and are easyto clean and maintain. For example, wood-effectvinyl can be used to create a less clinical environment,but cleanliness can be maintained. Vinyl is easy tomaintain and requires less frequent replacement.

• In some specialties within mental health bedroomareas, porcelain basins and toilets would present arisk; alternatives such as resin or stainless steel shouldbe considered. Cleaning of these materials should,however, be considered carefully.

• There is no requirement for a clinical wash-handbasin in an en suite bedroom. Alternativearrangements to provide healthcare staff with accessto hand hygiene should be made.

• There should be sufficient access to hand-hygienefacilities for staff. Clinical wash-hand basins shouldbe sited only in supervised areas such as the cleanutility room, treatment rooms and dirty utility room.Antimicrobial hand-rub should be provided. Wherenecessary, the use of patient wash-hand basins inen suite rooms can be used with care to avoidrecontamination of hands.

• In secure mental health units, hand dryers or vandal-proof integral hand-wash dryers in communal toiletsmay provide a safer option for hand hygiene whileencouraging those in the service to clean their hands.

• Single rooms can be used for source isolation.

• Risk assessment should inform the storage ofprotective clothing, soap and paper towels, clinicalwaste receptacles etc. All fixtures and fittings shouldbe anti-ligature.

• Assessment of the need for a macerator or bedpanwasher-disinfector should be undertaken. If a specificdirty utility room is not required, alternativeprocedures should be in place for the disposal of bodyfluids and urine testing.

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Appendix 2: Example of a typical IPC checklist

For non-clinical issues related to the design, construction and fitting out of multi-bed rooms and associated areas Date:

To be completed by the healthcare provider

Healthcare provider

Site

Project/scheme

Building/ward

Project manager for thehealthcare provider

Business case or design stageto which this checklist/review applies

Completed by (for healthcare provider) Date:

Reviewed by Date:

General notes

Business case

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Appendix 2

Part 1. Sign-offThe infection prevention and control checklist/review should be signed off by the relevant parties before the schemeproceeds. Some of the roles below (not chief executive officer) may be covered by a relevant director in thehealthcare provider organisation. If appropriate, a single sign-off, clearly stating which areas of responsibility arecovered, may suffice.

Check Reason Involvement Design signed-off by:

Chief executive With regard to control and To ensure that all departments/officer prevention of infection and privacy commissioners are satisfied

and dignity issues of the facilities with the IPC issues for the to be provided by his/her facilities proposed. The personorganisation to patients, staff and ultimately responsible.visitors.

Director With regard to IPC of the facilities The provision of coordination,responsible for and resources to be provided advice and management acrossinfection by his/her organisation to clinical boundaries and to prevention and patients, staff and visitors. inform the health board/control (DIPC) management team.

Director of With regard to design, operation The provision of coordination, Estates & and maintenance of the buildings advice and management acrossFacilities and resources to be provided by the estates and facilities team

his/her organisation in order to and to inform the health board/ensure a safe estate is provided for management team.patients, staff and visitors.

IPC team To ensure involvement in the To provide specialist input intomanager design and signing-off process and the design and management

that the design is to their process to facilitate effectivesatisfaction for IPC purposes. IPC performance.

Facilities To ensure that the design and Working with the maintenancemanager detailing is approved with respect manager, current and

to the potential for effective and anticipated problems should beefficient cleaning and that designed out of the new/sufficient resources are/will be refurbished facility.available.

Maintenance To ensure that the design and As above. manager detailing is approved with respect

to the potential for effective andefficient maintenance to promoteand maintain effective andefficient cleaning.

Ward/nurse To ensure that the physical design Nursing/local input is essential manager/matron and the operation of the facility or as the nursing staff are

ward can be run and managed ultimately those using thein an efficient and hygienic facility. Their buy-in as a manner. stakeholder in direct patient

care is very important.

Equipping To ensure that storage facilities and One of the prime causes of manager space provided for equipment is poor cleaning is clutter and

adequate and is suitable. poor storage facilities.

Part 2. DesignCheck Reason Possible issues to Y/N Comments on scheme

consider

1 Has an infection To assist in designing-out See issues below. prevention and all IPC-related risks.control riskassessment beencompleted in relationto the completedfacility as proposed?

