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Principles of design of burn units: report of a working group of the British Burn Association and Hospital Infection Society
Bums (1992) 18,(2), 137-138
Prhfed in Great Britain
137
Principles of design of burn units: report of a Working Group of the British Burn Association and Hospital Infection Society* Members of the Working Party: G. A. J. Ayliffe (Chairman), J. C. Lawrence (Secretary), E. M. Cooke, K. C. Judk’ ms, J. A. D. Settle and P. J. Wilkinson The Bums Research Group, Birmingham
Accident Hospital, Bath Row, Birmingham
The overall design of burns units will depend on the required size and available finance. The Working Party has considered the optimal location ana’specijic requirewzents of a unit, including dressing, operating ana’ isolation rooms, intensive care and ancilhy facilities. Various possibilities for ventilation system in these areas have also been discxwd.
B15 INA, UK
especially renal dialysis, and full laboratory and transfusion facilities. Bums units may be adjacent to other units, such as plastic surgery, provided that there is physical separation, no direct airflow between the bums unit and other areas, and no uncontrolled exchange of staff. Access to physiotherapy, occupational therapy and dietetics will be required, also psychology services.
Introduction The principles of prevention of infection in bums were described by Colebrook in 1950. These principles are still relevant today, although modifications based on increased knowledge of the spread of organisms and new antimicrobial agents have been introduced. Colebrook and his colleagues also described the requirements for a ventilated dressing room (Bourdillon and Colebrook, 1946; Colebrook et al., 1948). Spread by contact is now considered to be more important than airborne spread, but it is accepted that patients with extensive bums require protective isolation before the bums become infected, and source isolation if they become infected. Since it is difficult to determine when infection occurs, it is suggested that these patients should be provided with a system of combined source and protective isolation (Lowbury et al., 1981). Little information has been published on the design of modem bums units, but the problems of infection control in bums were reviewed in a symposium in 1985 (Ayliffe and Lawrence, 1985).
Requirements of unit
Spread by contact is the major route of transmission of infection in the bums unit. Good infection control discipline, particularly handwashing, is more important than complex air conditioning, as is adequate space. The majority of units in the UK contain 10-20 beds. In general, single-bedded rooms and two- to four-bedded bays are needed, but the actual number will be calculated on the anticipated work load. Internal flexibility, e.g. readily removable partitioning, is highly desirable. Washhandbasins should be provided adjacent to all beds. Three or four of the single rooms should be large (5 x 4 m, although 5 x 5 m would be better), and should be equipped to intensive care standards for the management of large bums. These rooms could also be used to isolate infected patients if required. Depending on the size of the unit, a number of other single rooms should be available for the isolation of infected or disturbed patients and these require minimal additional facilities apart from a wash-handbasin and an Site extractor fan. However, at least half of the single rooms should be fitted with a toilet and shower. The latter facilities A major bums unit should, if possible, be part of a teaching should also be fitted in the two- and four-bedded areas if or district general hospital. A ground floor location is possible. preferred, but not essential. A major wound dressing facility is essential. This needs to The unit should ideally be part of a trauma centre with be large, at least 5 x 5 m, though 7 x 7 m would be intensive care facilities since bums patients may also have preferable. multiple injuries; at the least, intensive care facilities should A dedicated operating theatre is also necessary and this be available in close proximity to the bums unit. Ready should be at least the same size as the dressing room. It access is needed on the hospital site to other specialist skills, needs its own ventilation system, double, or preferably, *This report was previously published in the J,~uml of Hospital Infection triple lighting and full piped anaesthetic gases, including compressed air at 400 KPa and 700 KPa (the latter for power (1991; 19, 63-66). 0 1992 Butteworth-Heinemann 030554179/92/020137-02
Ltd
138
dermatomes). All these specialized rooms need power sockets, together with provision of piped gases, etc. The ambient temperature of the unit should be maintained at 22-25°C. High temperatures, e.g. 3O”C, are not needed, provided that infrared heaters are available for specific patients and in theatre/dressing rooms.
