BASICS LOWS AND TASKS OF THE HYGIENE

BASICS LOWS AND TASKS OF THE HYGIENE.

EVALUATION OF THE MEDICAL-PROPHYLACTIC ESTABLISHMENTS. SANITARY-HYGIENIC REQUIREMENTS FOR THE PLANNING AND BUILDING OF THE MEDICAL-PROPHYLACTIC ESTABLISHMENTS.

MODERN PROBLEMS OF INTRAHOSPITAL INFECTION AND PRINCIPLES OF ITSPROPHYLACTIC. HYGIENIC ESTIMATION OF WORKING CONDITIONS OF THE MEDICAL PERSONNEL IN MEDICAL-PROPHYLACTIC ESTABLISHMENTS.

 

Hygiene is a basic preventive science. It studies influence of the environmental factors on the human organism and social health; it has the goal to determine and substantiate theoretically hygienic norms, sanitary regulations and measures, realization of which provides optimum condition for life and activity of people, improving the health and preventing diseases.

This subject studies the factors which influence on the human body, create the threshold values and maximum admissible concentrations, levels and doses for these factors. There are psychogenic (information) and material (chemical, physical, biological) factors.

Afferent stimulation causes various emotions (grief, horror, joy etc), changes physical state of the organism. Positive emotions are realized in positive changes: better blood supply of the brain, heart, normalizing blood pressure. Distress, negative emotions can cause disease. They are risk factors for myocardium infarction, hypertension, ulcerous disease, diabetes etc. Great part of afferent loading has social nature. Chemical compounds are often necessary for vital activity and health, but they can be the cause of disease. For example: iodine deficit causes goiter and cretinism, chemical hazards (pollutants) can cause poisoning. Physical factors (microclimate, noise, ionizing radiation, vibration, air pressure) present various kinds of energies. They form an environment we live in but all these factors can be the hazards too. For example, high air temperature can cause overheating and heat stroke, intensive noise – cochlear neuritis and deafness, etc. Biological factors are microbes, viruses, fungi, and helminthes. They can cause diseases of the man and animals, spoil food products, damage sanitary-technical equipment. In real life human being is under the influence of not only one but also complex of environmental factors. They use the terminology: combined influence – influence of several factors of common origin (for example, several chemical compounds). “Common influence” means several factors of different origin are acting. Complex influence is characterized by the situation when only one factor is present but it has different routes of exposure.

The main aim of the subject is the prevention of diseases. Successful prevention depends upon knowledge of causation, dynamics of transmission, identification of risk factors and risk group, an organization for applying these measures to appropriate persons or group and continuous evaluation and development of procedures applied. Nowadays prevention is defined in terms of three levels:

·       Primary prevention

·       Secondary prevention

·       Tertiary prevention.

Hygiene is dealing with the first level mainly. The aim of primary prevention is to maintain health by removing the precipitating causes and determinants of departures from good health.

Hygiene is a science of preserving and promoting the health of both the individual and the community. It has many aspects: personal hygiene (proper living habits, cleanliness of body and clothing, healthful diet, a balanced regimen of rest and exercise); domestic hygiene (sanitary preparation of food, cleanliness, and ventilation of the home); public hygiene (supervision of water and food supply, containment of communicable disease, disposal of garbage and sewage, control of air and water pollution); industrial hygiene (measures that minimize occupational disease and accident); mental hygiene (recognition of mental and emotional factors in healthful living) and so on. The World Health Organization promotes hygienic practices on an international level.

Methods of hygienic researches:

·       -method of sanitary examination and describing

·       -experimental methods:

·       -experiment with simulation of natural conditions

·       -laboratory experiment on animals

·       -chambers experiment on people

·       -“natural experiment”

·       -sanitary statistic methods:

·       -method of mathematical modeling

·       -epidemiological method

Specific hygienic method is method of sanitary examination and describing which is used for studying the environment. Sanitary examination and describing is carried out according to special programs (schemes), which contain questions. Answers to these questions characterize the object, which is being examined hygienically. As a rule it is usually supplemented by laboratory analyses (chemical, physical, microbiological and other), which allows characterizing environment from the qualitative side.

Aim of hygiene is preserving and promoting the health. Its objectives are:

1.    Studying environmental factors

2.    Studying interaction between human organism and environment

3.    Environmental hygienic standards and guidelines developing

4.    Sanitary supervision substantiating

5.    Prospective analysis of environmental health

Hygiene has close links with social medicine and public health, clinical epidemiology, pediatrics, internal diseases, human ecology.

 

Hygienic standardization:

Environmental standards are definite ranges of environmental factors, which are optimal, or the least dangerous for human life and health. In Ukraine basic objects of hygienic standardization are:

§       MAC – maximum admissible concentration (for chemical admixtures, dust and other hazards)

§       MAL – maximum admissible level (for physical factors)

§       LD – dose limit (for lionizing radiation)

§                 Optimum and admissible parameters of microclimate, lighting, solar radiation, atmospheric pressure and other natural environmental factors.

§                  Optimum and admissible daily requirements in food and water.

Important methodological problems of hygienic norms setting are:

1) Possibility of application of data got in the experiment on animals to people;

2) Conception about levels of harmful influence (MAC and MAL, must be below them).

