The Hospital Environment

The Hospital Environment

Wednesday, 02 March 2011 16:30

Buildings for Health Care Facilities

The health maintenance and enhancement, the safety and the comfort of people in health care facilities are seriously affected if specific building requirements are not met. Health care facilities are rather unique buildings, in which heterogeneous environments coexist. Different people, several activities in each environment and many risk factors are involved in the pathogenesis of a broad spectrum of diseases. Functional organization criteria classify health care facility environments as follows: nursing units, operating theatres, diagnostic facilities (radiology unit, laboratory units and so on), outpatients’ departments, administration area (offices), dietary facilities, linen services, engineering services and equipment areas, corridors and passages. The group of people which attends a hospital is composed of health personnel, staff personnel, patients (long-stay inpatients, acute inpatients and outpatients) and visitors. The processes include health care specific activities—diagnostic activities, therapeutic activities, nursing activities—and activities common to many public buildings—office work, technological maintenance, food preparation and so on. The risk factors are physical agents (ionizing and non-ionizing radiation, noise, lighting and microclimatic factors), chemicals (e.g., organic solvents and disinfectants), biological agents (viruses, bacteria, fungi and so on), ergonomics (postures, lifting and so on) and psychological and organizational factors (e.g., environmental perceptions and work hours). The illnesses related to the above-mentioned factors range from environmental annoyance or discomfort (e.g., thermal discomfort or irritative symptoms) to severe diseases (e.g., hospital-acquired infections and traumatic accidents). In this perspective, the risk assessment and control require an interdisciplinary approach involving physicians, hygienists, engineers, architects, economists and so on and fulfilment of preventive measures in the building planning, design, construction and management tasks. Specific building requirements are extremely important among these preventive measures, and, according to the guidelines for healthy buildings introduced by Levin (1992), they should be classified as follows:

site planning requirements

architectural design requirements

requirements for building materials and furnishings

requirements for heating, ventilation and air-conditioning systems and for microclimatic conditions.

This article focuses on general hospital buildings. Obviously, adaptations would be required for specialty hospitals (e.g., orthopaedic centres, eye and ear hospitals, maternity centres, psychiatric institutions, long-term care facilities and rehabilitation institutes), for ambulatory care clinics, emergency/urgent care facilities and offices for individual and group practices. These will be determined by the numbers and types of patients (including their physical and mental status) and by the number of HCWs and the tasks they perform. Considerations promoting the safety and well-being of both patients and staff that are common to all health care facilities include:

ambience, including not only decoration, lighting and noise control but also partitioning and placement of furniture and equipment that avoid entrapment of workers with potentially violent patients and visitors

ventilation systems that minimize exposure to infectious agents and potentially toxic chemicals and gases

storage facilities for clothing and effects of patients and their visitors that minimize potential contamination

lockers, changing rooms, wash-up facilities and rest rooms for staff

conveniently-located hand-washing facilities in each room and treatment area

doorways, elevators and toilets that accommodate wheel chairs and stretchers

storage and filing areas designed to minimize workers’ stooping, bending, reaching and heavy lifting

automatic and worker-controlled communication and alarm systems

mechanisms for collection, storage and disposition of toxic wastes, contaminated linens and clothing and so on.

Site Planning Requirements

The health care facility site must be chosen following four main criteria (Catananti and Cambieri 1990; Klein and Platt 1989; Decree of the President of Ministers Council 1986; Commission of the European Communities 1990; NHS 1991a, 1991b):

Environmental factors. The terrain should be as level as possible. Ramps, escalators and elevators can offset sides of hills, but they hinder the access of elderly and handicapped people, adding both a higher cost to the project and an extra burden to fire departments and evacuation teams. Heavy wind sites should be avoided, and the area should be far from sources which create pollution and noise (especially factories and landfills). Radon and radon daughters levels should be assessed, and measures to reduce exposure should be taken. In colder climates, consideration should be given to embedding snow-melting coils in sidewalks, entrance ways and parking areas to minimize falls and other accidents.
Geological configuration. Earthquake-prone areas should be avoided, or at least anti-seismic construction criteria must be followed. The site must be chosen following an hydrogeological assessment, to avoid water infiltrations into the foundations.
Urbanistic factors. The site should be easily accessible to potential users, ambulances and service vehicles for goods supply and waste disposal. Public transportation and utilities (water, gas, electricity and sewers) should be available. Fire departments should be nearby, and fire-fighters and their apparatus should find ready access to all parts of the facility.
Space availability. The site should allow some scope for expansion and provision of adequate car parking.

Architectural Design

Health care facilities architectural design usually follows several criteria:

class of the health care facility: hospital (acute-care hospital, community hospital, rural hospital), large or small health care centre, nursing homes (extended care facilities, skilled nursing homes, residential care homes), general medical practice premise (NHS 1991a; NHS 1991b; Kleczkowski, Montoya-Aguilar and Nilsson 1985; ASHRAE 1987)

catchment area dimensions

management issues: costs, flexibility (susceptibility to adaptation)

ventilation provided: an air-conditioned building is compact and deep with as small an amount of external walls as possible, to reduce the heat transfer between outside and inside; a naturally ventilated building is long and thin, to maximize exposure to breezes and to minimize internal distances from windows (Llewelyn-Davies and Wecks 1979)

building/area ratio

environmental quality: safety and comfort are extremely relevant targets.

The listed criteria lead health care facilities planners to choose the best building shape for each situation, ranging essentially from an extended horizontal hospital with scattered buildings to a monolithic vertical or horizontal building (Llewelyn-Davies and Wecks 1979). The first case (a preferable format for low-density buildings) is normally used for hospitals up to 300 beds, because of its low costs in construction and management. It is particularly considered for small rural hospitals and community hospitals (Llewelyn-Davies and Wecks 1979). The second case (usually preferred for high-density buildings) becomes cost-effective for hospitals with more than 300 beds, and it is advisable for acute-care hospitals (Llewelyn-Davies and Wecks 1979). The internal space dimensions and distribution have to cope with many variables, among which one can consider: functions, processes, circulation and connections to other areas, equipment, predicted workload, costs, and flexibility, convertibility and susceptibility of shared use. Compartments, exits, fire alarms, automatic extinction systems and other fire prevention and protection measures should follow local regulations. Furthermore, several specific requirements have been defined for each area in health care facilities:

1. Nursing units. Internal layout of nursing units usually follows one of the following three basic models (Llewelyn-Davies and Wecks 1979): an open ward (or “Nightingale” ward)—a broad room with 20 to 30 beds, heads to the windows, ranged along both walls; the “Rigs” layout—in this model beds were placed parallel to the windows, and, at first, they were in open bays on either side of a central corridor (as at Rigs Hospital in Copenhagen), and in later hospitals the bays were often enclosed, so that they became rooms with 6 to 10 beds; small rooms, with 1 to 4 beds. Four variables should lead the planner to choose the best layout: bed need (if high, an open ward is advisable), budget (if low, an open ward is the cheapest one), privacy needs (if considered high, small rooms are unavoidable) and intensive care level (if high, the open ward or Rigs layout with 6 to 10 beds are advisable). The space requirements should be at least: 6 to 8 square metres (sqm) per bed for open wards, inclusive of circulation and ancillary rooms (Llewelyn-Davies and Wecks 1979); 5 to 7 sqm/bed for multiple bedrooms and 9 sqm for single bedrooms (Decree of the President of Ministers Council 1986; American Institute of Architects Committee on Architecture for Health 1987). In open wards, toilet facilities should be close to patients’ beds (Llewelyn-Davies and Wecks 1979). For single and multiple bedrooms, handwashing facilities should be provided in each room; lavatories may be omitted where a toilet room is provided to serve one single-bed room or one two-bed room (American Institute of Architects Committee on Architecture for Health 1987). Nursing stations should be large enough to accommodate desks and chairs for record keeping, tables and cabinets for preparation of drugs, instruments and supplies, chairs for sit-down conferences with physicians and other staff members, a wash-up sink and access to a staff toilet.

2. Operating theatres. Two main classes of elements should be considered: operating rooms and service areas (American Institute of Architects Committee on Architecture for Health 1987). Operating rooms should be classified as follows:

general operating room, needing a minimum clear area of 33.5 sqm.

room for orthopaedic surgery (optional), needing enclosed storage space for splints and traction equipment

room for cardiovascular surgery (optional), needing a minimum clear area of 44 sqm. In the clear area of the surgical suite, nearby the operating room, an additional pump room should be designed, where extracorporeal pump supplies and accessories are stored and serviced.

room for endoscope procedures, needing a minimum clear area of 23 sqm

rooms for waiting patients, induction of anaesthesia and recovery from anaesthesia.

Service areas should include: sterilizing facility with high-speed autoclave, scrub facilities, medical gas storage facilities and staff clothing change areas.

3. Diagnostic facilities: Each radiology unit should include (Llewelyn-Davies and Wecks 1979; American Institute of Architects Committee on Architecture for Health 1987):

appointment desk and waiting areas

diagnostic radiographic rooms, needing 23 sqm for fluoroscopic procedures and about 16 sqm for radiographic ones, plus a shielded control area, and rigid support structures for ceiling-mounted equipment (where necessary)

dark room (where necessary), needing almost 5 sqm and appropriate ventilation for the developer

contrast media preparation area, clean-up facilities, film quality control area, computer area and film storage area

viewing area where films can be read and reports dictated.

The wall thickness in a radiology unit should be 8 to 12 cm (poured concrete) or 12 to 15 cm (cinder block or bricks). The diagnostic activities in health care facilities may require tests in haematology, clinical chemistry, microbiology, pathology and cytology. Each laboratory area should be provided with work areas, sample and material storage facilities (refrigerated or not), specimen collection facilities, facilities and equipment for terminal sterilization and waste disposal, and a special facility for radioactive material storage (where necessary) (American Institute of Architects Committee on Architecture for Health 1987).

4. Outpatient departments. Clinical facilities should include (American Institute of Architects Committee on Architecture for Health 1987): general-purpose examination rooms (7.4 sqm), special-purpose examination rooms (varying with the specific equipment needed) and treatment rooms (11 sqm). In addition, administrative facilities are needed for the admittance of outpatients.

5. Administration area (offices). Facilities such as common office building areas are needed. These include a loading dock and storage areas for receiving supplies and equipment and dispatching materials not disposed of by the separate waste removal system.

6. Dietary facilities (optional). Where present, these should provide the following elements (American Institute of Architects Committee on Architecture for Health 1987): a control station for receiving and controlling food supplies, storage spaces (including cold storage), food preparation facilities, handwashing facilities, facility for assembling and distributing patients’ meals, dining space, dishwashing space (located in a room or an alcove separated from the food preparation and serving area), waste storage facilities and toilets for dietary staff.

7. Linen services (optional). Where present, these should provide the following elements: a room for receiving and holding soiled linen, a clean-linen storage area, a clean-linen inspection and mending area and handwashing facilities (American Institute of Architects Committee on Architecture for Health 1987).

8. Engineering services and equipment areas. Adequate areas, varying in size and characteristics for each health care facility, have to be provided for: boiler plant (and fuel storage, if necessary), electrical supply, emergency generator, maintenance workshops and stores, cold-water storage, plant rooms (for centralized or local ventilation) and medical gases (NHS 1991a).

9. Corridors and passages. These have to be organized to avoid confusion for visitors and disruptions in the work of hospital personnel; circulation of clean and dirty goods should be strictly separated. Minimum corridor width should be 2 m (Decree of the President of Ministers Council 1986). Doorways and elevators must be large enough to allow easy passage of stretchers and wheelchairs.

Requirements for Building Materials and Furnishings

The choice of materials in modern health care facilities is often aimed to reduce the risk in accidents and fire occurrence: materials must be non-inflammable and must not produce noxious gases or smokes when burnt (American Institute of Architects Committee on Architecture for Health 1987). Trends in hospital floor-covering materials have shown a shift from stone materials and linoleum to polyvinyl chloride (PVC). In operating rooms, in particular, PVC is considered the best choice to avoid electrostatic effects that may cause explosion of anaesthetic flammable gases. Up to some years ago, walls were painted; today, PVC coverings and fibreglass wallpaper are the most used wall finishes. False ceilings are today built mainly from mineral fibres instead of gypsum board; a new trend appears to be that of using stainless steel ceilings (Catananti et al. 1993). However, a more complete approach should consider that each material and furnishing may cause effects in the outdoor and indoor environmental systems. Accurately chosen building materials may reduce environmental pollution and high social costs and improve the safety and comfort of building occupants. At the same time, internal materials and finishes may influence the functional performance of the building and its management. Besides, the choice of materials in hospitals should also consider specific criteria, such as ease of cleaning, washing and disinfecting procedures and susceptibility to becoming a habitat for living beings. A more detailed classification of criteria to be considered in this task, derived from the European Community Council Directive No. 89/106 (Council of the European Communities 1988), is shown in table 1 .

