guidelines for prevention of tb centers for disease control & prevention

Guidelines for Guidelines for Prevention of TBPrevention of TB

Centers for Disease Control & Centers for Disease Control & PreventionPrevention

Administrative ControlsAdministrative Controls

Infection Control Policies and ProceduresInfection Control Policies and Procedures

Risk Assessment/HCW ScreeningRisk Assessment/HCW Screening

Investigation of HCW TST ConversionsInvestigation of HCW TST Conversions

TB Infection Control Policies & TB Infection Control Policies & Procedures 1Procedures 1

High index of suspicion for TBHigh index of suspicion for TB

Prompt triage Prompt triage

Prompt initiation of respiratory isolationPrompt initiation of respiratory isolation AII room under negative pressure (monitored)AII room under negative pressure (monitored) UVGI and HEPA filtration as necessaryUVGI and HEPA filtration as necessary Limit movement of patient outside AII roomLimit movement of patient outside AII room

Prompt initiation of appropriate treatmentPrompt initiation of appropriate treatment

TB Infection Control Policies & TB Infection Control Policies & Procedures 2Procedures 2

Personal respiratory protection during exposure (N-Personal respiratory protection during exposure (N-

95 respirators)**fit testing req.95 respirators)**fit testing req.

Limit employee and visitor exposure Limit employee and visitor exposure

Monitor clinical status by symptoms, laboratory and Monitor clinical status by symptoms, laboratory and

CXR to ensure appropriate duration of airborne CXR to ensure appropriate duration of airborne

precautionsprecautions Appropriate discharge to the communityAppropriate discharge to the community

Respiratory ProtectionRespiratory Protection

The ability to filter 1um in size with a filter The ability to filter 1um in size with a filter efficiency of >95% efficiency of >95%

Fit test to insure face seal leakage of Fit test to insure face seal leakage of <10%<10%

Making respirators available in at least Making respirators available in at least three sizesthree sizes

Reuse of Respirators Reuse of Respirators

Why do we place patients in Why do we place patients in isolation?isolation?

Patients who are immunocompromised Patients who are immunocompromised are placed in a “protective environment”are placed in a “protective environment”

Patients who have communicable Patients who have communicable diseases are placed in “airborne infection diseases are placed in “airborne infection isolation”(AII)isolation”(AII)

Patients who have both problems are put Patients who have both problems are put in a room with a combination of controls in a room with a combination of controls but always protect the staff, visitors and but always protect the staff, visitors and other patientsother patients

Protective EnvironmentProtective Environment

Protective EnvironmentProtective Environment

Install central or point-of-use HEPA filters for Install central or point-of-use HEPA filters for incoming airincoming air

Maintain Maintain >> 12 air changes per hour (ACH) 12 air changes per hour (ACH) Maintain positive pressure (Maintain positive pressure (>> 2.5 Pa) in relation 2.5 Pa) in relation

to corridorto corridor Ensure that rooms are well sealedEnsure that rooms are well sealed

Properly constructed windows, doors and intake and Properly constructed windows, doors and intake and exhaust portsexhaust ports

Maintain ceilings that are smooth and free of fissures, Maintain ceilings that are smooth and free of fissures, open joints and crevicesopen joints and crevices

Monitor for leakageMonitor for leakage

Airborne Airborne Spread of Spread of Smallpox Smallpox

in the in the Meschede Meschede HospitalHospital

Fenner. 1988.Fig. 4.9

AII RoomsAII Rooms

AII RoomsAII Rooms Maintain continuous negative pressure (2.5 Pa) Maintain continuous negative pressure (2.5 Pa)

in relation to the air pressure in the corridor and in relation to the air pressure in the corridor and ensure monitoringensure monitoring

Ensure that rooms are well sealedEnsure that rooms are well sealed Provide ventilation to ensure Provide ventilation to ensure >> 12 ACH for new 12 ACH for new

and renovated rooms and and renovated rooms and >> 6 ACH for existing 6 ACH for existing roomsrooms