Possibility of application of results got in the experiment on animals to people and studying of toxic influence of chemical substances (and some physical factors) is corroborated by hygienic and toxicological investigations. It was an idea to use the so-called reserve coefficients or 'coefficients of extrapolation’ to increase the safety of hygienic norms. It was made because of different sensitivity of animals and people. It was recommended to decrease experimental MAC by 2, 100 and more times in the dependence on the toxic abilities, cumulative action of substance and type of experiment on animals. It is possible to apply data of the sanitary-toxicological experiment on “average animal” to “average human being”. But it is more hard to apply these data to human population among which genetic and other differences are present (age, disease, pregnancy, etc.) which stipulate differentiated sensitivity to the agents. This problem is theoretically unsolved today. But in practice solution is found the in increase of types of experiment on animals of different age, on pregnant animals with modeling of disease and in increase of reserve coefficient and obligatory checking the hygienic norms reliability (MAC and MAL in natural conditions).

As it was said one of the main problems of hygienic norms setting is elaboration of correct conception about the level of harmful influence. Some investigators consider that it is necessary to distinguish the level of biological influence and the level of harmful influence. According to their conception all first stages of physiologic and biochemical reactions which occur as a result of influence of a factor are within limits of adaptation possibilities of the organism. Only when they "come out” of their limits reaction of the organism has a compensatory character. In this case their influence can be considered as harmful because physiologic and biochemical reactions get hygienic significance. But it is too hard to determine the distinction between adaptation and compensatory processes in the experiment. To solve this problem the following rules should be used - data got in the experiment can be considered hygienically valuable only if they are stable (for example, during one month), reliable in the comparison with control group and especially progressive in time. It is recommended to apply loading method, which allows comparing adaptation resources of animals being tested with the control group. Besides that, it is recommended to orient basically on integral parameters of organism condition (weight, temperature, functionality of CNS, concentration of sugar in the blood, etc.) or changes on the organism level, which show the upset of relative equilibrium between the organism and environment. Degree of different of different constants of the organism must be token into account. Changes of stable constants indicate the hygienic significance of changes. Thus, according to this conceptions threshold dosage of toxic substance is that minimum concentration of it in the object of environment influence of which brings about changes in the organism, which result from physiological adaptation reactions.

But some investigators consider that distinction between adaptation and compensatory processes is conditional. That's why threshold of action must be considered as any statistically reliable deflection of physiological and biochemical reactions (parameters) in tested animals from animals of the control group. In this case threshold of action and consequently MAC will be some lower. It is considered that such principle can be used while the setting of norms for factors, which influence on the whole population.

A group of scientists came to the conclusion that there are no any threshold dosages for mutagenous or cancerogenous substances because even the smallest concentration of them can cause mutation (or development of tumor) in the organism. It is known that degree of risk is in proportion to the dosage and quantity of people who were under influence of cancerogenous (mutagenous) substance. International Committee of Radiation Protection (ICRP) in relation to approves this conception mutagenous and cancerogenous influence of ionizing radiation. That's why MAL of ionizing radiation must not bring about more frequent development of tumors or mutations than spontaneous level of this pathology, which is typical for people living in normal not polluted conditions. Conception of ICRP about the non-threshold influence is cruel and, therefore, the best measure is to protect the health of the human being, from the influence of such dangerous factors.

But it was found out in experiments on animals with decreasing dosages of cancerogenous substances that there can be such concentration at which tumors occurs not more often than in the control group. Besides the following fact is against the conception about non-threshold action of cancerogenous (mutagenous) substances. It was found out that substances differ one from another by dosage, which brings to development of tumour (mutation). Supporters of non-threshold theory consider "thresholds imaginary because of small number of animals in the experiment. For example, cancerogenous substance inducts tumours - with the frequency 2,000 per 1,000,000 animals; it means that probability of tumour development is low – 0,2 per 100 animals. Supporters of non-threshold theory suggest to set MAC or MAL according the following way: to determine on animals the dependence of “dosage effect” for 4-6 dosages of cancerogenous (mutagenous) substance, extrapolate the obtained data into small dosages and find the dosage which slightly increases the level of spontaneous pathology.

Let's study the methodical scheme of hygienic norms of substantiation using, the example of MAC for some toxic substance. The first stage is stud physical and chemical properties of the substance, elaboration of methods of quantitative determination of this substance in different subjects, determination of its regimen of action on the human (duration, interruption, changes of intensity), ways of getting into the organism, study migration in different elements of the surrounding, mathematical prediction of duration of existence in different surroundings.

The second stage is study direct influence on the organism. It is started from 'sharp' experiments the main goal of which is getting initial toxicometric data about the substance (determination of LD50, or LC50 threshold of strong action (LIMac) and other. With the knowledge of physical and chemical properties of t he substance, its initial toxicological characteristics and approximate level of MAC can be calculated.

The third stage - is conduction of 'subsharp' experiment during l-2 months for determination of cumulating coefficient and the most vulnerable physiologic systems and organs specification of mechanisms of action and metabolism.

The fourth (basic) stage is carrying out chronic experiment which lasts 4-6 months in the case of modelling of working conditions, 8-12 - communal conditions, 24-36 - in study processes of aging or induction of tumours.

During the experiment integral parameters are studied. They reflect condition of animals, degree of strain of regulative systems, functions and structure of organs, which take part in processes of metabolism (activity of enzymes), influence of functional loadings.

Numbers of MACs of toxic chemical substances in the Ukraine are various: for the air of working zone - more than 800, water- 700, atmosphere air- 200, foodstuffs - more than 200, soil - more than 30.