2 Isolation facilities The primary aim of IPC A risk assessment should is to prevent the spread of be used to inform decisionsinfection between patients, regarding which patients tovisitors and staff by nurse in single-bed rooms.control or containment Healthcare providers of… should audit the use of

en-suite single-bed roomsto determine where furtherlocal requirements and…

3

Part 3. Management of the construction of the new facility (including demolition and enabling works)

Check Reason Possible issues to Y/N Comments on schemeconsider

1 Has an infection To minimise and See issues below. prevention and manage risks.control riskassessment beencompleted in relationto the constructionrefurbishment of thehealthcare facility?

2 Will the new Has the design and Protecting facilities… project planning taken immunocompromised

into account the patients from airborneimplications on existing fungal infection. patients and staff? IPC... Prevent interference with

specialist ventilation systems, eg if work isadjacent to an operatingtheatre or isolation room…

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Recommendation

• Healthcare organisations will each have their ownspecific design and build issues to consider. Theyshould use the guidance in this document to developbespoke IPC checklists for sign-off by the relevantparties.

Appendix 3: IPC risk assessment duringconstruction/refurbishment ofa healthcare facility

1. Quality assurance in IPC associated with buildingwork, fungal spore generation and susceptiblepatients should be centred on the three principlesof:

a. identifying susceptible patient groups;

b. where necessary, using methods of work thatreduce the dissemination of airborne fungalspores; and

c. protecting susceptible patients from thoseairborne fungal spores that will be generated.

2. The first principle is one of clinical riskassessment. The second and third are deciding onactions and ensuring those actions are constantlyapplied for the duration of the risk. This could beachieved by:

• instruction of those working on the project,those in the estates team and clinical staff inaffected areas;

• routine monitoring of actions and precautions;and

• an efficient reporting and reaction system(should deficiencies be identified).

3. Patients who are highly immunocompromised arethought to be at particular risk from infection byinhalation of fungal spores whose airborneconcentrations are thought to increase inassociation with demolition, construction,maintenance and refurbishment (that is, building)works. The occurrence of clusters of fungalinfection associated with building works has beenobserved on a number of occasions, whichsuggests the need to minimise the risk of sporedispersal during this time. Many of therecommendations in this appendix are based onconsensus rather than scientific observation. Thefollowing measures are thought to reduce thedissemination of spores, including aspergillus.

Help to reduce specific infectionproblems during construction4. A planned contamination control programme is

essential when building work of any nature isplanned.

5. Early and sustained involvement of the IPC teamin the planning process is essential and will lead tominimising of potential infection risks. Buildingdust control measures may not be sufficient forthe control of fungal spore release; therefore, thefollowing should be considered:

• Use floor-to-ceiling barriers that completelyenclose the work area.

• Seal windows in areas accommodating patientsassessed as susceptible to minimise ingress offungal spores generated by nearby buildingwork.

• If vacuum cleaners are used, ensure they havehigh efficiency filters on exhausted air.

• Use a vacuum cleaner with a HEPA filter toclean areas daily or more often if necessary.

• Transport debris in sealed bags or containerswith tightly fitting lids, or cover debris with awet sheet.

• The removal of debris by chutes is liable toproduce airborne fungal spores. The use andpositioning of chutes should be carefullyconsidered.

• Do not haul debris through patient-care areas,but through an exit restricted to theconstruction crew.

• Commission additional hotel services withregard to cleaning during construction projects.

• Temporary storage for clinical equipment andclean linen should be clean and free of pests.

Monitoring6. Demonstration that measures have reduced ingress

of fungal spores into protected areas can bedemonstrated by exposing settle plates inprotected areas and comparing fungal depositionon these with equivalent settle plates exposedoutside protected areas at the same time and forthe same duration.

7. There is limited evidence that occasional activesampling for fungal spores demonstrates thatprotective measures are effective.

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1. First, identify construction activity type from the table below

Type A Inspection and non-invasive activities, includes, but not limited to:

• removal of ceiling tiles for visual inspection on corridors and non-clinical areas;

• painting and minimum preparation in corridors and non-clinical areas;

• electrical trim work (all plugs, switches, light fixtures, smoke detectors, ventilation fans);

• minor plumbing and activities that do not generate dust or require cutting of walls or access toceilings other than for visual inspection

Type B Small scale, short duration activities that create minimal dust. Includes:

• removal of a limited number of ceiling tiles in low risk clinical areas for inspection only;

• installation of telephone and computer cabling;

• access to chase spaces;

• cutting of walls or ceiling where dust migration can be controlled in non-clinical areas.