Direct exhaust air to the outside, away from air Direct exhaust air to the outside, away from air intake and populated areas. If this is not intake and populated areas. If this is not practical, air from the room can be recirculated practical, air from the room can be recirculated after passing through a HEPA filter, ?UVGIafter passing through a HEPA filter, ?UVGI

GuidelinesGuidelines 2001 AIA “Guidelines for Design and Construction of 2001 AIA “Guidelines for Design and Construction of

Hospital and Health Care Facilities - ????NEW July 2006Hospital and Health Care Facilities - ????NEW July 2006 2003 CDC “Guidelines for Environmental Infection 2003 CDC “Guidelines for Environmental Infection

Control in Health-Care Facilities”Control in Health-Care Facilities” 2004 JCAHO “Environment of Care – Essentials for 2004 JCAHO “Environment of Care – Essentials for

Health Care” Fourth EditionHealth Care” Fourth Edition

AIA Guidelines Section:AIA Guidelines Section: 7.2.C Airborne Infectious 7.2.C Airborne Infectious Isolation Rooms does not require anterooms. The Isolation Rooms does not require anterooms. The requirement for an anteroom was dropped in the requirement for an anteroom was dropped in the 1996-97 edition of the Guidelines on the basis of a 1996-97 edition of the Guidelines on the basis of a study.study.

CDC Guideline:CDC Guideline: Does not require anteroom. For Does not require anteroom. For Viral Hemorrhagic Fever and Smallpox, use AII Viral Hemorrhagic Fever and Smallpox, use AII preferably with an anteroom – if not available use preferably with an anteroom – if not available use industrial-grade HEPA filters to provide additional industrial-grade HEPA filters to provide additional ACHACH

JCAHO EC Standard:JCAHO EC Standard: No reference to anterooms No reference to anterooms

What about an anteroom?What about an anteroom?

ASHRAE’s Design ManualASHRAE’s Design Manual (American Society of Heating, Refrigeration, and Air-conditioning (American Society of Heating, Refrigeration, and Air-conditioning

Engineers)Engineers)

“HVAC Design Manual for “HVAC Design Manual for Hospitals and Clinics” 2003Hospitals and Clinics” 2003

Chapter 12: Room DesignChapter 12: Room DesignOn negative air pressure, as is required for Airborne Infectious On negative air pressure, as is required for Airborne Infectious

Isolation Rooms: Isolation Rooms:

“…“…Through dilution, a 500 cubic feet anteroom (for example) Through dilution, a 500 cubic feet anteroom (for example) with an AVM of 50 cubic feet would experience a 90 percent with an AVM of 50 cubic feet would experience a 90 percent reduction in the transmission of contaminated air to and from reduction in the transmission of contaminated air to and from the isolation room. the isolation room. An anteroom is recommended as a means An anteroom is recommended as a means of controlling airborne contaminant concentration via of controlling airborne contaminant concentration via containment and dilution of the migrating air.”containment and dilution of the migrating air.”

Why add an anteroom or airlock?Why add an anteroom or airlock?

To provide a barrier against loss of To provide a barrier against loss of pressurization, and against entry/exit of pressurization, and against entry/exit of contaminated air into/out of isolation room when contaminated air into/out of isolation room when the door to the airlock is openedthe door to the airlock is opened

To provide a controlled environment in which To provide a controlled environment in which protective garments can be donned without protective garments can be donned without contamination before entry into and exit out of contamination before entry into and exit out of roomroom

To provide a controlled environment in which To provide a controlled environment in which equipment and supplies can be transferred fro equipment and supplies can be transferred fro the isolation room without contaminating the the isolation room without contaminating the surrounding areasurrounding area

AnteroomsAnterooms

Creating Isolation RoomsCreating Isolation Rooms

Funding by governmental agencies to Funding by governmental agencies to increase isolation capacityincrease isolation capacity

Many healthcare facilities have upgraded Many healthcare facilities have upgraded or retrofitted existing negative pressure or retrofitted existing negative pressure isolation roomsisolation rooms

Many healthcare facilities have purchased Many healthcare facilities have purchased “quick fixes” to increase isolation capacity“quick fixes” to increase isolation capacity

What’s out there?What’s out there?