Ventilation Although the air is not a major route of spread of infection in bums patients, it is generally agreed that a ventilation system is necessary for the operating, dressing and intensive care rooms. A particular problem with bums patients is that both protective and source isolation facilities are required at the same time. A balanced air control system would be optimal but is difficult to attain in practice. Air should not enter these rooms unless filtered, and as the patients may also be infected, air should be discharged directly to the outside and not to other parts of the unit. The following options should be considered for intensive care rooms: 1. Filtered air from a common
corridor to individual rooms fitted with an extraction system to maintain them at a negative pressure. 2. Filtered air at positive pressure into individual rooms, extracted in the corridor outside each room. 3. Filtered air at positive pressure into individual rooms and extraction of air from a lobby which separates the room from other parts of the unit. 4. Filtered air at positive pressure into individual rooms, extracted directly to the exterior, balanced if possible. Although option 3 is the most efficient, a separate lobby anteroom may be undesirable, since . patient observation . and access to rooms may be restricted and it may take up space unnecessarily. The other options all have possible deficiencies, but in practice should be satisfactory. Option I is probably the compromise option of choice if a balanced system (option 4) cannot be provided. A system with an individual lobby and an extraction system is required for the operating theatre and the dressing room, particularly if these are interchangeable, e.g. in small units. The air supply to the operating room can be conventional (i.e. 20-25 changes/h, filtering to a particle size of 5 pm) (DHSS, 1983). A similar standard should be applied to dressing rooms since rapid clearance of bacteria from the air is required between patients. A lower air flow (to provide 10 changes/h) is sufficient for intensive care rooms. Other single rooms used occasionally for the isolation of infected patients can be provided with an extraction system only (e.g. a window fan). No lobby is necessary. This is adequate for dressing an individual patient in his/her own room. Recommendations are summarized in Table I. 01
Other requirements Specialized beds, cots for children and equipment appropriate to a specialized graded care unit are required. An on-site biochemistry and haematology laboratory is necessary unless the existing hospital facility can guarantee a rapid response time (i.e. minutes). As a minimum, a facility for blood gas measurement is needed. Bums units require above average storage space, at least equivalent to an extra bed space for every bay. There are no special requirements for food, but a small kitchen may be considered desirable, particularly if pro-
Bums (1992) Vol. M/No. 2 Table I. Summary of recommendations on design of bums units I. Burns units should be part of a teaching or district general hospital and preferably adjacent to an intensive care unit 2. Internal flexibility of room space is desirable and ample storage space is essential. A wash-handbasin should be provided adjacent to each bed 3. A dedicated dressing room and operating theatre are essential in large burns units. Filtered air should be provided at 20-25 air changes/h. A lobby is required separating the dressing room and theatre from the main unit 4. At least two large single rooms should be equipped to intensive care standards and provided with filtered air at 10 or more air changes/h. A lobby or air lock with air extraction is desirable but not essential 5. Air from ventilated rooms should be extracted to the exterior. 6. Other single rooms with an extraction fan or system should be available for patients requiring source isolation
vision for baby feeding is required. Waste should be sealed in plastic bags and treated according to hospital policy. Double bagging is not necessary. An adequate storage area for waste bags should be provided, but a separate disposal corridor is unnecessary. Waste chutes should be avoided. A bedpan washer/disinfector and possibly a washing-up machine should be provided. Both should reach a temperature (e.g. 80°C) suitable for disinfection. A bedpan macerator is an alternative to a washer provided it is well maintained and drainage is satisfactory. Baths can be a source of infection. In general, large baths which are difficult to clean, or with jacuzzi and similar recirculating systems which are difficult to disinfect, should be avoided. Bathroom air should be extracted to the outside. A staff rest area is essential. There should also be good staff changing facilities. No special arrangements are required for visitors. Other facilities, e.g. offices, stores and seminar rooms etc., will also be required, but will not be considered in this document.
References Ayliffe G. A. J. and Lawrence J. C. (eds) (1985) Symposium on infection control in bums. J. Hosp. Infect. 6, (~uppl. B), 3-66. Bourdillon R. B. and Colebrook L. (1946) Air hygiene in dressing rooms for burns or major wounds. Lancet i, 561-565,601-605. Colebrook L. (1950) A Npw Approach to the Treatment of Bums and Scalds. London: Fine Technical Publications. Colebrook L., Duncan J. M. and Ross W. P. D. (1948) The control of infection in bums. Lancef i, 893-899. DHSS (1983) Venfi~fion of Qxrating Departments: A Desigrz Guide. Inter-authority Engineering Working Group NO. 10. London:
DHSS. Lowbury E. J. L., Ayliffe G. A. J., Geddes A. M. et al. (eds) (1981) revised edition (1992) Control of Hospital Infecfion: A Practical Handbook. London: Chapman and Hall (in press).
Correspondence shouti be addressed to: Dr J. C. Lawrence, Bums Research Group, Accident Hospital, Bath Row, Birmingham B15 INA, UK.