Table 1. Criteria and variables to be considered in the choice of materials

Criteria	Variables
Functional performance	Static load, transit load, impact load, durability, construction requirements
Safety	Collapse risk, fire risk (reaction to fire, fire resistance, flammability), static electric charge (explosion risk), disperse electric power (electric shock risk), sharp surface (wound risk), poisoning risk (hazardous chemical emission), slip risk, radioactivity
Comfort and pleasantness	Acoustic comfort (features related to noise), optical and visual comfort (features related to light), tactile comfort (consistence, surface), hygrothermal comfort (features related to heat), aesthetics, odour emissions, indoor air quality perception
Hygienicity	Living beings habitat (insects, moulds, bacteria), susceptibility to stains, susceptibility to dust, easiness in cleaning, washing and disinfecting, maintenance procedures
Flexibility	Susceptibility to modifications, conformational factors (tile or panel dimensions and morphology)
Environmental impact	Raw material, industrial manufacturing, waste management
Cost	Material cost, installation cost, maintenance cost

Source: Catananti et al. 1994.

On the matter of odour emissions, it should be observed that a correct ventilation after floor or wall-coverings installation or renovation work reduces exposure of personnel and patients to indoor pollutants (especially volatile organic compounds (VOCs)) emitted by building materials and furnishings.

Requirements for Heating, Ventilation and Air-Conditioning Systems and for Microclimatic Conditions

The control of microclimatic conditions in health care facilities areas may be carried out by heating, ventilation and/or air-conditioning systems (Catananti and Cambieri 1990). Heating systems (e.g., radiators) permit only temperature regulation and may be sufficient for common nursing units. Ventilation, which induces changes of air speed, may be natural (e.g., by porous building materials), supplementary (by windows) or artificial (by mechanical systems). The artificial ventilation is especially recommended for kitchens, laundries and engineering services. Air-conditioning systems, particularly recommended for some health care facility areas such as operating rooms and intensive-care units, should guarantee:

the control of all microclimatic factors (temperature, relative humidity and air speed)

the control of air purity and concentration of micro-organisms and chemicals (e.g., anaesthetic gases, volatile solvents, odours and so on). This target may be achieved by adequate air filtration and air changes, right pressure relationships among adjacent areas and laminar airflow.

General requirements of air-conditioning systems include outdoor intake locations, air filter features and air supply outlets (ASHRAE 1987). Outdoor intake locations should be far enough, at least 9.1 m, from pollution sources such as exhaust outlets of combustion equipment stacks, medical-surgical vacuum systems, ventilation exhaust outlets from the hospital or adjoining buildings, areas that may collect vehicular exhaust and other noxious fumes, or plumbing vent stacks. Besides, their distance from ground level should be at least 1.8 m. Where these components are installed above the roof, their distance from roof level should be at least 0.9 m.

Number and efficiency of filters should be adequate for the specific areas supplied by air conditioning systems. For example, two filter beds of 25 and 90% efficiency should be used in operating rooms, intensive-care units and transplant organ rooms. Installation and maintenance of filters follow several criteria: lack of leakage between filter segments and between the filter bed and its supporting frame, installation of a manometer in the filter system in order to provide a reading of the pressure so that filters can be identified as expired and provision of adequate facilities for maintenance without introducing contamination into the air flow. Air supply outlets should be located on the ceiling with perimeter or several exhaust inlets near the floor (ASHRAE 1987).

Ventilation rates for health care facility areas permitting air purity and comfort of occupants are listed in table 2 .

Table 2. Ventilation requirements in health care facilities areas

Areas	Pressure relationships to adjacent areas	Minimum air changes of outdoor air per hour supplied to room	Minimum total air changes per hour supplied to room	All air exhausted directly to outdoors	Recirculated within room units
Nursing units
Patient room	+/–	2	2	Optional	Optional
Intensive care	P	2	6	Optional	No
Patient corridor	+/–	2	4	Optional	Optional
Operating theatres
Operating room (all outdoor system)	P	15	15	Yes¹	No
Operating room (recirculating system)	P	5	25	Optional	No²
Diagnostic facilities
X ray	+/–	2	6	Optional	Optional
Laboratories
Bacteriology	N	2	6	Yes	No
Clinical chemistry	P	2	6	Optional	No
Pathology	N	2	6	Yes	No
Serology	P	2	6	Optional	No
Sterilizing	N	Optional	10	Yes	No
Glasswashing	N	2	10	Yes	Optional
Dietary facilities
Food preparation centres³	+/–	2	10	Yes	No
Dishwashing	N	Optional	10	Yes	No
Linen service
Laundry (general)	+/–	2	10	Yes	No
Soiled linen sorting and storage	N	Optional	10	Yes	No
Clean linen storage	P	2 (Optional)	2	Optional	Optional

P = Positive. N = Negative. +/– = Continuous directional control not required.

¹ For operating rooms, use of 100% outside air should be limited to these cases where local codes require it, only if heat recovery devices are used; ² recirculating room units meeting the filtering requirement for the space may be used;³ food preparation centres shall have ventilation systems that have an excess of air supply for positive pressure when hoods are not in operation. The number of air changes may be varied to any extent required for odour control when the space is not in use.

Source: ASHRAE 1987.

Specific requirements of air-conditioning systems and microclimatic conditions regarding several hospital areas are reported as follows (ASHRAE 1987):

Nursing units. In common patient rooms a temperature (T) of 24 °C and a 30% relative humidity (RH) for winter and a T of 24 °C with 50% RH for summer are recommended. In intensive-care units a variable range temperature capability of 24 to 27 °C and a RH of 30% minimum and 60% maximum with a positive air pressure are recommended. In immunosuppressed patient units a positive pressure should be maintained between patient room and adjacent area and HEPA filters should be used.

In full-term nursery a T of 24 °C with RH from 30% minimum to 60% maximum is recommended. The same microclimatic conditions of intensive-care units are required in special-care nursery.

Operating theatres. Variable temperature range capability of 20 to 24 °C with RH of 50% minimum and 60% maximum and positive air pressure are recommended in operating rooms. A separate air-exhaust system or special vacuum system should be provided in order to remove anaesthetic gas traces (see “Waste anaesthetic gases” in this chapter).