Basic objects, which are under the hygienic norms setting, can be divided into two groups.

The first group contains factors of anthropogenesis origin, which are unfavourable for human being, and are not necessary for the normal life activity (dust, noise, vibration, ionising radiation, etc.). MAC, MAL and LD are those parameters, which are set for this group of factors.

The second group contains factors of natural surrounding which are necessary (in certain amount) for normal life activity (food-stuffs, solar radiation, microclimatic factors and others). For this group the following parameters must be set: optimum, minimum and maximum admissible parameters.

In those cases when factors influence on the human not only directly (physiologically) but also indirectly (through the environment) all types of possible influence must be examined at hygienic norms setting. For example setting of hygienic norms for toxic substance in the water of natural reservoirs determination of maximum concentrations must be based on worsening of organoleptic properties of the water (organoleptic sign), toxic influence (sanitary - toxicological sign) and disturbance of processes of self-clearing of reservoirs (general sanitary sign). In this case MAC are set according that harmful parameter which is characterized by the lowest level of concentration. Such parameter is called limiting.

 

BASIC TASKS AND LAWS OF HYGIENE

The homeostasis of organism of practically healthy people can be also kept at changing (denaturation, pollution) of up to the certain meanings of parameters of the factors of natural environment. It is possible due to processes of adaptation (at the healthy man) and compensation (at the ill man), having also individual limits for every organism.

That is why, the basic and specific purpose of hygiene as science is the studying of the laws and regularities of the healthy man, healthy collectives, populations, population with the natural and changed environment and, on the basis of it, development of ways and means ensuring preservation and strengthening health of the man and whole society.

It is established, that if all etiological factors of not infectious nature, which can change a level of health of the population take as 100 %, the densities of each of them will be such as: the conducting meaning in formation of level of health of the population is a healthy or unhealthy way of life (49-53 %), the second place occupies the genetic factor (18-22 %), third one - factors of pollution of an environment (17-20 %) and only fourth (8-10 %) - medical etiological factors (out of time rendered medical aid, poor quality , inefficiency of preventive measures and etc). From these data follows, that for all responsible for health people services of the country, including sanitary - epidiological, it is necessary to make basic emphasis formation of healthy way of life, and then on struggle with pollution of environment by substances, which can be potential mutagens receipt in organism of the man or influence on it, can promote occurrence of genetic defects, which is shown in first and the subsequent generations.

The role of doctor - hygienist is development and introduction of medical measures promoting recovery of the patients, and also development of organizational measures on duly and effective rendering of medical aid is great. However paramount role in decrease of negative influence of etiological dangerous factors of environment on health of the people the doctors - hygienist should play.

Thus, all laws of hygiene are formulated preceding mainly that the doctors - hygienist in the greatest degree answer for level of health of the people, which depends from adverse and beneficial effect of the factors of environment on organism of man.

The basic law of hygiene is based on principles fixed in a basis of one of the conducting laws of the epidiology, which was formulated by the academician L.B. Gromashevski. According to this law the driving forces (conditions), that are determining epidemic process, are: a source of an infection – the ill or contagious man, mechanism of transfer and susceptible to the given infection organism. At deenergizing even by one of these driving forces the occurrence of infectious disease or epidemics (epidemic process) is impossible.

The first law of hygiene

The first law of hygiene (about three driving forces of adverse influence of factors of an environment on health of the population) can be formulated as follows: the infringement of level of health of the people (disease, decreasing of the resistance, immunological status, adaptation-compensatory opportunities of organism), caused by physical, chemical, biological and psychogenic etiological factors, can arise only at presence of three driving forces: a source of insalubrity (polluting substance) or the complex of the insalubrities, factor (mechanism) of influence or transfer of this polluting substance and susceptible (sensitive to influence of the insalubrity) organism. At the absence of one of these conditions, or the driving forces of process of changing of level of health under influence of the factors of environment for the given age-sexual or professional group of the people the disturbances of health will not take place.

From the first law of hygiene follows, that it is necessary the presence of all three driving forces for the decreasing of health of the population. The exception of uniform circuit of one of these driving forces eliminates probability of deterioration of health, and the reduction of size of one of driving forces of this circuit limits a degree of infringement of level of health of the people. Hence, basic task of hygiene as the science should be the scientific substantiation of a complex of preventive measures directed on elimination or even on reduction (at the beginning) of role of one, two or all three driving forces of deterioration of health of the population.

This law allows a hygienic science on the basis of the first driving force of level of health, i.e. a source of insalubrity (polluting substance) to create the systematized doctrine about various substances, that are polluting the environment, their qualitative and quantitative criteria’s, to classify them on a degree of danger for health of the people. For example, on a degree of danger distinguish four groups of chemical substances – pollutes:

 I - especially high toxic (middle death doze -DL - is lower than 50 mg/kg of weight of body);

 II - high toxic (DL = 50-200 mg/kg);

Ø - middle toxic (DL = 200-1000 mg/kg);

IV - low toxic (DL- more than 1000 mg/kg)

A variety of physical, chemical, biological and other substances polluting environment, allows to create the doctrine about constant, faltering, isolated, complex, combined receipt in organism, and also about antagonistic, summarized, potentional influence of pollution.

The concept about the second driving force of level of health is a concept about role of the factors of transfer mechanisms of the report of polluting substances up to susceptible organism, about densities of each factor, if them works simultaneously, that allows to study ways of migration of polluting substances of a source of pollution to the man. Thus the polluting substance can enough long be in objects of an environment (atmospheric air, water of reservoirs, ground), but can’t be dangerous for the man. Only then it can render harmful influence, when it gets in the organism of the man with inhaled air, water, food in quantities exceeding hygienic norm.