Type C Any work of long/short duration which generates a moderate-to-high level of dust or requiresminor building works, demolition or removal of any fixed building components or assemblies.Includes, but is not limited to:

• sanding of walls for painting or wall covering;

• removal of floor coverings, ceiling tiles, panelling, and wall-mounted shelving and cabinets;

• new wall construction;

• minor duct work or electrical work above ceilings;

• major cabling activities.

Type D Major demolition and construction projects. Includes, but is not limited to newconstruction/machinery and equipment installations, rectifications and modifications

2. Then identify the infection control risk group by area

Group 1 (low risk) Group 2 (medium risk) Group 3 (high risk)

Office areas/corridors A&E clinical rooms Day surgery roomsPlant rooms/service ducts Radiology/magnetic resonance imaging All intensive care unitsPrimary care/community General surgery recovery units All operating suitestreatment rooms Wards All high dependency units

Nuclear medicine Dialysis & transplant unitsAdmissions/discharge units OncologyEchocardiography CardiologyOther departmental clinical areas Cardiac catheterization suiteOutpatient department Pharmacy clean roomsPharmacy (general) Sterile services departmentsLaboratories Bone marrow transplant unitsEndoscopy clinicsExamination rooms

3. Now identify the ‘risk class’ by correlating ‘construction type’ with ‘risk group’ (from 1 and2 above) in the matrix below

Construction activity type

Risk group Type A Type B Type C Type D

Group 1 Class 1 Class 2 Class 2 Class 3



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Appendix 3

4. After identifying the risk class from 3, follow the risk measures advised for each class

Class 1 • Execute work by methods to minimise dust from construction

• Immediately replace any ceiling tile displaced for visual inspection

Class 2 • Where appropriate, isolate HVAC (heating, ventilating, and air conditioning) system in areas wherework is being performed

• Provide active means to prevent airborne dust from dispersing into atmosphere if practicable,ie dust bag to machine

• Water-mist work surfaces to control dust while cutting

• Avoid pooling of water which may be prolonged

• Seal unused doors with duct tape

• Block off and seal air vents

• Wipe work surfaces with detergent

• Contain construction waste before transport in tightly covered containers

• Wet-mop and vacuum with filtered vacuum cleaner before leaving work area

• Place dust-attracting mat at entrance and exit of work area (tacky mat)

• Remove isolation of HVAC system

Class 3 • Where appropriate, isolate HVAC system in area where work is being done to preventcontamination of duct system

• Complete all critical barriers and implement dust control methods before construction begins

• Maintain negative air pressure within work site. Use HEPA (high efficiency particulate air)-equipped air filtration unit if there is a risk that air will enter building

• Do not remove barriers from work area until complete project is clinically clean

• Vacuum with filtered vacuum cleaner during works

• Wet-mop area during works

• Remove barrier materials carefully to minimise spreading of dust and debris associated withconstruction

• Contain construction waste before transport in tightly covered containers

• Remove isolation of HVAC system in areas where work has been done and appropriate checksperformed

Class 4 • Isolate HVAC system in area where work is being done to prevent contamination of duct system

• Complete all critical barriers and implement dust control methods before construction begins

• Maintain negative air pressure within work site using HEPA-equipped air filtration unit

• Seal holes, pipes, conduits and punctures appropriately

• Construct airlock and require all personnel to remove dirty apparel and clean down before leavingthe work site. The use of cloth/paper disposable overalls/shoes, etc., may be required

• Do not remove barriers from work area until completed project is thoroughly cleaned (as before)and repeat clinical clean after barrier removed

• Vacuum work area with filtered vacuum cleaner

• Wet-mop area with detergent during works

• Remove barrier materials carefully to minimise spreading of dust and debris associated withconstruction

• Contain construction waste before transport in tightly covered and sealed containers

• Remove isolation of HVAC system in areas where work has been done and appropriate checksperformed

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Appendix 4: Microorganisms and infections:a guide for designers

1. Microorganisms are classified into bacteria,viruses, fungi and parasites. A human body hasprobably more bacteria in or on it than it hascells. The vast majority of microorganisms thatpeople encounter will, for most of their lives, dono harm. However, some of them can takeadvantage of susceptible individuals and causeinfections. Many patients in hospitals areunusually susceptible to infection and it is this,rather than the pathogenicity (disease-causingability) of the microorganisms, that is responsiblefor most infection in hospitals.