Diagnostic facilities. In the radiology unit, fluoroscopic and radiographic rooms require T of 24 to 27 °C and RH of 40 to 50%. Laboratory units should be supplied with adequate hood exhaust systems to remove dangerous fumes, vapours and bioaerosols. The exhaust air from the hoods of the units of clinical chemistry, bacteriology and pathology should be discharged to the outdoors with no recirculation. Also, the exhaust air from infectious disease and virology laboratories requires sterilization before being exhausted to the outdoors.

Dietary facilities. These should be provided with hoods over the cooking equipment for removal of heat, odours and vapours.

Linen services. The sorting room should be maintained at a negative pressure in relation to adjoining areas. In the laundry processing area, washers, flatwork ironers, tumblers, and so on should have direct overhead exhaust to reduce humidity.

Engineering services and equipment areas. At work stations, the ventilation system should limit temperature to 32 °C.

Conclusion

The essence of specific building requirements for health care facilities is the accommodation of external standard-based regulations to subjective index-based guidelines. In fact, subjective indices, such as Predicted Mean Vote (PMV) (Fanger 1973) and olf, a measure of odour (Fanger 1992), are able to make predictions of the comfort levels of patients and personnel without neglecting the differences related to their clothing, metabolism and physical status. Finally, the planners and architects of hospitals should follow the theory of “building ecology” (Levin 1992) which describes dwellings as a complex series of interactions among buildings, their occupants and the environment. Health facilities, accordingly, should be planned and built focusing on the whole “system” rather than any particular partial frames of reference.

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Published in The Hospital Environment

Wednesday, 02 March 2011 16:36

Hospitals: Environmental and Public Health Issues

A hospital is not an isolated social environment; it has, given its mission, very serious intrinsic social responsibilities. A hospital needs to be integrated with its surroundings and should minimize its impact upon them, thus contributing to the welfare of the people who live near it.

From a regulatory perspective, the health industry has never been considered to be on the same level as other industries when they are ranked according to the health risks they pose. The result is that specific legislation in this sphere has been non-existent until recently, although in the last few years this deficiency has been addressed. While in many other kinds of industrial activities, health and safety is an integral part of the organization, most health centres still pay little or no attention to it.

One reason for this could be the attitudes of HCWs themselves, who may be preoccupied more with research and the acquisition of the latest technologies and diagnostic and treatment techniques than with looking into the effects that these advances could have on their own health and on the environment.

New developments in science and health care must be combined with environmental protection, because environmental policies in a hospital affect the quality of life of HCWs within the hospital and those who live outside it.

Integrated Health, Safety and Environmental Programmes

HCWs represent a major group, comparable in size to the large enterprises of the private sector. The number of people who pass through a hospital every day is very large: visitors, inpatients, outpatients, medical and commercial representatives, subcontractors and so on. All of them, to a greater or lesser degree, are exposed to the potential risks posed by the activities of the medical centre and, at the same time, contribute on a certain level to the improvement or the worsening of the safety and the care of the centre’s surroundings.

Strict measures are needed in order to safeguard HCWs, the general public and the surrounding environment from the deleterious effects that may stem from hospital activities. These activities include the use of ever more sophisticated technology, the more frequent use of extremely powerful drugs (the effects of which can have a profound and irreparable impact on the people who prepare or administer them), the too-often uncontrolled use of chemical products and the incidence of infectious diseases, some of which are incurable.

The risks of working in a hospital are many. Some are easy to identify, while others are very hard to detect; the measures to be taken should therefore always be rigorous.

Different groups of health professionals are particularly exposed to risks common to the health care industry in general, as well as to specific risks related to their profession and/or to the activities they perform in the course of their work.

The concept of prevention, therefore, must of necessity be incorporated to the health care field and encompass:

safety in the broadest sense, including psychosociology and ergonomics as part of the programmes to improve the quality of life in the workplace

hygiene, minimizing as much as possible any physical, chemical or biological factor that may affect the health of people in the work environment

environment, following policies to protect nature and people in the surrounding community and decreasing the impact on the environment.

We should be aware that the environment is directly and intimately related to the safety and hygiene in the workplace, because natural resources are consumed at work, and because these resources are later reincorporated into our surroundings. Our quality of life will be good or bad depending on whether we make correct use of these resources and use appropriate technologies.

Everyone’s involvement is necessary in order to contribute to further:

nature conservancy policies, designed to guarantee the survival of the natural heritage that surrounds us

environmental improvement policies as well as policies to control indoor and environmental pollution in order to integrate human activity with the environment

environmental research and training policies to improve working conditions as well as to reduce environmental impact

planning organizational policies designed to set goals and develop norms and methodology for workers’ health and the environment.

Goals

Such a programme should endeavour to:

change the culture and habits of health professionals in order to stimulate behaviour more conducive to safeguarding their health

set goals and develop internal safety, hygiene and environmental guidelines through adequate planning and organization

improve the methods of work to avoid a negative impact on health and the environment through environmental research and education

increase the involvement of all personnel and have them take responsibility for health in the workplace

create an adequate programme to establish and publicize the guidelines as well as to monitor their continued implementation

correctly classify and manage the waste generated

optimize costs, avoiding added expenditures that cannot be justified by the increased levels of safety and health or environmental quality.

Plan

A hospital should be conceived as a system that, through a number of processes, generates services. These services are the main goal of the activities performed in a hospital.

For the process to begin, certain commitments of energy, investments and technology are needed, which in turn will generate their own emissions and wastes. Their only aim is to provide service.

In addition to these prerequisites, consideration should be given to the conditions of the areas of the building where these activities will take place, since they have been designed a certain way and built with basic construction materials.

Control, planning and coordination are all necessary for an integrated safety, health and environmental project to succeed.

Methodology

Because of the complexity and the variety of risks in the health care field, multidisciplinary groups are required if solutions to each particular problem are to be found.

It is important for health care workers to be able to collaborate with safety studies, participating in the decisions that will be made to improve their working conditions. This way changes will be seen with a better attitude and the guidelines will be more readily accepted.

The safety, hygiene and environmental service should advise, stimulate and coordinate the programmes developed at the health centre. Responsibility for their implementation should fall upon whoever heads up the service where this programme will be followed. This is the only way to involve the entire organization.