Prhfed in Great Britain
137
Principles of design of burn units: report of a Working Group of the British Burn Association and Hospital Infection Society* Members of the Working Party: G. A. J. Ayliffe (Chairman), J. C. Lawrence (Secretary), E. M. Cooke, K. C. Judk’ ms, J. A. D. Settle and P. J. Wilkinson The Bums Research Group, Birmingham
Accident Hospital, Bath Row, Birmingham
The overall design of burns units will depend on the required size and available finance. The Working Party has considered the optimal location ana’specijic requirewzents of a unit, including dressing, operating ana’ isolation rooms, intensive care and ancilhy facilities. Various possibilities for ventilation system in these areas have also been discxwd.
B15 INA, UK
especially renal dialysis, and full laboratory and transfusion facilities. Bums units may be adjacent to other units, such as plastic surgery, provided that there is physical separation, no direct airflow between the bums unit and other areas, and no uncontrolled exchange of staff. Access to physiotherapy, occupational therapy and dietetics will be required, also psychology services.
Introduction The principles of prevention of infection in bums were described by Colebrook in 1950. These principles are still relevant today, although modifications based on increased knowledge of the spread of organisms and new antimicrobial agents have been introduced. Colebrook and his colleagues also described the requirements for a ventilated dressing room (Bourdillon and Colebrook, 1946; Colebrook et al., 1948). Spread by contact is now considered to be more important than airborne spread, but it is accepted that patients with extensive bums require protective isolation before the bums become infected, and source isolation if they become infected. Since it is difficult to determine when infection occurs, it is suggested that these patients should be provided with a system of combined source and protective isolation (Lowbury et al., 1981). Little information has been published on the design of modem bums units, but the problems of infection control in bums were reviewed in a symposium in 1985 (Ayliffe and Lawrence, 1985).
Requirements of unit
Spread by contact is the major route of transmission of infection in the bums unit. Good infection control discipline, particularly handwashing, is more important than complex air conditioning, as is adequate space. The majority of units in the UK contain 10-20 beds. In general, single-bedded rooms and two- to four-bedded bays are needed, but the actual number will be calculated on the anticipated work load. Internal flexibility, e.g. readily removable partitioning, is highly desirable. Washhandbasins should be provided adjacent to all beds. Three or four of the single rooms should be large (5 x 4 m, although 5 x 5 m would be better), and should be equipped to intensive care standards for the management of large bums. These rooms could also be used to isolate infected patients if required. Depending on the size of the unit, a number of other single rooms should be available for the isolation of infected or disturbed patients and these require minimal additional facilities apart from a wash-handbasin and an Site extractor fan. However, at least half of the single rooms should be fitted with a toilet and shower. The latter facilities A major bums unit should, if possible, be part of a teaching should also be fitted in the two- and four-bedded areas if or district general hospital. A ground floor location is possible. preferred, but not essential. A major wound dressing facility is essential. This needs to The unit should ideally be part of a trauma centre with be large, at least 5 x 5 m, though 7 x 7 m would be intensive care facilities since bums patients may also have preferable. multiple injuries; at the least, intensive care facilities should A dedicated operating theatre is also necessary and this be available in close proximity to the bums unit. Ready should be at least the same size as the dressing room. It access is needed on the hospital site to other specialist skills, needs its own ventilation system, double, or preferably, *This report was previously published in the J,~uml of Hospital Infection triple lighting and full piped anaesthetic gases, including compressed air at 400 KPa and 700 KPa (the latter for power (1991; 19, 63-66). 0 1992 Butteworth-Heinemann 030554179/92/020137-02
Ltd
138
dermatomes). All these specialized rooms need power sockets, together with provision of piped gases, etc. The ambient temperature of the unit should be maintained at 22-25°C. High temperatures, e.g. 3O”C, are not needed, provided that infrared heaters are available for specific patients and in theatre/dressing rooms.