Thus, the polluting substance can render damaging action on organism, if mechanism of transfer it in organism of man enclose or work by one of the ecological chains, for example for polluting chemical substances: polluting substance - air-man; polluting substance - water - man; polluting substance - soil - plant - animal - man. If from ecological circuit to withdraw this or that factor (link) of transfer (polluted air, water, foodstuff), the mechanism of transfer will not work.

At last, the conception about the third driving force of the first law - about susceptible to the given polluting substance or complex of substances of organism, allowing to systematize our knowledge and to prove scientifically the preventive measures, directed on amplification of the imunological reactivity of organism, on disclosing and using of laws, determining ways and meanings of increasing of stability of organism to influence of the adverse factors of environment, amplification of mechanisms  of self regulating, adaptation and compensation.

The knowledge and using of the laws of hygiene allows practical medicine and its sanitary - preventive branch successfully to develop and to introduce measures, directed on all driving forces of level of health of the population. The knowledge of the first law of hygiene - law on dependence of level of health on three driving forces - requires of the doctor of the creative approach to the decision of question, on which one or what of these driving forces in concrete conditions first of all to direct the preventive measures.

 

The second law of hygiene

The second law of hygiene is law of inevitable negative influence on environment of activity of the people.  Irrespective of the will and consciousness, in connection with physiological, household and industrial activity, the people negatively influence on the environment, that the more dangerously, than below scientific and technical level of production, culture of the population and social conditions of life.

During the process of live the man allocates in environment excrement (faces, urine), which are very dangerous in the epidemic and sanitary attitude. This danger grows if not to undertake of measures of immediate removal of excrements from the inhabited localities through the water drain with the further neutralization on clearing sewer structures.

The negative influence of the people on environment is shown more strongly owing to household and especially unreasonable irresponsible industrial activity. The inevitability of amplification of negative influence is caused by further extending use of natural resources for satisfaction of growing material and spiritual needs of society, scientific and technical progress which is not taking into account this influence. This historically natural process inevitably conducts to dangerous to health of the man interrelations with environment, brings in essential and at times unforeseen changes to elements of biosphere, which, being polluted, negatively influence health of the man. So, is authentically proved, that caused by scientific and technical progress of industrial activity of the man, integration of cities and industrial centers, if they occur without the account of the hygienic requirements, result in progressing pollution of environment by the chemical, physical, biological polluting factors in quantities dangerous to biosphere in whole and to the man in particular.

The technological measures assume the organization, adjustment of production processes so that any harm of physical, chemical, biological origin (initial raw material, basic or collateral products of manufacture, it wastes) has not got in environment in quantities, exceeding it of an opportunity to self cleaning and dangerous for health of the man both in immediate and mediate influence. Among such measures effective are waste less technology, turnaround water supply, hermetic sealing of technological systems etc. For protection of atmospheric air against the pollution by exhaust gases of transit measures it is developed the system end burning of exhaust gases, replacement of carburetor engines, that are working on petrol, diesel, gas, electricity.

In basis of scientific - hygienic measures lays the hygienic norm. So, the decreasing in atmospheric emissions of concentration of harmful chemical substances is reached by the appropriate accounts of extreme allowable emissions by the enterprise, group of the enterprises.

To ensure decreasing of concentration of harmful substances in emissions, wastewater, it is using the various designs of sanitary - technical clearing structures, for example dust-, aurum-, gas-catchers, sedimentation, filters.

However listed above protective measures and means are not always effective. In these cases the doctor -prevents should apply the natural factors, planes measures. At the using the last one it is taking into account the winds, prevailing in the given district (rose of winds), which defines the accommodation of the industrial enterprise, height of pipes (for the greater dispersion of emissions in an atmosphere height of pipes is increased) etc. Besides it is allocated the sanitary - protective zones between the enterprises the inhabited zone, applied the shielding gardening of these zones etc. The sizes of sanitary - protective zones depend on character and degree of the harm of technological emissions of the enterprises. For example, the size of sanitary - protective zone for confectionery factories, bred factors, and other manufactures on processing foodstuff of the fifth class, according to sanitary classification of the enterprises, is determined within the limits of 50 m. For the chemical enterprises and other manufactures of the first class A this size makes 3000 ì, B- 1000 m. For large heat and power plants size of sanitary - protective zone is accounting to dispersion of technological emissions in an atmosphere and can reach three and more kilometers from borders of the inhabited territory. The sanitary - protective zones is defined also for high-voltage transmission lines, radio transmitting and television stations creating fields of high and super high frequencies of electromagnetic radiation.

Completely to exclude the hitting of polluting substance, especially dangerous, with wastewater in a reservoir, and then with water in organism of the man, the doctor - prophylactic should demand on a substantiation of zones of sanitary protection, introduction of turnaround systems of water supply of the industrial enterprises in development of measures. Thus the wastewater is cleared on factory clearing structures and again goes in a production cycle.

 

The third law of hygiene

The third law of hygiene –is the law of inevitable negative influence on an environment and health of the people of natural ecological accidents (flood, earthquake etc), natural both toxic biochemist provinces and toxic failures (on AES, enterprises, transport). The natural environment becomes soiled not only under influence of physiological, household and industrial activity of the people, but also at the extreme natural phenomena, cataclysms, such as flares on the Sun, volcanic activity, earthquake, active cyclonic and anticyclones activity etc.