In each particular case, the following will be selected:

the system involved

the parameters of the study

the time needed to carry it out.

The study will consist of:

an initial diagnosis

analysis of the risk

deciding on the course of action.

In order to implement the plan successfully it will always be necessary to:

educate and inform people of the risks

improve the management of human resources

improve the channels of communication.

This type of study may be a global one encompassing the centre as a whole (e.g., internal plan for the disposal of hospital wastes) or partial, encompassing only one concrete area (e.g., where cancer chemotherapeutic drugs are prepared).

The study of these factors will give an idea of the degree to which safety measures are disregarded, as much from the legal as from the scientific point of view. The concept of “legal” here encompasses advances in science and technology as they occur, which requires the constant revision and modification of established norms and guidelines.

It would be convenient indeed if the regulations and the laws by which safety, hygiene and the environment are regulated were the same in all countries, something that would make the installation, management and use of technology or products from other countries much easier.

Results

The following examples show some of the measures that can be taken while following the aforementioned methodology.

Laboratories

An advisory service can be developed involving professionals of the various laboratories and coordinated by the safety and hygiene service of the medical centre. The main goal would be to improve the safety and health of the occupants of all the labs, involving and giving responsibility to the entire professional staff of each and trying at the same time to make sure that these activities do not have a negative impact on public health and the environment.

The measures taken should include:

instituting the sharing of materials, products and equipment among the different laboratories, in order to optimize resources

reducing the stocks of chemical products in laboratories

creating a manual of basic norms of safety and hygiene

planning courses to educate all laboratory workers on these matters

training for emergencies.

Mercury

Thermometers, when broken, release mercury into the environment. A pilot project has been started with “unbreakable” thermometers to consider eventually substituting them for the glass thermometers. In some countries, such as the United States, electronic thermometers have replaced mercury thermometers to a very great extent.

Training the workers

The training and the commitment of the workers is the most important part of an integrated safety, health and environment programme. Given enough resources and time, the technicalities of almost any problem can be solved, but a complete solution will not be achieved without informing the workers of the risks and training them to avoid or control them. The training and education must be continuous, integrating health and safety techniques into all the other training programmes in the hospital.

Conclusions

The results that have been achieved so far in applying this work model allow us so far to be optimistic. They have shown that when people are informed about the whys and wherefores, their attitude toward change is very positive.

The response of health care personnel has been very good. They feel more motivated in their work and more valued when they have participated directly in the study and in the decision-making process. This participation, in turn, helps to educate the individual health care worker and to increase the degree of responsibility he or she is willing to accept.

The attainment of the goals of this project is a long-term objective, but the positive effects it generates more than compensate for the effort and the energy invested in it.

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Published in The Hospital Environment

Wednesday, 02 March 2011 16:38

Hospital Waste Management

An adaptation of current guidelines on the disposal of hospital wastes, as well as improvements in internal safety and hygiene, must be part of an overall plan of hospital waste management that establishes the procedures to follow. This should be done through properly coordinating internal and external services, as well as defining responsibilities in each of the management phases. The main goal of this plan is to protect the health of health care personnel, patients, visitors and the general public both in the hospital and beyond.

At the same time, the health of the people who come in contact with the waste once it leaves the medical centre should not be overlooked, and the risks to them should also be minimized.

Such a plan should be campaigned for and applied according to a global strategy that always keeps in mind the realities of the workplace, as well as the knowledge and the training of the personnel involved.

Stages followed in the implementation of a waste management plan are:

informing the management of the medical centre

designating those responsible at the executive level

creating a committee on hospital wastes made up of personnel from the general services, nursing and medical departments that is chaired by the medical centre’s waste manager.

The group should include personnel from the general services department, personnel from the nursing department and personnel from the medical department. The medical centre’s waste manager should coordinate the committee by:

putting together a report on the present performance of the centre’s waste management

putting together an internal plan for advanced management

creating a training programme for the entire staff of the medical centre, with the collaboration of the human resources department

launching the plan, with follow-up and control by the waste management committee.

Classification of hospital wastes

Until 1992, following the classical waste management system, the practice was to classify most hospital wastes as hazardous. Since then, applying an advanced management technique, only a very small proportion of the large volume of these wastes is considered hazardous.

The tendency has been to adopt an advanced management technique. This technique classifies wastes starting from the baseline assumption that only a very small percentage of the volume of wastes generated is hazardous.

Wastes should always be classified at the point where they are generated. According to the nature of the wastes and their source, they are classified as follows:

Group I: those wastes that can be assimilated into urban refuse

Group II: non-specific hospital wastes

Group III: specific hospital wastes or hazardous wastes

Group IV: cytostatic wastes (surplus antineoplastic drugs that are not fit for therapeutic use, as well as the single-use materials that have been in contact with them, e.g., needles, syringes, catheters, gloves and IV set-ups).

According to their physical state, wastes can be classified as follows:

solids: wastes that contain less than 10% liquid

liquids: wastes that contain more than 10% liquid

Gaseous wastes, such as CFCs from freezers and refrigerators, are not normally captured (see article “Waste anaesthetic gases”).

By definition, the following wastes are not considered sanitary wastes:

radioactive wastes that, because of their very nature, are already managed in a specific way by the radiological protection service

human cadavers and large anatomical parts which are cremated or incinerated according to regulations

waste water.

Group I Wastes

All wastes generated within the medical centre that are not directly related to sanitary activities are considered solid urban wastes (SUW). According to the local ordinances in Cataluna, Spain, as in most communities, the municipalities must remove these wastes selectively, and it is therefore convenient to facilitate this task for them. The following are considered wastes that can be assimilated to urban refuse according to their point of origin:

Kitchen wastes:

food wastes

wastes from leftovers or single-use items

containers.

Wastes generated by people treated in the hospital and non-medical personnel:

wastes from cleaning products

wastes left behind in the rooms (e.g., newspapers, magazines and flowers)

wastes from gardening and renovations.

Wastes from administrative activities:

paper and cardboard

plastics.

Other wastes:

glass containers

plastic containers

packing cartons and other packaging materials

dated single-use items.

So long as they are not included on other selective removal plans, SUW will be placed in white polyethylene bags that will be removed by janitorial personnel.