What is an infection?2. An infection occurs when microorganisms on or

in a person’s body cause them harm. In order todo this, the microorganisms will have to combatthe person’s defences against infection (immunity);they can invade the tissues and produce harmfulsubstances (toxins) that cause damage eitherlocally or systemically.

3. To produce an infection, a sufficient number of asuitably virulent microorganism has to beintroduced into a suitably susceptible site on asuitably susceptible individual. The point mostamenable to control is that of reducing thenumbers of microorganisms that are transferredbetween patients – this is the most valuablecontrol point in IPC.

4. Microorganisms that can cause infectionsometimes exist in an individual without causingdisease. This is termed colonisation or carriage.However, they can cause infection if transferred toanother, more susceptible, person. As there is noobvious disease when an individual is colonised, itmay not be recognised that they are a source ofpotentially dangerous microorganisms. Thesemicroorganisms can also cause disease in theperson originally colonised if they become moresusceptible, either due to another disease processor as a complication of their treatment.

5. A patient can also be infected by microorganismsthat have been harmlessly living on or in them foryears. This change in interrelationship can be as aresult of increased patient susceptibility toinfection. Infection with one’s own residentmicroorganisms is termed endogenous, as opposedto infection with microorganisms from elsewhere,which is termed exogenous.

6. Patients can acquire infections as a consequence oftheir treatment in a healthcare facility (HCAI).They can acquire an infection outside hospital andbring that infection into hospital (community-acquired infections). Sometimes the community-acquired infection will be the reason a patient isadmitted into hospital, and so the infectionshould be obvious, but other times it may not be(for example, a patient with hepatitis B who hasbeen admitted hospital for an unrelated surgicalprocedure). At any one time in a hospital, abouthalf of the infections are HCAIs and half arecommunity-acquired, but both can be a risk oftransmission to other patients.

Acts and RegulationsBuilding Regulations (2010). Drainage and wastedisposal. Approved document Hhttp://gov.wales/docs/desh/publications/130205building-regs-approved-document-h-drainage-en.pdf

Environmental Protection Act 1990http://www.legislation.gov.uk/ukpga/1990/43/contents

Water supply (Water Fittings) Regulations 1999, SI1999/1148http://www.legislation.gov.uk/uksi/1999/1148/introduction/made

Water, England and Wales. The Water Supply (WaterQuality) Regulations 2010, Welsh Statutory Instruments2010/994 (W.99)http://www.legislation.gov.uk/wsi/2010/994/contents/made

Workplace (Health, Safety and Welfare) Regulations 1992,SI 1992/3004http://www.legislation.gov.uk/uksi/1992/3004/introduction/made

British Standards InstitutionThe latest version of any standard should be usedprovided that it continues to address the relevantrequirements of these recommendations.http://shop.bsigroup.com/en/

BS EN 12056:2000. Gravity drainage systems insidebuildings.

NHS Wales Shared ServicesPartnership – Specialist EstatesServicesHealth Technical Memoranda (HTMs) and HealthBuilding Notes (HBNs) issued by the Department ofHealth in England are being superseded by specificWelsh editions which will be titled Welsh HealthTechnical Memoranda (WHTMs) and Welsh HealthBuilding Notes (WHBNs) and which will use the samenumerical coding. The guidelines referenced below werethe most recent at time of publication; however, thelatest version should always be used, provided that itcontinues to address the relevant requirements of theserecommendations. All are available from the NHS WalesShared Services Partnership – Specialist Estates Serviceswebsites:

Intranet:http://howis.wales.nhs.uk/sites3/page.cfm?orgid=254&pid=39106

Internet:http://www.wales.nhs.uk/sites3/page.cfm?orgid=254&pid=6142

Welsh Health Building Notes (WHBN)