Source Control – Local Source Control – Local Exhaust/VentilationExhaust/Ventilation

DisclaimerDisclaimer

Following are illustrations of actual Following are illustrations of actual products available to healthcare facilities. products available to healthcare facilities. These are being used for educational These are being used for educational purposes only and are not meant to purposes only and are not meant to endorse or criticize any individual endorse or criticize any individual company or product. I have no financial company or product. I have no financial interest in any healthcare products.interest in any healthcare products.

What’s out there?What’s out there?

Key PointsKey Points

There needs to be a clear understanding by all There needs to be a clear understanding by all of our goals when using isolation rooms – who of our goals when using isolation rooms – who are we trying to protect and why.are we trying to protect and why.

There needs to be a clear understanding of how There needs to be a clear understanding of how to appropriately use the equipment/resources to appropriately use the equipment/resources available to accomplish our goals.available to accomplish our goals.

There needs to be a clear understanding of how There needs to be a clear understanding of how to minimize risks and maximize benefits to to minimize risks and maximize benefits to patients and health care workers by using the patients and health care workers by using the equipment/resources.equipment/resources.


A portable HEPA device will not create a A portable HEPA device will not create a negative pressure room unless exhaust can be negative pressure room unless exhaust can be discharged directly to the outside. discharged directly to the outside.

Trying to connect a HEPA unit into a return duct Trying to connect a HEPA unit into a return duct to create negative pressure would pressurize the to create negative pressure would pressurize the return duct and result in blowback into adjacent return duct and result in blowback into adjacent rooms. rooms.

If the unit is vented directly to the outside, return If the unit is vented directly to the outside, return air grilles must be sealed off – remember to take air grilles must be sealed off – remember to take into account the direction of flow into the into account the direction of flow into the attached bathroom.attached bathroom.

Key PointsKey Points All personnel must understand the use of these All personnel must understand the use of these

devices – housekeeping, nursing. devices – housekeeping, nursing. The portable air filtration device should not be The portable air filtration device should not be

plugged into a power strip or extension cord. plugged into a power strip or extension cord. Consider using an emergency power outlet.Consider using an emergency power outlet.

The HEPA unit must not create an obstruction The HEPA unit must not create an obstruction that would interfere with the proper delivery of that would interfere with the proper delivery of health care.health care.

The placement of the device needs to be pre-The placement of the device needs to be pre-determined to maximize air mixing for better air determined to maximize air mixing for better air scrubbing. scrubbing.


The intake of the device should be placed The intake of the device should be placed as close to the suspected source of as close to the suspected source of contamination.contamination.

The device should be placed so that it The device should be placed so that it does not draw contaminated air past the does not draw contaminated air past the breathing zone of the caregiver.breathing zone of the caregiver.

The air flowing out of the device must not The air flowing out of the device must not be directed in a way that would cause be directed in a way that would cause discomfort to patients, visitors and staff.discomfort to patients, visitors and staff.


The air flow needs to be appropriate for the size The air flow needs to be appropriate for the size of the room to give the desired air exchanges of the room to give the desired air exchanges per hour. Consider a locked panel to prevent a per hour. Consider a locked panel to prevent a change in the air flow controls.change in the air flow controls.

Rooms in which the devices may be utilized Rooms in which the devices may be utilized should be chosen beforehand ensuring that the should be chosen beforehand ensuring that the noise created is not disruptive to others.noise created is not disruptive to others.

If the unit is ducted to the outside or into the If the unit is ducted to the outside or into the existing ventilation system, ensure that an existing ventilation system, ensure that an appropriately fitting interface is available.appropriately fitting interface is available.


Place HEPA filters over exhaust grilles that Place HEPA filters over exhaust grilles that cannot be blocked.cannot be blocked.

The use of the portable filtration devices should The use of the portable filtration devices should be guided by a written policy that is facility-be guided by a written policy that is facility-specific with appropriate reviews and approvals specific with appropriate reviews and approvals from infection control, administration, clinical and from infection control, administration, clinical and facility engineering and the departments in which facility engineering and the departments in which the units will be used.the units will be used.