Group II Wastes

Group II wastes include all those wastes generated as a by-product of medical activities that do not pose a risk to health or the environment. For reasons of safety and industrial hygiene the type of internal management recommended for this group is different from that recommended for Group I wastes. Depending on where they originate, Group II wastes include:

Wastes derived from hospital activities, such as:

blood-stained materials

gauze and materials used in treating non-infectious patients

used medical equipment

mattresses

dead animals or parts thereof, from rearing stables or experimental laboratories, so long as they have not been inoculated with infectious agents.

Group II wastes will be deposited in yellow polyethylene bags that will be removed by janitorial personnel.

Group III Wastes

Group III includes hospital wastes which, due to their nature or their point of origin, could pose risks to health or the environment if several special precautions are not observed during handling and removal.

Group III wastes can be classified in the following way:

Sharp and pointed instruments:

needles

scalpels.

Infectious wastes. Group III wastes (including single-use items) generated by the diagnosis and treatment of patients who suffer from one of the infectious diseases are listed in table 1.

Table 1. Infectious diseases and Group III wastes

Infections	Wastes contaminated with
Viral haemorrhagic fevers Congo-Crimean fever Lassa fever Marburg virus Ebola Junin fever Machupo fever Arbovirus Absettarow Hanzalova Hypr Kumlinge Kiasanur Forest Disease Omsk fever Russian spring-summer encephalitis	All wastes
Brucellosis	Pus
Diphtheria	Pharyngeal diphtheria: respiratory secretions Cutaneous diphtheria: secretions from skin lesions
Cholera	Stools
Creutzfelt-Jakob encephalitis	Stools
Borm	Secretions from skin lesions
Tularaemia	Pulmonary tularaemia: respiratory secretions Cutaneous tularaemia: pus
Anthrax	Cutaneous anthrax: pus Respiratory anthrax: respiratory secretions
Plague	Bubonic plague: pus Pneumonic plague: respiratory secretions
Rabies	Respiratory secretions
Q Fever	Respiratory secretions
Active tuberculosis	Respiratory secretions

Laboratory wastes:

material contaminated with biological wastes

waste from work with animals inoculated with biohazardous substances.

Wastes of the Group III type will be placed in single-use, rigid, colour-coded polyethylene containers and hermetically sealed (in Cataluna, black containers are required). The containers should be clearly labelled as “Hazardous hospital wastes” and kept in the room until collected by janitorial personnel. Group III wastes should never be compacted.

To facilitate their removal and reduce risks to a minimum, containers should not be filled to capacity so that they can be closed easily. Wastes should never be handled once they are placed in these rigid containers. It is forbidden to dispose of biohazardous wastes by dumping them into the drainage system.

Group IV Wastes

Group IV wastes are surplus antineoplastic drugs that are not fit for therapeutic use, as well as all single-use material that has been in contact with the same (needles, syringes, catheters, gloves, IV set-ups and so on).

Given the danger they pose to persons and the environment, Group IV hospital wastes must be collected in rigid, watertight, sealable single-use, colour-coded containers (in Cataluna, they are blue) which should be clearly labelled “Chemically contaminated material: Cytostatic agents”.

Other Wastes

Guided by environmental concerns and the need to enhance waste management for the community, medical centres, with the cooperation of all personnel, staff and visitors, should encourage and facilitate the selective disposal (i.e., in special containers designated for specific materials) of recyclable materials such as:

paper and cardboard

glass

used oils

batteries and power cells

toner cartridges for laser printers

plastic containers.

The protocol established by the local sanitation department for the collection, transport and disposal of each of these types of materials should be followed.

Disposal of large pieces of equipment, furniture and other materials not covered in these guidelines should follow the directions recommended by the appropriate environmental authorities.

Internal transport and storage of wastes

Internal transport of all the wastes generated within the hospital building should be done by the janitorial personnel, according to established schedules. It is important that the following recommendations be observed when transporting wastes within the hospital:

The containers and the bags will always be closed during transport.

The carts used for this purpose will have smooth surfaces and be easy to clean.

The carts will be used exclusively for transporting waste.

The carts will be washed daily with water, soap and lye.

The waste bags or containers should never be dragged on the floor.

Waste should never be transferred from one receptacle to another.

The hospital must have an area specifically for the storage of wastes; it should conform to current guidelines and fulfil, in particular, the following conditions:

It should be covered.

It should be clearly marked by signs.

It should be built with smooth surfaces that are easy to clean.

It should have running water.

It should have drains to remove the possible spillage of waste liquids and the water used for cleaning the storage area.

It should be provided with a system to protect it against animal pests.

It should be located far away from windows and from the intake ducts of the ventilation system.

It should be provided with fire extinguishing systems.

It should have restricted access.

It should be used exclusively for the storage of wastes.

All the transport and storage operations that involve hospital wastes must be conducted under conditions of maximum safety and hygiene. In particular, one must remember:

Direct contact with the wastes must be avoided.

Bags should not be overfilled so that they may be closed easily.

Bags should not be emptied into other bags.

Liquid Wastes: Biological and Chemical

Liquid wastes can be classified as biological or chemical.

Liquid biological wastes

Liquid biological wastes can usually be poured directly into the hospital’s drainage system since they do not require any treatment before disposal. The exceptions are the liquid wastes of patients with infectious diseases and the liquid cultures of microbiology laboratories. These should be collected in specific containers and treated before being dumped.

It is important that the waste be dumped directly into the drainage system with no splashing or spraying. If this is not possible and wastes are gathered in disposable containers that are difficult to open, the containers should not be forced open. Instead, the entire container should be disposed of, as with Group III solid wastes. When liquid waste is eliminated like Group III solid waste, it should be taken into consideration that the conditions of work differ for the disinfection of solid and liquid wastes. This must be kept in mind in order to ensure the effectiveness of the treatment.

Liquid chemical wastes

Liquid wastes generated in the hospital (generally in the laboratories) can be classified in three groups:

liquid wastes that should not be dumped into the drains

liquid wastes that can be dumped into the drains after being treated

liquid wastes that can be dumped into the drains without being previously treated.

This classification is based on considerations related to the health and quality of life of the entire community. These include:

protection of the water supply

protection of the sewer system

protection of the waste water purification stations.

Liquid wastes that can pose a serious threat to people or to the environment because they are toxic, noxious, flammable, corrosive or carcinogenic should be separated and collected so that they can subsequently be recovered or destroyed. They should be collected as follows:

Each type of liquid waste should go into a separate container.

The container should be labelled with the name of the product or the major component of the waste, by volume.