So, during geological formation of the terrestrial cortex the geochemical anomalies with the increased or reduced contents of active microelements, such as F, Mo, others and I were formed under influence of extreme conditions. Such anomalies have resulted in occurrence of biogeochemical provinces, in which the diseases of the natural- pesthole   character, which has received the name endemic, are observed by A.P. Vinogradoff (1938). The most well known among them are goiter, endemic fluorose, caries, endemic molybdenose etc.

 

The fourth law of hygiene

The fourth law of hygiene – is the law of positive influence of human society on environmental . During creation of favorable conditions of residing and labor activity the human society, that is depending on social level of development, culture, achievement of scientific and technical progress, economic opportunities, purposefully renders positive influence on an environment, the sanitary processes of it, warning pollution and by that. Thanks to this the level of health of the population is raising.

The man, due to the labor activity during all historical development creates and constantly increases conditions, which improve its existence with the help of using of the resources and gifts of a nature. Now technical progress creates completely new ways of moving material and power resources in biosphere, which is directed on improvement of conditions of life.

However we must not think, that the environment is absolutely defenseless in front of the activity of the man. The nature has huge resources of self-preservation, self-updating, self-regulation, maintenance of ecological balance, self-cleaning, but these reserves are not boundless. So, due to solar radiation, temperature processes, occurring in an atmosphere, there are winds, that are promoting the moving and dispersion of smokes and gases, which are thrown out by an industry and vehicle. A ultra-violet part of a solar spectrum, dispersion, concretion, neutralization promotes decomposition of many chemical components of emissions, clearing of air of biological impurity.

 

The fifth law of hygiene

The fifth law of hygiene is the law of inevitable negative influence of the muddy environment on health of the population. At contact of the man with an environment, that is polluted by physiological extraction, household or technogenic pollution in quantities, that are exceeding the hygienic specifications, it comes inevitably change of a level of health in the part of its deterioration.

The numerous hygienic researches it was established communication between concentration of harmful emissions in an atmosphere of cities and morbidity of the population by illnesses of respiratory system and the cardiovascular systems. Such impurity of atmospheric air of cities, as oxides of sulfur, nitrogen, the various organic substances, irritate mucous environments, are the reason of occurrence of a plenty inflammation of diseases of an eye, respiratory system. The cases of bronchial asthma have become frequent. With pollution of water by heavy metals, in particular by connections cadmium, mercury, connected development heavy intoxications among the population. So, in 1956 it is described endemic named of the disease of Mina Mata. This disease was by a consequence of the using by the population of coast of a gulf Mina Mata (Japan) of a fish (basic products of a feed of the local population), polluted   by the metylmercury, which was dumped in great quantities in the sea by a chemical factory. Among the inhabitants of coast of the river Initsu   in Japan the mass poisoning cadmium is registered, that was named the disease Itai-itai (disease of bones). 200 men were ill, and there were fatal outcome in half of cases. As well as in the previous examples, the poisoning of the local population is connected to consumption a fish, containing much cadmium owing to pollution one of gulfs on the Japanese islands by waste water of the industrial enterprises with high concentration cadmium. Among the population, living in some regions of USA, Australia, Germany, the cases of a poisoning by selenium are registered. The disease is shown as infringement of function of the digestive channel, development of the yellow coloring of a skin, defeat of teeth.

 

The sixth law of hygiene

The sixth law of hygiene is the law of positive influence of the factors of a natural environment on health of the population. The natural factors of an environmental, pure air, pure water, good-quality, high-grade food positively influence on health of the people, promoting its preservation and strengthening at reasonable using.

All organic life of the Earth is obliged by the existence to solar radiation. The influence of solar radiation on organism and health is defined by his spectral structure: the seen radiation provides function of the visual analyzer, infra-red has thermal, ultra-violet - stimulating, biological, bacteriostatic action.

Rational using of solar radiation, sufficient insolation of dwellings and other premises promotes strengthening of health of the man, increasing of it reactivity and the stability to the adverse factors of environment. The man feels the thermal comfort, if the temperature of air under clothes is in limits 32-34îÑ, humidity of air - within the limits of 40-60 %, speed of movement of air - 0,2-0,5 m/s, and radiating temperature on 1-2îÑ is lower than temperature of air. The fluctuation of parameters of a microclimate in limits of the adaptation opportunities of organism promotes increasing of stability of it, strengthening of health of the man, his hardening. The natural fluctuations of atmospheric pressure also positively influence on the health of the healthy man, rendering stimulating action on vascular system. The positive influence on health of the man renders pure air containing about 21 % of oxygen, no more than 0,03 % of carbonic gas, and also sufficiently ionized (containing easy negative ions). At pollution of air the contents of carbonic gas is increased, the concentration of negative ions is reduced, on change with which there come heavy positive ions adversely influencing on organism.

The strongest positive action on a level of health of the people renders a balanced diet. The balanced diet is the balanced feed ensuring normal growth and development of organism, his high serviceability and stability to the adverse factors of an environment. Conditions of a balanced diet are: quantitative sufficiency of food (accordingly to the power inputs of the organism); qualitative full value, that is the presence in a diet of all necessary food substances (fibers, fats, carbohydrates, vitamins, mineral salts and microelements, flavoring substances, water) in optimum quantities and parity; a rational mode of a feed (accordingly to quantity and time of reception of food with biological rhythms of organism); high assimilated food (accordingly to the quality of food  opportunities of digestive system); epidemic safety (absence in food of activators of diseases) and toxic harmlessness of food (absence of poisonous substances in toxic concentration).

