Building design and fit-out
Practice design should consider how the building design can facilitate:
- monitoring of entries
- isolation of patients with potentially transmissible infections
- effective cleaning surfaces and fixtures
- adequate ventilation
- appropriate traffic flow of personnel through rooms and corridors, reducing unnecessary contact or proximity between staff, patients and visitors (see Table 5.1. Managing practice access and patient flow)
- safe and effective workflow in the reprocessing area.
Materials and fixtures
Surfaces and fixtures should be:
- easily cleanable and nonporous, with no grooves or crevices (such as tiles with grouting)
- able to withstand repeated cleaning
- easy to maintain and repair to avoid cracks or degradation
- resistant to microbial growth.
Hard (non-carpeted), easily cleaned flooring is required in treatment rooms and other rooms that require frequent cleaning and sometimes disinfection, such as waiting areas).
Sharps containers should be placed at the correct height (see 7. Sharps).
Adequate ventilation, whether achieved by natural airflow or air conditioning, is necessary to reduce the risk of airborne transmission of microbial infections in enclosed indoor environments. Practices could consult a ventilation engineer or an occupational hygienist for advice on optimal ventilation when designing the space, refitting the space or during an airborne-transmitted outbreak.
Ventilation must be designed to achieve 6–8 air changes per hour (ie the number of times per hour that the whole volume of air in each room is replaced by fresh air) in general areas. Fresh air is preferable to recirculated air. Flows less than 6 air changes per hour are inadequate to help prevent airborne microbial transmission. In rooms where aerosol-generating procedures (eg spirometry) occur, a ventilation rate of 12 air changes per hour is recommended.1
The direction of airflow must be from ‘clean’ to less clean areas, to avoid dispersing contaminated air.
Standard heating, ventilation, and air conditioning systems are not specifically designed to prevent transmission of airborne infections, but can be used to optimise ventilation to assist in reduction of risk of transmission. Some contain high efficiency particulate air (HEPA) filters, which require regular cleaning or replacement. Heating, ventilation, and air conditioning systems must be well maintained and regularly serviced. Unless the practice has adequate natural ventilation that consistently achieves adequate cross-flow of air (possibly assisted by a ceiling fan), air conditioning must be run to ventilate the area to achieve 6–8 air changes per hour, even when heating or cooling are not needed.
Windows and doors can be opened for additional ventilation when there is a high risk of airborne transmission, although this does not guarantee adequate airflow. Fans can be used to improve air flow. Practices could obtain advice on whether the air conditioning system can be used at the same time.
Air purifiers/cleaners do not provide ventilation. However, if necessary, portable air-cleaning devices with HEPA filtration can be used in addition to other ventilation in areas with inadequate fresh air and circulation. The clean air delivery rate must be sufficient for the room volume. Before buying an air purifier, practices could obtain advice from an expert (eg industrial or occupational hygienist, or heating, ventilation and air conditioning professional) on whether it is likely to improve ventilation significantly, and to determine the most effective placement (generally at the site where there is least air movement).
Toilets must be fitted with exhaust fans. When there is risk of airborne transmission of relevant infections (eg during a respiratory infection outbreak), the practice could ensure that exhaust fans in toilets are functional, operating continuously and at full capacity when the building is occupied. Toilet fans should exhaust directly outdoors and away from windows and air intake systems. Toilets can be fitted with a second passive fan on the external wall, which moves fresh air into the toilet area, while the active fan removes used air. These are located sufficiently apart so that fresh air is not immediately exhausted.
Design of reprocessing area
During reprocessing of reusable medical devices such as instruments, ‘clean’ and ‘dirty’ activities need to be segregated (for example, in different sections of the bench as far away from each other as the space allows; Figure 12.1. Sample design and workflow of reprocessing area). The objective is to minimise the risk of cross-contamination of a cleaned, disinfected and sterilised reusable medical device (see 10. Reprocessing reusable medical devices).
Design of the area designated for reprocessing reusable medical devices should include the following considerations (Figure 12.1. Sample design and workflow of reprocessing area based on best practice; see also 10. Reprocessing reusable medical devices):
- Surfaces (benches, sinks, splashbacks, walls) must be smooth, with no rough or textured areas where soiling can accumulate (such as tiles with grouting or silicon sealant), and made of material that does not shed fibres or particles. Ideally there should be no crevices between the walls and floor, or around any fixtures, where dirt can collect. The floor must be washable non-slip material.
- If the practice does not use an automatic washer-disinfector for cleaning reusable medical devices, it should contain two sinks: one designated ‘dirty’ (for pre-cleaning and cleaning) and one designated ‘clean’ (that is, less contaminated). Sinks must be deep enough to immerse reusable devices during cleaning, and should not have shower-heads. These considerations also apply when using a bowl. Reprocessing sinks must not be used for handwashing.
- Ideally, a reprocessing area is fitted with a type B handbasin.
- One or more (as required) alcohol-based handrub dispensers could be installed on the wall adjacent to the bench areas where reprocessing is done, but not directly over the work area. They must be placed where they will not be splashed.
- The area should be well lit to make it easy for staff to inspect devices for soiling.
- All supplies should be stored in closed cupboards or drawers; no materials, supplies or equipment may be left out or stored on benches or floors. Even clean boxes shed fibres that could compromise device asepsis/sterility.
- The area cannot be shared with linen or waste and should be a low-traffic area.
- The area must include facilities for hand hygiene, either alcohol-based handrub in a hands-free dispenser, or a dedicated sink for handwashing. Handrub must not be placed at a sink.
- Clean, dry gloves and aprons, masks and full-face shields should be easily accessible in the reprocessing area. They must be stored in a closed dry cupboard, well away from possible splashing or contamination.
Storage areas for packs of reusable medical devices (eg instruments) that have been through the steriliser must be well sealed to prevent dust contamination.
Sample design and workflow of reprocessing area
PPE: personal protective equipment
The workflow is strictly in one direction: the staff member enters the zone with clean hands, dons required PPE, and proceeds to work from the ‘dirty’ to ‘clean’ (less contaminated) zones (left to right), washing hands with soap and water if they become visibly contaminated, and reusing alcohol-based handrub after each stage of the process while hands remain visibly clean.
The direction of airflow is from the ‘clean’ zone to the ‘dirty’ zone. The ultrasonic pre-cleaner is ideally placed between the two sinks, contingent on plumbing, power and safety considerations.
The diagram is intended as a sample. Alternatives are possible:
- The location of the ultrasonic pre-cleaner (either before Sink 1 or between Sinks 1 and 2) is decided based on a practice's pre-cleaning process.
- If the practice does not have a washer/disinfector, the drying area would take the position of the washer/disinfector in this diagram, to the immediate left of the packing area.
- A washer/disinfector may be on or under the bench.
A sluice or laundry sink can be considered for disposing of wastewater from cleaning, rinsing bloody linen, and cleaning buckets and mops. The sluice or laundry sink is best located in the practice laundry or utility room.
Wastewater must not be poured down the laundry sink.