Each laboratory, except the pathological anatomy laboratory, should provide its own individual receptacles to collect liquid wastes that are correctly labelled with the material or family of materials it contains. Periodically (at the end of each work day would be most desirable), these should be emptied into specifically labelled containers which are held in the room until collected at appropriate intervals by the assigned waste removal subcontractor.

Once each receptacle is correctly labelled with the product or the family of products it contains, it should be placed in specific containers in the labs.

The person responsible for the laboratory, or someone directly delegated by that person, will sign and stamp a control ticket. The subcontractor will then be responsible for delivering the control ticket to the department that supervises safety, hygiene and the environment.

Mixtures of chemical and biological liquid wastes

Treatment of chemical wastes is more aggressive than treatment of biological wastes. Mixtures of these two wastes should be treated using the steps indicated for liquid chemical wastes. Labels on containers should note the presence of biological wastes.

Any liquid or solid materials that are carcinogenic, mutagenic or teratogenic should be disposed of in rigid colour-coded containers specifically designed and labelled for this type of waste.

Dead animals that have been inoculated with biohazardous substances will be disposed of in closed rigid containers, which will be sterilized before being reused.

Disposal of Sharp and Pointed Instruments

Sharp and pointed instruments (e.g., needles and lancets), once used, must be placed in specifically designed, rigid “sharps” containers that have been strategically placed throughout the hospital. These wastes will be disposed of as hazardous wastes even if used on uninfected patients. They must never be disposed of except in the rigid sharps container.

All HCWs must be repeatedly reminded of the danger of accidental cuts or punctures with this type of material, and instructed to report them when they occur, so that appropriate preventive measures may be instituted. They should be specifically instructed not to attempt to recap used hypodermic needles before dropping them into the sharps container.

Whenever possible, needles to be placed in the sharps container without recapping may be separated from the syringes which, without the needle, can generally be disposed of as Group II waste. Many sharps containers have a special fitting for separating the syringe without risk of a needlestick to the worker; this saves space in the sharps containers for more needles. The sharps containers, which should never be opened by hospital personnel, should be removed by designated janitorial personnel and forwarded for appropriate disposal of their contents.

If it is not possible to separate the needle in adequately safe conditions, the whole needle-syringe combination must be considered as biohazardous and must be placed in the rigid sharps containers.

These sharps containers will be removed by the janitorial personnel.

Staff Training

There must be an ongoing training programme in waste management for all hospital personnel aimed at indoctrinating the staff on all levels with the imperative of always following the established guidelines for collecting, storing and disposing wastes of all kinds. It is particularly important that the housekeeping and janitorial staffs be trained in the details of the protocols for recognizing and dealing with the various categories of hazardous waste. The janitorial, security and fire-fighting staff must also be drilled in the correct course of action in the event of an emergency.

It is also important for the janitorial personnel to be informed and trained on the correct course of action in case of an accident.

Particularly when the programme is first launched, the janitorial staff should be instructed to report any problems that may hinder their performance of these assigned duties. They may be given special cards or forms on which to record such findings.

Waste Management Committee

To monitor the performance of the waste management programme and resolve any problems that may arise as it is implemented, a permanent waste management committee should be created and meet regularly, quarterly at a minimum. The committee should be accessible to any member of the hospital staff with a waste disposal problem or concern and should have access as needed to top management.

Implementing the Plan

The way the waste management programme is implemented may well determine whether it succeeds or not.

Since the support and cooperation of the various hospital committees and departments is essential, details of the programme should be presented to such groups as the administrative teams of the hospital, the health and safety committee and the infection control committee. It is necessary also to obtain validation of the programme from such community agencies as the departments of health, environmental protection and sanitation. Each of these may have helpful modifications to suggest, particularly with respect to the way the programme impinges on their areas of responsibility.

Once the programme design has been finalized, a pilot test in a selected area or department should permit rough edges to be polished and any unforeseen problems resolved. When this has been completed and its results analysed, the programme may be implemented progressively throughout the entire medical centre. A presentation, with audio-visual supports and distribution of descriptive literature, can be delivered in each unit or department, followed by delivery of bags and/or containers as required. Following the start-up of the programme, the department or unit should be visited so that any needed revisions may be instituted. In this manner, the participation and support of the entire hospital staff, without which the programme would never succeed, can be earned.

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Wednesday, 02 March 2011 16:42

Managing Hazardous Waste Disposal Under ISO 14000

A formal Environmental Management System (EMS), using the International Organization for Standardization (ISO) standard 14001 as the performance specification, has been developed and is being implemented in one of the largest teaching health care complexes in Canada. The Health Sciences Centre (HSC) consists of five hospitals and associated clinical and research laboratories, occupying a 32-acre site in central Winnipeg. Of the 32 segregated solid waste streams at the facility, hazardous wastes account for seven. This summary focuses on the hazardous waste disposal aspect of the hospital’s operations.

ISO 14000

The ISO 14000 standards system is a typical continuous improvement model based on a controlled management system. The ISO 14001 standard addresses the environmental management system structure exclusively. To conform with the standard, an organization must have processes in place for:

adopting an environmental policy that sets environmental protection as a high priority

identifying environmental impacts and setting performance goals

identifying and complying with legal requirements

assigning environmental accountability and responsibility throughout the organization

applying controls to achieve performance goals and legal requirements

monitoring and reporting environmental performance; auditing the EMS system

conducting management reviews/ identifying opportunities for improvement.

The hierarchy for carrying out these processes in the HSC is presented in table 1.

Table 1. HSC EMS documentation hierarchy

EMS level	Purpose
Governance document Mission/strategic plan	Includes the Board’s expectations on each core performance category and its requirements for corporate competency in each category.
Level 1 Output requirements	Prescribes the outputs that will be delivered in response to customer and stakeholder (C/S) needs (including government regulatory requirements).
Level 2 Corporate policy	Prescribes the methodologies, systems, processes and resources to be used for achieving C/S requirements; the goals, objectives and performance standards essential for confirming that the C/S requirements have been met (e.g., a schedule of required systems and processes including responsibility centre for each).
Level 3 System descriptions	Prescribes the design of each business system or process that will be operated to achieve the C/S requirements (e.g., criteria and boundaries for system operation; each information collection and data reporting point; position responsible for the system and for each component of the process, etc.).
Level 4 Work instructions	Prescribes detailed task instructions (specific methods and techniques), for each work activity (e.g., describe the task to be done; identify the position responsible for completing the task; state skills required for the task; prescribe education or training methodology to achieve required skills; identify task completion and conformance data, etc.).
Level 5 Records of work and process compliance	Organizes and records measurable outcome data on the operation of systems, processes and tasks designed to verify completion according to specification. (e.g., measures for system or process compliance; resource allocation and budget compliance; effectiveness, efficiency, quality, risk, ethics, etc.).
Level 6 Performance reports	Analyses records and processes to establish corporate performance in relation to standards set for each output requirement (Level 1) related to C/S needs (e.g., compliance, quality, effectiveness, risk, utilization, etc.); and financial and staff resources.