WHBN 00-02:2013 Sanitary spaces

WHBN 00-03:2013 Clinical and clinical support spaces

WHBN 00-10 Part A:2014 Flooring

WHBN 00-10 Part B:2014 Walls and ceilings

WHBN 00-10 Part C:2014 Sanitary assemblies

WHBN 04-01:2014 Adult in-patient facilities

WHBN 04-01 Supplement 1:2014 Isolation facilities forinfectious patients in acute settings

WHBN 04-02 Critical care units. In production at timeof publication. Please view the Publication page of theNWSSP – Specialist Estates Services website to check ifit has been publishedhttp://www.wales.nhs.uk/sites3/page.cfm?orgid=254&pid=64096 or contact us at 029 2090 4118

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References

http://gov.wales/topics/planning/buildingregs/publications/part-h-drainage/?lang=en

http://www.legislation.gov.uk/uksi/1999/1148/introduction/made

http://www.legislation.gov.uk/wsi/2010/994/contents/made

http://www.legislation.gov.uk/uksi/1992/3004/introduction/made

http://howis.wales.nhs.uk/sites3/page.cfm?orgid=254&pid=39106



Welsh Health Technical Memoranda (WHTM)

WHTM 01-01 Parts A-E Decontamination of medicaldevices within acute services

HTM 02-01:2006 Medical gas pipeline systems. Part A:design, installation, validation and verification

HTM 02-01:2006 Medical gas pipeline systems. Part B:operational management

HTM 03-01:2007 Specialised ventilation for healthcarepremises. Part A: design and validation

HTM 03-01:2007 Specialised ventilation for healthcarepremises. Part B: operational management

Please view the Publication page of the NWSSP –Specialist Estates Services website to check whetherrecent Welsh versions of the above two HTMs have beenpublishedhttp://www.wales.nhs.uk/sites3/page.cfm?orgid=254&pid=64096

HTM 04-01:2006 The control of Legionella, hygiene,“safe” hot water, cold water and drinking water systems.Part A: Design, installation and testing

HTM 04-01:2006 The control of Legionella, hygiene,“safe” hot water, cold water and drinking water systems.Part B: Operational management

WHTM 04-01:2014 The control of Legionella, hygiene,“safe” hot water, cold water and drinking water systems.Addendum: Pseudomonas aeruginosa – advice foraugmented care units

WHTM 07-01:2013 Safe management of healthcare waste

HTM 08-03:2011 Bedhead services

HTM 2009:1995 Pneumatic air tube transport systems

Other publications Berthelot P, Chord F, Mallaval F et al (2006). Magneticvalves as a source of faucet contamination withPseudomonas aeruginosa? Intensive Care Medicine32(88): 1271

CIBSE (2014). Public health and plumbing engineering(CIBSE Guide G). London: Chartered Institution ofBuilding Services Engineers

CIBSE (2008). Lighting Guide 2: Hospitals and healthcarebuildings (SLL LG2). London: Chartered Institution ofBuilding Services Engineers.

Davies SC (2013). Annual Report of the Chief MedicalOfficer. Volume Two, 2011: Infections and the rise ofantimicrobial resistancehttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138331/CMO_Annual_Report_Volume_2_2011.pdf

DH (2010). Estates and Facilities Alert DH(2010) 03.Flexible water supply hoseshttp://webarchive.nationalarchives.gov.uk/20110503171839/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_115847.pdf

DH (2011). Environmental Design Guide: adult mediumsecure serviceshttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215623/dh_126177.pdf

Health & Safety Executive (2013). Legionnaires’ disease.The control of legionella bacteria in water systems: ApprovedCode of Practice and guidancehttp://www.hse.gov.uk/pubns/priced/l8.pdf

Health Facilities Scotland (2007). Dementia DesignChecklist http://www.hfs.scot.nhs.uk/publications/dementia-checklist-v1.pdf

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https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138331/CMO_Annual_Report_Volume_2_2011.pdf

http://webarchive.nationalarchives.gov.uk/20110503171839/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_115847.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215623/dh_126177.pdf

http://www.hfs.scot.nhs.uk/publications/dememntia-checklist-v1.pdf

http://www.hfs.scot.nhs.uk/publications/dementia-checklist-v1.pdf

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