It is necessary to note, that the positive action of the factors of an environment on organism and health can be effective only at their complex influence. Using of a complex of the improving factors (sun, air, water, physical activity, high-grade feed) is a necessary condition of preservation and strengthening of health both individual and public.

HOSPITAL HYGIENE.

THE HYGIENICAL ESTIMATION OF PLACING AND PLANNING OF SEPARATE STRUCTURAL SUBDIVISIONS OF HOSPITAL ON MATERIALS OF PROJECT.

Functioning of medical-preventive institutions represents a complex of technological, scientific - practical, economic and social - psychological problems, which decision impossible without the hygienic requirements and recommendations.

Tasks of hospital hygiene:

Ø     Preference to acceleration of recovery the patient, achievement of indemnification of functions, medical and psychological rehabilitation.

Ø     Achievement for psychological and somatic comfort for the patients during stay in hospital institutions.

Ø     Prevention of nosocomial infection

Ø     Maintenance of epidemic and radiologic safety.

Ø     Maintenance of healthy occupational environment for the medical personnel.

Ø     A regulation of use of new disinfectants, detergents, polymeric materials, newest equipment and technologies in medical institutions.

Ø     Formation of bases of a healthy life style at the personnel and patients MPI.

Ø     Minimization of influence on an environment for construction and operation of medical institutions.

         The main characteristic of all medical-preventive institutions is presence so called "hospital environment ". Hospital environment is a set of all factors of physical, chemical, biological and information nature, which carries out influence on an organism of the patient during treatment. There are microclimate of hospital premises, various radiation end wave influences, medicines, antiseptics and polymer material, special hospital strains of bacteria. These factors define dynamics of medical rehabilitation and health of patient and staff.

Before to buid any health facilities it’s recommended to arrange their planning with the authorized general plans and projects on the basis of the circuits of area development.

Fig. Situation plan of hospital

 

 

Fig. General plan of hospital

 

 When they develop the general plans of medical-preventive institutions it is necessary to take into account local climatic conditions and to provide measures on protection of building and nearby area from the adverse external factors. A choice of the ground area for an arrangement of houses of hospitals, maternity houses and others in-patient institutions should be agreed with local authorities and institutions of environmental health service. The medical institutions have to settle down in residential or suburb zones in conformity with the authorized plan and projects of detailed planning of the residential area in view of its functional application. General hospitals and maternity houses should be placed outside of the centre of cities and settlements, the hospitals of emergency care have to be under construction in view of the maximal approximation to groups of the population, which they are served. The specialized hospitals or complexes with capacity for over than on 1000 beds for  the patient stay during long time, and also special hospitals (psychiatric, tuberculosis and other) is necessary to place in a suburb zone, with 1000 m sanitary space from residential territories. In a choice of a site for health facility it is necessary to remember an environmental sanitary situation and prevailing direction of winds ("wind rose").

 

Table 7.1 Standards for area of health facility in Ukraine

Health Facilities

Units of operational structure

 

Land area

m2 per unit

 

 

 

Children

Adults

Hospitals

beds

35

50

150

300

400

500

600

800

1000

250

125

125

135

135

350

300

150

200

200

100

100

80

80

Sanitariums

1 place

Up to 500

Up to 1000

More than 1000

150.

125

120.

Out-patient istitutions

Daily visits per 1000 persons

0,5 ha per one object

dispensaries

Daily visits per 1000 persons

0,4 ha per one object

Ambulance stations

1 ambulance van per 1000 persons

0,07 ha per 1 van

The ground in hospital area must be clean, dry, without sharp differences a relief. The hospital area should be placed in aerodynamic shadow, so that the velocity of air movement did not exceed 5 m/s. They electrify the area, supply it with waterpipes and water drain, border on perimeter and protect by a strip of green plantings with width not less than 15 meters (2-3 lines of trees with low schtamb and rich crone). . It is forbidden to construct hospital institutions in places which were earlier used  for landfills, field of assenization (irrigation, filtration), cemetery, etc., and also that have polluted soil.

         Hospitals and maternity houses should be remoted from the railways, airports, high-speed highways and other powerful sources of pollution.

          At an arrangement medical and maternity institutions in residential zone it is necessary to place them not closer than 30 m from a red line of building and 30-50 m from apartment houses, depending on the number of floors in houses of medical-preventive institutions.

          The hospital area should be gardened and comfortable. The area of green plantings and lawns has to make not less than 60 % of the general area and area of garden zone - 25 sq. m. on a bed.

Bush it is necessary to place not closer than 5 m from a hospital house, trees - not closer than 10 m. Trees and the bushes with poisonous fruits, sharp hooks, allergic-dangerous (give a lot of pollen) plants are not used for gardening.

Hygienic meaning of vegetations:

Positive:

    Protection against wind, dust and noise

    Optimization of microclimatic conditions: they give a shadow, normalize a humidity of air and make an aerodynamic shadow

    Bactericide influence of phytoncides on bacterial pollution of air

    Oxygenation of air

    Fixing of dust by a grassy lawn

    Architectural-planning meaning

    Aesthetic and psychohygienic meaning

Negative:

    They can be a potential source of allergens

    Some plants are poisonous

    Danger of traumatisation with sharp and rigid stalks of plants, with heavy fruits etc

    Adsorption of dust particles by plants surface

Hospital area located in territory of settlements should have a strip of green plantings with width not less than 15 m with two-line planting of high-schtamb trees and  a line of bushes. Behind perimeter of a site of polyclinics, woman wealness centers and dispensary without IPD, and also ambulance stations they use a strip of green plantings.