ISO standards encourage businesses to integrate all environmental considerations into mainstream business decisions and not restrict attention to concerns that are regulated. Since the ISO standards are not technical documents, the function of specifying numerical standards remains the responsibility of governments or independent expert bodies.

Management System Approach

Applying the generic ISO framework in a health care facility requires the adoption of management systems along the lines of those in table 1, which describes how this has been addressed by the HSC. Each level in the system is supported by appropriate documentation to confirm diligence in the process. While the volume of work is substantial, it is compensated by the resulting performance consistency and by the “expert” information that remains within the corporation when experienced persons leave.

The main objective of the EMS is to establish consistent, controlled and repeatable processes for addressing the environmental aspects of the corporation’s operations. To facilitate management review of the hospital’s performance, an EMS Score Card was conceived based on the ISO 14001 standard. The Score Card closely follows the requirements in the ISO 14001 standard and, with use, will be developed into the hospital’s audit protocol.

Application of the EMS to the Hazardous Waste Process

Facility hazardous waste process

The HSC hazardous waste process currently consists of the following elements:

procedure statement assigning responsibilities

process description, in both text and flowchart formats

Disposal Guide for Hazardous Waste for staff

education programme for staff

performance tracking system

continuous improvement through multidisciplinary team process

a process for seeking external partners.

The roles and responsibilities of the four main organizational units involved in the hazardous waste process are listed in table 2.

Table 2. Role and responsibilities

Organizational unit	Responsibility
S&DS Supply and Distribution Services	Operates the process and is the process owner/leader, and arranges responsible disposal of waste.
UD–User Departments the source of waste materials	Identifies waste, selects packaging, initiates disposal activities.
DOEM Department of Occupational and Environmental Medicine	Provides specialist technical support in identifying risks and protective measures associated with materials used by HSC and identifies improvement opportunities.
EPE Environmental Protection Engineer	Provides specialist support in process performance monitoring and reporting, identifies emerging regulatory trends and compliance requirements, and identifies improvement opportunities.
ALL–All participants	Shares responsibility for process development activities.

Process description

The initial step in preparing a process description is to identify the inputs (see table 3 ).

Table 3. Process inputs

Organizational unit	Examples of process inputs and supporting inputs
S&DS (S&DS)	Maintain stock of Hazardous Waste Disposal Requisition forms and labels — order requisition forms and labels.
S&DS (UD, DOEM, EPE) (S&DS)	Maintain supply of packaging containers in warehouse for UDs — determine appropriate packaging for each waste class — build adequate stock of containers for requisitioning by UD.
DOEM	Produce SYMBAS Classification Decision Chart.
EPE	Produce the list of materials for which HSC is registered as a waste generator with regulatory department.
S&DS	Produce a database of SYMBAS classifications, packaging requirements, TDG classifications, and tracking information for each material disposed by HSC.

The next process component is the list of specific activities required for proper disposal of waste (see table 4 ).

Table 4. List of activities

Unit	Examples of activities required
UD	Order Hazardous Waste Disposal Requisition, label and packaging from S&DS as per standard stock ordering procedure.
S&DS	Deliver Requisition, label and packaging to UD.
UD	Determine whether a waste material is hazardous (check MSDS, DOEM, and such considerations as dilution, mixture with other chemicals, etc.).
UD	Assign the Classification to the waste material using SYMBAS Chemical Decision Chart and WHMIS information. Classification can be checked with the S&DS Data Base for materials previously disposed by HSC. Call first S&DS and second DOEM for assistance if required.
UD	Determine appropriate packaging requirements from WHMIS information using professional judgement or from S&DS Data Base of materials previously disposed by HSC. Call first S&DS and second DOEM for assistance if required.

Communication

To support the process description, the hospital produced a Disposal Guide for Hazardous Waste to assist staff in the proper disposal of hazardous waste materials. The guide contains information on the specific steps to follow in identifying hazardous waste and preparing it for disposal. Supplemental information is also provided on legislation, the Workplace Hazardous Materials Information System (WHMIS) and key contacts for assistance.

A database was developed to track all relevant information pertaining to each hazardous waste event from originating source to final disposal. In addition to waste data, information is also collected on the performance of the process (e.g., source and frequency of phone calls for assistance to identify areas which may require further training; source, type, quantity and frequency of disposal requests from each user department; consumption of containers and packaging). Any deviations from the process are recorded on the corporate incident reporting form. Results from performance monitoring are reported to the executive and the board of directors. To support effective implementation of the process, a staff education programme was developed to elaborate on the information in the guide. Each of the core participants in the process carries specific responsibilities on staff education.

Continuous Improvement

To explore continuous improvement opportunities, the HSC established a multidisciplinary Waste Process Improvement Team. The Team’s mandate is to address all issues pertaining to waste management. Further to encourage continuous improvement, the hazardous waste process includes specific triggers to initiate process revisions. Typical improvement ideas generated to date include:

prepare list of high hazard materials to be tracked from time of procurement

develop material “shelf life” information, where appropriate, for inclusion in the materials classification database

review shelving for physical integrity

purchase spill containing trays

examine potential for spills entering sewer system

determine whether present storage rooms are adequate for anticipated waste volume

produce a procedure for disposing of old, incorrectly identified materials.

The ISO standards require regulatory issues to be addressed and state that business processes must be in place for this purpose. Under the ISO standards, the existence of corporate commitments, performance measuring and documentation provide a more visible and more convenient trail for regulators to check for compliance. It is conceivable that the opportunity for consistency provided by the ISO documents could automate reporting of key environmental performance factors to government authorities.

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Yassi, A, D Gaborieau, I Gi

Buildings for Health Care Facilities

Hospitals: Environmental and Public Health Issues

Hospital Waste Management

Managing Hazardous Waste Disposal Under ISO 14000

Contents

Health Care Facilities and Services References