Ventilation Although the air is not a major route of spread of infection in bums patients, it is generally agreed that a ventilation system is necessary for the operating, dressing and intensive care rooms. A particular problem with bums patients is that both protective and source isolation facilities are required at the same time. A balanced air control system would be optimal but is difficult to attain in practice. Air should not enter these rooms unless filtered, and as the patients may also be infected, air should be discharged directly to the outside and not to other parts of the unit. The following options should be considered for intensive care rooms: 1. Filtered air from a common
corridor to individual rooms fitted with an extraction system to maintain them at a negative pressure. 2. Filtered air at positive pressure into individual rooms, extracted in the corridor outside each room. 3. Filtered air at positive pressure into individual rooms and extraction of air from a lobby which separates the room from other parts of the unit. 4. Filtered air at positive pressure into individual rooms, extracted directly to the exterior, balanced if possible. Although option 3 is the most efficient, a separate lobby anteroom may be undesirable, since . patient observation . and access to rooms may be restricted and it may take up space unnecessarily. The other options all have possible deficiencies, but in practice should be satisfactory. Option I is probably the compromise option of choice if a balanced system (option 4) cannot be provided. A system with an individual lobby and an extraction system is required for the operating theatre and the dressing room, particularly if these are interchangeable, e.g. in small units. The air supply to the operating room can be conventional (i.e. 20-25 changes/h, filtering to a particle size of 5 pm) (DHSS, 1983). A similar standard should be applied to dressing rooms since rapid clearance of bacteria from the air is required between patients. A lower air flow (to provide 10 changes/h) is sufficient for intensive care rooms. Other single rooms used occasionally for the isolation of infected patients can be provided with an extraction system only (e.g. a window fan). No lobby is necessary. This is adequate for dressing an individual patient in his/her own room. Recommendations are summarized in Table I. 01
Other requirements Specialized beds, cots for children and equipment appropriate to a specialized graded care unit are required. An on-site biochemistry and haematology laboratory is necessary unless the existing hospital facility can guarantee a rapid response time (i.e. minutes). As a minimum, a facility for blood gas measurement is needed. Bums units require above average storage space, at least equivalent to an extra bed space for every bay. There are no special requirements for food, but a small kitchen may be considered desirable, particularly if pro-
Bums (1992) Vol. M/No. 2 Table I. Summary of recommendations on design of bums units I. Burns units should be part of a teaching or district general hospital and preferably adjacent to an intensive care unit 2. Internal flexibility of room space is desirable and ample storage space is essential. A wash-handbasin should be provided adjacent to each bed 3. A dedicated dressing room and operating theatre are essential in large burns units. Filtered air should be provided at 20-25 air changes/h. A lobby is required separating the dressing room and theatre from the main unit 4. At least two large single rooms should be equipped to intensive care standards and provided with filtered air at 10 or more air changes/h. A lobby or air lock with air extraction is desirable but not essential 5. Air from ventilated rooms should be extracted to the exterior. 6. Other single rooms with an extraction fan or system should be available for patients requiring source isolation
vision for baby feeding is required. Waste should be sealed in plastic bags and treated according to hospital policy. Double bagging is not necessary. An adequate storage area for waste bags should be provided, but a separate disposal corridor is unnecessary. Waste chutes should be avoided. A bedpan washer/disinfector and possibly a washing-up machine should be provided. Both should reach a temperature (e.g. 80°C) suitable for disinfection. A bedpan macerator is an alternative to a washer provided it is well maintained and drainage is satisfactory. Baths can be a source of infection. In general, large baths which are difficult to clean, or with jacuzzi and similar recirculating systems which are difficult to disinfect, should be avoided. Bathroom air should be extracted to the outside. A staff rest area is essential. There should also be good staff changing facilities. No special arrangements are required for visitors. Other facilities, e.g. offices, stores and seminar rooms etc., will also be required, but will not be considered in this document.
References Ayliffe G. A. J. and Lawrence J. C. (eds) (1985) Symposium on infection control in bums. J. Hosp. Infect. 6, (~uppl. B), 3-66. Bourdillon R. B. and Colebrook L. (1946) Air hygiene in dressing rooms for burns or major wounds. Lancet i, 561-565,601-605. Colebrook L. (1950) A Npw Approach to the Treatment of Bums and Scalds. London: Fine Technical Publications. Colebrook L., Duncan J. M. and Ross W. P. D. (1948) The control of infection in bums. Lancef i, 893-899. DHSS (1983) Venfi~fion of Qxrating Departments: A Desigrz Guide. Inter-authority Engineering Working Group NO. 10. London:
DHSS. Lowbury E. J. L., Ayliffe G. A. J., Geddes A. M. et al. (eds) (1981) revised edition (1992) Control of Hospital Infecfion: A Practical Handbook. London: Chapman and Hall (in press).
Correspondence shouti be addressed to: Dr J. C. Lawrence, Bums Research Group, Accident Hospital, Bath Row, Birmingham B15 INA, UK.