          The bushes should be in width not less than 5 m around of radiologic and infectious departments, and also along the X-ray studies if they are on the ground floor.

Now they use 3 basic systems of building of medical institutions. They are distinguished by a various degree of centralization and isolation of functional departments.

The centralized system of building of hospitals is characterized by the maximal concentration of medical service. Usually the hospital house represents a multi-storeyed structure the separate departmentes and services situated at various levels in general architectural space. In Ukraine the hospital could not have more than 9 floors.

The basic advantages of the centralized system is:

Ø     Economy. At the expense of the small area and absence of duplication of the basic building volumes, functional departments, and engineering networks, the charges on construction and technical equipment of hospital decrease.

Ø     The reduction of the vertical and horizontal ways of movement of the personnel and patients allows to raise efficiency of medical process.

Ø     The large concentration of scientific and technical resources allows to develop departrments on the basis of this centralized type hospitals, which give the qualified and specialized medical care.

In the same time for this system has some drawback:

Ø     The raised risk of nosocomial infections. Difficulty of isolation of departments with a various structure, presence of ascending flows of bacterial aerosols, intensification of loading on hospital environment lead to increased risk of disease.

Ø     Deterioration of conditions of hospital environment. High concentration of technical equipment makes excessing of noise level. The microclimate of the top floors could be overcooling because of power wind drafts.

Ø     The architectural flexibility of the centralized system is low usually.

The decentrilized system is characterized by organization of various functional departments in separate houses.

The essence of pavilion system is the arrangement of separate functional departments in 2-3 floor-houses. The basic advantage of this system is:

        Good isolation of various departments, that allows to prevent occurrence of nosocomial infections,

        Good conditions for observance medical care regimen

         However, nowadays they were compelled to refuse decentralized  system. It is connected with:

        The large expenses on building works and technical equipment

        Reduction of garden zone

        Increase of the length of movement for the personnel and patients. There are some technical decisions for reduction of the routes of the personnel, in particular underground type of communication, but it does not solve a problem

          Presently most perspective is the mixed system of construction. It unites features of centralized and decentralized system. It has the most flexible architectural planning.

         The territory of hospitals, maternity houses and other in-patent institutions should have convenient access roads with a firm covering. Internal roads and foot paths should be covered by the concret or asphalt.

The optimum capacity of multiprofile hospitals is accepted in 600-800 beds (allowable - 1000 beds).

Table 7.2 Zones of sanitary space between hospital objects

Departments

Size

Radiological department

Other departments

More than 25 m

 

Vivarium

Hospital departments

Residential Houses

More than 100 m

                    50 m

Furnace for waste incineration (<100 kg)

    In economic yard

    Separate building (> 100 kg)

Hospital departments

Residential Houses

 

More than 30 ì

                  100 ì

Central medical gases station

(more than 10 tanks, volume is not less than 50 l)

Hospital departments

Residential Houses

25 m

Warehouse for X-ray films (< 1000 kg)

Other

> 20 m

Hospitals and maternity houses

Residential buildings

> 30 m

OPD and WWC

Residential buildings

> 15 m

         In the territory of hospitals there should be the following zones:

1.              Zone of medical departments:  for the infectious patient, medical departments for noninfectious  patient, for pediatric departments, for patrimonial houses and maternity departments, psychosomatic departments, dermato-veneralogical departments, radiologic departments

2.              OPD and administrative zone

3.              Garden zone

4.              Zone of court yard

Separate entrances to the various hospital zones should be provided. For emergencies they provide “Ambulance Road” – the entrance and exit for ambulance should create one-flow driving in and out of the hospital department area.

          The patologo-anatomic departments with a funeral zone should be isolated from ward departments and they should not be looked through windows of the departments, from the hospital garden, and also through windows of inhabited and public houses.

          Distance between houses with windows of chambers has to make 2,5 heights of opposite house, but not less than 24.

          Infectious, maternity, psychosomatic, dermatovenerologic and the children's departments of hospitals should be placed in the separate houses. If hospital has the out-patient department, the last should situate close to periphery of a site.

          Before front entrances to the hospitals, polyclinics, SES, dispensaries and the maternity houses they are provided grounds for the visitors by the account 0,2 m2 per one bed or per one visit on duty, but not less than 50 m2. Parking area for a vehicle of institutions, employees and visitors should be placed not closer than 100 from ward departments. The temporary parking of a vehicle of individual usage should be placed on distance not closer than 40 m from the entrance to the hospital.

          In territory of infectious hospital (department) should be allocated a "clean" and "dirty" zone isolated by one from one strip of green plantings. On departure from a "dirty" zone there should be stipulated platforms for desinfection of transport.

         Buildings of out-patient  institution as rule do not have more than 5 floors.

         The departments of children's hospitals for children till 3 years with the mothers should be placed not above than fifth floor, the chambers for infants and children's psychiatric departmentes - are not higher than the second floor.

