Number Indicator Detail Data Source Alert O.F Domain, 1,2,3,4,5 CQC Key question, Well led, responsive, effective, caring, safe Descriptor Notes Evidence documents Clinical Outcomes - quantitative data where possible using national data need to minimise the burden 101 Number of occasions where unit is unable to commence treatment on a patient within six hours Number of occasions where unit is unable to admit and start treatment of any patient with a confirmed diagnosis of airborne HCID within 6 hours (maximum) of notification. Annual Report Provider > 0 1, 3, 4, 5 responsive, effective, caring 102 Number of cases where HCID infection has spread from the Specialist Isolation Unit Number of cases where HCID infection has spread from the Specialist Isolation Unit Annual Report Provider > 0 1, 5 effective, safe Patient Experience - PROMS PREMS can be difficult to gather if no national survey can put in process indicator if required 201 Patient feedback included in formal debrief The review of the patient pathway and clinical practice by the HCID team includes patient feedback. No 1, 3, 4, 5 responsive, effective, caring Structure and Process - infrastructure requirements, staffing, facilities etc 301 Infectious Diseases team The Infectious Diseases specialist clinicians include: The trained Specialist Isolation Unit staff will include the following staff groups: Consultants in Infectious Diseases and Critical Care; Doctors in training; Nurses, including critical care nurses with an expertise in HCID; Physiotherapists with an expertise in HCID; Pharmacists with an expertise in HCID; No 1, 3, 4, 5 well led, effective, caring, responsive, safe Self-
Radiographers with an expertise in HCID. First-line personnel must be trained and ready and able to open the unit within 6 hours (maximum) of notification of a confirmed case. 302 Infrastructure and facilities The HCID unit will be in an area away from general circulation of staff, patients and visitors and meet the requirements as per the service specification. No 1, 3, 4, 5 safe, effective 303 Isolation unit The Specialist Isolation undertakes at least one training exercise per annum to simulate ‘real life’ situations, and reports the outcome of these exercises to NHS England. based on with Health Building Note 1 Isolation facilities for infectious patients in acute settings, (DoH 2013) No 1, 3, 4, 5 safe, effective 304 System preparedness - annual readiness exercise The HCID unit reviews its level of preparedness annually, undertaking at least one 'readiness exercise'. No 1, 3, 4, 5 safe, effective 305 System preparedness - staff training All staff are trained in the whole safe system of work within the high hazard environment. This training must include emergency procedures in event of fire, power failure etc. Comprehensive training records that demonstrate that individual staff No 1, 3, 4, 5 safe, effective
Health Technical Memorandum 03 Heating and ventilation systems Health Technical Memorandum 04 Water systems Health Technical Memorandum 05 Fire safety Health Technical Memorandum 06 Electrical services Health Technical Memorandum 07 Environment and sustainability Health Technical Memorandum 08 Specialist services Some subject areas may be further developed into topics shown as -01, -02 etc and further referenced into Parts A, B etc. Example: Health Technical Memorandum 06-02 Part A will represent: Electrical Services – Electrical safety guidance for low voltage systems In a similar way Health Technical Memorandum will simply represent: Environment and Sustainability – EnCO2de. All Health Technical Memoranda are supported by the initial document Health Technical Memorandum 00 which embraces the management and operational policies from previous documents and explores risk management issues. Some variation in style and structure is reflected by the topic and approach of the different review working groups. DH Estates and Facilities Division wishes to acknowledge the contribution made by professional bodies, engineering consultants, healthcare specialists and NHS staff who have contributed to the review. Figure 2 Engineering guidance HTM 08 Specialist Services HTM 01 Decontamination HTM 07 Environment & Sustainability HTM 02 Medical Gases HTM 00 Policies and HTM 06 Electrical Services HTM 03 Heating & Systems HTM 05 Fire Safety HTM 04 Water Systems
Acknowledgements Malcolm Thomas – Consulting Engineer – Lead Author Principal contributors Craig Macintosh – Principal Clinical Scientist - Wirral Hospitals NHS Trust Andy McGrath – Instrument Solutions Helen & Philip Sturdy – DSSR consultancy Richard Gatley – Apreco Russell Pitman - Henderson Green consultancy Kevin Reynolds – Deputy Head of Estates – Sandwell and West Birmingham NHS Trust Ian Fraser – Department of Health Main Steering Group and Working Groups comprising representatives from: Department of Health Welsh Health Estates NHS in Scotland Health & Social Services, Northern Ireland Health Protection Agency (HPA) Building Research Establishment (BRE) Building Services Research and Information Association University of Leeds CIBSE Healthcare Group IMechE/ASHRAE IHEEM HEFMA BSI Faber Maunsell consultancy Couch Perry Wilkes consultancy DSSR consultancy Howorth Airtech Medical Air Technology/Thermo Electric BPG Medical Admeco/Trumpf Medical Systems Volkes SPX Weiss Klimatechnik Research Laboratories NHS Security Management Service Pennine Acute NHS Trust Hospital Infection Society (HIS) Central Sterilising Club HEVAC – Air-handling Unit Manufactures Group
4 Annual inspection and verification requirements Ventilation systems inspection 4.1 All ventilation systems should be subject to at least a simple visual inspection annually. 4.2 The purpose of the inspection is to establish that: a. the system is still required; b. the AHU conforms to the minimum standard (see Chapter 3); c. the fire containment has not been breached; d. the general condition of the system is adequate for purpose; e. the system overall is operating in a satisfactory manner. 4.3 It is recommended that a simple check sheet be used to record the result of the inspection. Examples are given in Appendices 1 and 2. Critical ventilation systems 4.4 All critical ventilation systems should be inspected quarterly and verified at least annually. In some circumstances the verification may need to be carried out more frequently. 4.5 The quarterly inspection should be as detailed in paragraphs 4.1–4.3. 