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Pharmacy- environmental testing - ANSWER ✓ Guidelines differ. CDC does not
recommend env testing in the hospital in general. FDA emphasizes air quality and
control. USP guidelines recommend testing the environment with and new
equipment, after any service, at certification, and in response to any identified or
suspected problem. Sampling should include air, surfaces, and personnel gloved
fingertips.
Pharmacy- aseptic technique and compounding - ANSWER ✓ Touch
contamination (direct contact) by compounding personnel poses the highest risk.
QA should include regular testing of each individual's ability to use aseptic
technique (gloved fingertip, surface sampling, and media fill). Use clean rooms
and hoods.
Laundry overview - ANSWER ✓ CDC considers risk of disease transmission
negligible, although large number of organisms can be present on soiled linens.
Thought that most infections that seem linked to laundry are actually community
acquired, or from HCW direct contact/the the patient environment. Still important
to properly launder though. Common organisms include normal skin flora, GNRs,
and CNS. Fungal and viruses known; outbreaks of fungal infection have been
known.
Laundering process - ANSWER ✓ Goal is to render laundry hygenically clean
(clean and free of pathogens in sufficient numbers to minimize the risk of
infection) by soil removal, pathogen removal and inactivation. Includes use of
water, heat, pH, oxidation, chemical sanitizers, drying and sanitization.
, Laundry regulation and system - ANSWER ✓ Laundry can be done on or off site,
or by a contractor. Facility can own own laundry or rent as part of cleaning
contract. If surgical textiles (sterile or not) are involved, FDA regulates. EPA and
OSHA regulations apply, as do state/local regs. There is accreditation for laundry
by the Healthcare Laundry Accreditation Council, which publishes standards.
Home laundering of healthcare attire - ANSWER ✓ Not allowed for
PPE/equipment (e.g. lab coats) or for anything contaminated by blood or OPIM.
May be allowed for other uniforms or scrubs. Data shows there is higher bacterial
burden on home laundered stuff, but no documented transmission from this. Not
recommended, but not prohibited.
Laundry QA - ANSWER ✓ Monitoring of cycle temperatures is not required, but
load size (weight) for each load should be recorded. Routine microbiological
sampling is not recommended; neither is ATP monitoring. In outbreak situations,
can use microbio if epi suggests laundry involvement.
Root Cause Analysis - ANSWER ✓ Goal is to determine what happened, why it
happened, and how we can prevent it happening again. Requires a
multidisciplinary team, including leadership and frontline experts. Should involve
literature.
Failure Mode and Effects Analysis (FMEA) - ANSWER ✓ Prospective technique
to determine which interventions/corrections may reduce the risk of a problem.
Essentially, the team maps out the process, indicates all the ways/places it could
fail, quantifies each risk in likelihood and consequence, and makes a plan to
eliminate/control/accept each potential failure
Plan, do, check, act - ANSWER ✓ Also called Shewart or Deming cycle. May be
preceded by the FOCUS tool to identify a process in need of improvement and the
method of improvement. Act in this case means taking steps to hold the gain and
continue or to reject and start a new cycle.
Waste management overview - ANSWER ✓ No indication that most hospital
waste is any more infectious than residential waste, or that disease has been caused
in the community by hospital waste. Most guidance therefore based on epi theory.
EPA, OSHA, and DoT have all published regulations; EPA and CDC also have
guidelines, and JC has standards. Additional regs for nuclear medicine waste. FDA
involved in some things, like sharps. State and local laws apply.
, Waste that is actually infectious - ANSWER ✓ Sharps, microbio cultures/stocks,
animal wastes (lie from research), blood and blood products, and anything
contaminated with any fluid from a class 4 (scary like Ebola) disease patient in
isolation. Pathology waste is weird because usually has been soaked in alcohol and
formaldyhyde. All other waste is fundamentally the same as household waste. An
official, specific definition of infectious waste should be made within the hospital
to categorize waste.
Waste Management plan components - ANSWER ✓ 1) designation- what is and is
not infectious waste? 2) Segregation- Waste should be separated at the point of
origin into appropriate designated containers. Use the designation with the most
stringent requirements.
3) Packaging- usually regulated by states. Infectious waste must be labeled as a
biohazard and colored red. Sharps must be in a sharps container, which must be
rigid, impervious, puncture resistant, leakproof except for top, and sealable.
4) Storage- Ideally waste should be treated and disposed of ASAP. Some states
limit storage time.
5) Transport- Should maintain integrity of packaging and protect handlers. State
laws about vehicle transport. Waste moved offsite must have a waste manifest
documenting all shipment info and tracking.
6) Treatment or disposal- Many treatment options. Choose based on type of waste,
amount, availability, and cost. Would be totally fine in a landfill, but public
concerns have made that illegal in many areas. A sanitary landfill is often used.
8) Contingency planning- There should be one.
9) Training- All personnel from generation to disposal should be trained. Special
OSHA and DOT training requirements.
Disposing of liquid infectious waste - ANSWER ✓ Can be poured down a
designated sanitary sewer with appropriate engineering controls and PPE. Or, can
be placed in leakproof containers that can be capped. If shipping, must be
surrounded with enough absorbent material to absorb entire contents. Don't pour
free flowing waste liquid straight into a waste can.
HVAC overview - ANSWER ✓ Overall air handling system: supply, filter,
condition (heat/cool/humidify/dehumidify), and exhaust. There are centralized and
decentralized versions. Centralized have a central air handling unit, decentralized
have individual fan coils under windows and mix outside air with room air.
Outbreaks associated with HVAC have been fungal.
, Ventilation standards (HVAC) - ANSWER ✓ ASHRAE and Facility Guidelines
institute put standards. CDC, NIOSH have guidelines for ID risk minimization.
Also fire safety, EPA, local authority, and TJC rules.
Air Source HVAC - ANSWER ✓ All air is conditioned by filtering,
heating/cooling, and adjusting humidity. Can use outside air or recirculated, or a
mix. Outside air dilutes microbial contamination, gases, and controls odor.
Recirculated air conserves energy; must not be allowed to mess with pressure
arrangements. Fresh air intakes must be at least 25 feet from vents/exhausts.
Central air intakes must be as high as practical, at least 6 feet or 3 ft off the roof.
Exhaust outlets should be above roof level and arranged to minimize recirculation
back into the building.
Air changes HVAC - ANSWER ✓ Measured in ACH, air changes per hour. A
minimum of 2 is needed to remove odors, but 6 is more comfortable. Some areas
have higher requirements. There are no requirements about how often ACH must
be measured, but there should be a schedule.
Air pressure HVAC - ANSWER ✓ Air pressure balancing is the whole +-netural
pressure process. + pressure is used to keep bugs out: used in ORs and sensitive
patient areas. Neg pressure is used to keep bugs in. Pressure balancing is very
sensitive- doors/windows must be closed in isolation rooms.
Air flow distribution HVAC - ANSWER ✓ Air should flow from "clean" to "less
clean" areas. Air usually enters from the ceiling with an exhaust intake near the
floor. ORs may have directional airflow of superclean air- should be in the style of
the new slower flow rather than old high velocity LAF.
HVAC filtering - ANSWER ✓ 90% filters for ORS as minimum, although many
use 95. HEPA is not required or recommended for anywhere except protective
environment rooms.
Environmental culturing- HVAC - ANSWER ✓ Should have a clear reason (e.g.
outbreak), process, and plan for how to interpret results. Consults micro, and
consider an expert consultant. With fungal outbreaks, consider comparing inside
spore counts to outside spore counts