Healthcare facilities should have a checklist Healthcare facilities should have a checklist establishing the proper room use.establishing the proper room use.


Based on manufacturer’s recommendation and Based on manufacturer’s recommendation and any additional suggested protocol from facility any additional suggested protocol from facility maintenance, a standard routine maintenance maintenance, a standard routine maintenance procedure should be developed for the unit. procedure should be developed for the unit. This should include:This should include: Changing of pre-filters. Be sure to include details of Changing of pre-filters. Be sure to include details of

PPE and proper disposal of filters.PPE and proper disposal of filters. Operational check for proper operation.Operational check for proper operation. Interior cleaning of the unitInterior cleaning of the unit Changing of UV lamp Changing of UV lamp General electrical and mechanical safety checkGeneral electrical and mechanical safety check


Clinical and/or facility engineering should Clinical and/or facility engineering should check the machine on a daily basis while check the machine on a daily basis while in use and measure the degree of in use and measure the degree of negative pressure between the room in negative pressure between the room in which it is situated and adjacent/affected which it is situated and adjacent/affected areas.areas.


The HEPA device must be leak tested and The HEPA device must be leak tested and certified. This should be done initially certified. This should be done initially when the equipment is received, at least when the equipment is received, at least annually thereafter, and every time the annually thereafter, and every time the HEPA filter is changed. The frequency of HEPA filter is changed. The frequency of changing the HEPA filter should be based changing the HEPA filter should be based upon manufacturer’s recommendation.upon manufacturer’s recommendation.


Policies and procedures should specify Policies and procedures should specify recommended PPE when performing recommended PPE when performing maintenance of the unit.maintenance of the unit.

Maintenance should be performed in an Maintenance should be performed in an area away from patient care.area away from patient care.

Monitoring Negative Air Pressure Monitoring Negative Air Pressure

Pressure-measuring Pressure-measuring devicesdevices Measure pressure at Measure pressure at

the bottom of the doorthe bottom of the door Audible warning with a Audible warning with a

time delaytime delay Check continuous Check continuous

monitoring devices at monitoring devices at least monthly using least monthly using smoke tubessmoke tubes

Smoke TestSmoke Test

Checked dailyChecked daily Hold 2 inches from Hold 2 inches from

bottom of doorbottom of door If room air cleaners If room air cleaners

are used they should are used they should be runningbe running

Door must be closedDoor must be closed

UV RadiationUV Radiation

Used to supplement other engineering Used to supplement other engineering controlscontrols

Duct IrradiationDuct Irradiation To recirculate air from an isolation room back To recirculate air from an isolation room back

into the room.into the room. Used in general use areas where air is Used in general use areas where air is

recirculated back into general ventilationrecirculated back into general ventilation Upper Room Air IrradiationUpper Room Air Irradiation

Mounted on ceiling or wallMounted on ceiling or wall

Effectiveness of UV SystemsEffectiveness of UV Systems

Intensity of UVGIIntensity of UVGI Duration of contactDuration of contact Relative humidityRelative humidity

UV Safety IssuesUV Safety Issues

Short Term ExposureShort Term Exposure EducationEducation LabelingLabeling MaintenanceMaintenance MonitoringMonitoring

Operating RoomOperating Room

Place bacterial filter on Place bacterial filter on patient endotracheal tubepatient endotracheal tube Expiratory side of breathing circuit of aExpiratory side of breathing circuit of a

• VentilatorVentilator• Anesthesia equipmentAnesthesia equipment

No anteroomsNo anterooms Keep doors closedKeep doors closed Control trafficControl traffic If possible schedule case at end of dayIf possible schedule case at end of day

Postoperative recoveryPostoperative recovery

Private roomPrivate room

Negative air pressureNegative air pressure

Autopsy roomsAutopsy rooms

Negative air PressureNegative air Pressure 12 ACH12 ACH Increase ventilation if possible using HEPA –Increase ventilation if possible using HEPA –

filtered air or UVGI recirculation systemsfiltered air or UVGI recirculation systems Exhausted directly to outsideExhausted directly to outside Respiratory protection Respiratory protection

guidelines for prevention of tb centers for disease control & prevention

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