4.6 The purpose of the annual verification will be to additionally ensure that the system: a. achieves minimum standards specific to the application; b. is operating to an acceptable performance c. remains fit for purpose. Definition of a critical system 4.7 Ventilation systems serving the following are considered critical: a. operating theatres of any type, including rooms used for interventional investigations (for example catheter laboratories); b. patient isolation facility of any type; c. critical care, intensive treatment or high- dependency unit; d. neonatal unit; e. Category 3 or 4 laboratory or room; f. pharmacy aseptic suite; g. inspection and packing room in a sterile services department; h. MRI, CAT and other types of emerging imaging technologies that require particularly stable environmental conditions to remain within calibration; j. any system classified as an LEV system under the COSHH Regulations; k. any other system that clearly meets the definition. 4.8 The loss of service from such a system would seriously degrade the ability of the premises to deliver optimal healthcare. Annual verification 4.9 The annual verification is intended to establish that: a. the system is required; b. the AHU conforms to the minimum standard (see Chapter 3); c. the fire containment has not been breached; d. the general condition of the ventilation system is adequate; e. the fabric of the area served is satisfactory;
Table 1 Operational management and routine verification process model Step Question Information/standard required Comment 1 Is the system required? Why was it installed? Is that function still required? 2 Does the AHU achieve the minimum standard? • Health and safety aspects • Intake/discharge positions • Inspection access • Legionella control and drainage • Fire and electrical safety • Leaks, cleanliness and insulation • Filtration Inspect to ascertain compliance with minimum standards set out in Chapter 3 of Health Technical Memorandum 03-01 (Part B) 3 Is the air distribution system satisfactory? • Access • Fire dampers • Cleanliness • Insulation • Identification • Room terminals • Pressure stabilisers Inspect to ascertain continued fitness for purpose 4 Does the measured system performance still accord with the design intent and achieve a minimum acceptable standard? • Design air velocities • Design air-flow rates • Room air-change • Pressure differentials • Noise levels • Air quality Establish the design values Measure the system output to verify its performance 5 Does the control system function correctly? • Desired environmental conditions • Control sequence • Run; set-back; philosophy Establish the design requirement Inspect/test to verify performance 6 Having regard to the foregoing, is the system “fit for purpose” and will it only require routine maintenance in order to remain so until the next scheduled verification? Yes or No! 7 What routine service and maintenance will be required for the system to remain fit for purpose and function correctly until the next scheduled verification? • Filter changes • System cleaning • Performance indication • Performance monitoring • Performance measurement Decide inspection frequency and maintenance schedule 2 Maximum sound levels (service noise only) Location Design sound level (NR) Measured sound level (dB(A)) Ultra-clean operating room 50 55 Conventional operating room 40 45 All other non-specified rooms 40 45 Corridors 40 45 Recovery room 35 40 Ward areas; sleeping areas 30 35 Note: Health Technical Memorandum 08-01 gives detailed guidance on acoustics and the measurement of sound
sealed type and marked with a biohazard symbol. If the fan has to be located inside the building, it should be as as practicable to the outside. The extract fan motor should be mounted out of the air stream and should be capable of being changed without withdrawing the impeller or opening up the ductwork. The extract fan should draw its power from the essential electrical system. 2.35 Extract filters will not be required provided that the fan can discharge in a safe location 3000 mm above the building height. If extract filters are fitted, they should be in a “safe change housing” outside the building on the suction side of the fan. Extract filters, where fitted, should be of HEPA grade. Even if filtered, extract air should not be recirculated. 2.36 Extract ductwork, the fan and discharge stack should be clearly marked to identify the isolation suite that they serve. Service, maintenance, cleaning and filter change of the system will be subject to a permit to work. 2.37 Ideally each isolation should have its own dedicated supply and extract system. If two or more suites share a ventilation system, there will be an inevitable increase in the complexity of the system and a corresponding reduction in reliability and serviceability. Routine maintenance or breakdown of the ventilation system will result in failure of all suites that it serves; therefore, ideally each such isolation should have its own dedicated AHU. 2.38 In a high-rise building, a common supply and extract system may be the only feasible solution. In this case, run and standby fans would be required for the extract, and a duplicate supply unit may be considered necessary. The common supply and extract systems will need to be controlled to ensure a constant volume in each isolation suite branch regardless of the number in use. 2.39 Ductwork should be kept as direct and simple as possible. Figure 1 Extract ventilation – negative pressure and PPVL rooms Extract 3000 mm Spectacle plate Supply Air Handling Unit (AHU ) E Fire/Plant Isolation damper Pressure Plantroom En-suite stabiliser Corridor Transfer grille Patient’s room Lobby Doorway
Documentation 2.40 A logbook retained by the estates department will be required for each isolation It should contain the following information: • a schematic layout of the isolation room/suite and ventilation system serving it; • information on the ventilation design parameters; • a record of the actual ventilation performance at initial validation; • records of the annual validations; • records of any routine service and maintenance activities; • records of any repairs or modifications.
References Health Facilities Note 30 – ‘Infection control in the built environment’ (DH, 2002). Health Building Note 04-01 – ‘Adult in-patient accommodation’. Health Building Note 00-03 – ‘Clinical and clinical support spaces’. Health Building Note 04-01 Supplement 1 (DH, 2005). Health Technical Memorandum 06-01 – ‘Electrical services supply and distribution’. Health Technical Memorandum 03-01 – ‘Specialised ventilation for healthcare premises’, Parts A and B. Health Technical Memorandum 05-02 – ‘Guidance in support of functional provisions for healthcare premises’. Health Building Note 00-10 Part C – ‘Sanitary assemblies’.