         Cleaning of territory has to be carried out daily. For collecting of wastes and household dust they establish containers with covers. These containers should be disinfected and washed properly. Distance between a ground for dust container and ward and medical-diagnostic departments should be not less than 25 m. They should dispose waste from containers every day. Specific (postoperation, patologo-anatomic and other) medical waste should be incinerated in special furnaces.

         Planning of medical and maternity hospitals have to provide optimum sanitary - hygienic and antiepidemic modes and conditions of  patient stay, work and rest of the personnel.

          Structure of institutions and planning of its premises have to exclude an opportunity of crossing or another contact of "clean" and "dirty" flows.

Maternity houses - specialized stationary institutions, which provide health care for pregnant women in childbirth, recently delivered women, newborns, to the gynecologic patients (at presence  of gynecological department).

         They offer to place in basement of medical-diagnostic departments warehouses, sanitary - household premises for the personnel (wardrobes, shower-room), sanitary care unit, buffets and restaurants for the personnel, central laundry, premises for collecting and sorting of a dirty linen, premises for desinfecting of bad pans, oil-clothes and beds, premises of preservation, regeneration and heating of a medical muds; storehouse of radioactive dross and linen polluted with radioactive substances.

         It’s forbidden to place medical-diagnostic departments, workshops using hazardous materials and reception wards in basement of hospital.

         X-ray rooms and laboratories of radiodiagnostic should not be adjacent on a horizontal or vertical with chambers for the pregnant woman and children. It is forbidden to place x-ray studies under premises of shower, lavatories and other possible sources of water.

         Premises of hospitals, maternity houses and others should be illuminated by day light. The illumination by the second light or only artificial illumination is used in premises of barns, toilets, bathrooms, enema room, rooms of personal hygiene, shower and wardrobe rooms for the personnel, thermostate, microbiological banks, preparation and operational, apparatus, narcosis, photolaboratories and some other premises which do not require natural illumination. Operation room projected with natural illumination, it is necessary to focus on the north.

         The corridors of ward sections (departments) should have natural illumination. Distance between light pockets should not exceed 24 m, and between the first light pocket and window in the dead end of the corridor – 30 m.

          For protection from blinding actions and overheating in summer time from direct solar rays in medical stationary located in 3 and 4 climatic areas aperture wrapped up on sector of horizon 70-240º of northern latitude they have to use solar protection equipment.

Table 7.3 Window orienting in the hospitals

Premises

Geographic latitudes

 45° N

45 - 55° N

> 55° N

Operation, IT wards, delivery room

N, NE, NW

N, NE, NW

N, NE, NW, E

Laboratories

N, NE, NW, SE, E

N, NE, NW, SE, E

N, NE, NW, S, SE, E

TB and Infection wards

S, SE, E, NE, NW

S, SE, E, NE, NW

S, SE, SW, NE, NW

Children departments

NO: W

* — not more than 10% of all beds

          The artificial illumination should answer assignment of a premise,  be sufficient, regulated and safe, to prevent the dazzling and other adverse influence on the human organism and internal hospital environment.

          The general artificial illumination is necessary stipulated in everything, without exclusions, premises. For illumination of separate functional zones and workplaces, they use local illumination.

          The artificial illumination of hospital premises is provided with luminescent and bulb lamps.

We use combined lighting (general and local illumination) in the hospital wards. In one-bed chambers the general illumination is provided. In chambers of children's and psychiatric departments, intensive therapy, the reanimation, in postoperation chambers they provide only ceiling fixtures of general illumination. For night shifts they use lamps in niches near doors

          The emergency illumination is provided at dressing, manipulation, procedural, ATS, assistant, drugstores, reception wards, laboratories of the urgent analysis, X-ray-operation room, and on the nurse stations.

Table 7.4 Artificial lighting of hospitals

 

Premises

 

Ålx

 

max. coef. cf pulsation

%

Max. admissible discomfort index

Environment

Operation room

400

10

25

 

Delivery room, IT wards

500

10

25

 

Pre-operation room

300

10

25

 

Examination rooms (SURG, OB/GYN, PED, INF, DERM/VEN, dentists)

500

10

25

 

Other examination rooms

300

10

25

 

Offices

300

10

40

 

Telemetry, endoscopy, physiotherapy departments

150

10

40

 

Spa therapy

150

20

60

humid

HBO ward

150

20

60

Fire-dangerous

X-ray room

50

-

40

 

Children departments

150

10

25

 

Mental hospitals

100

10

25

 

Other wards

100

10

25

 

Laboratory

300

10

40

 

         All hospitals should be equipped by centralized water supply, ssewege system, ventilation (if it’s necessary  - by systems of air conditioning), rubbish-collector with rubbish chamber, elevators as needed, electrical and telephone networks. If necessary they use centralized vacuum rubbish collectors and other equipment.

 

Fig. Hospital

 

 

Fig. General plan of hospital

The site land project of the patient care institution includes the following zones:

-         a zone of the patient care buildings for non-infectious patients;

-         a zone of the patient care building with infectious diseases;

-         a polyclinic zone;

-         a zone of morbid anatomical department;

-         a household zone;

-         a landscape zone.

The infectious, obstetric, children’s, tuberculosis and psychiatric departments should have separate landscape zone of their own.

The hospital site housing density depending on the amount of beds should not exceed 10 – 15 %. Up to 60 – 65 % of the area should be occupied by all kinds of green area; 20 – 25 % - a household zone, passages and passageways. The size of the landscape zone should be not less than 25 m2 per one bed.

The distances between the hospital buildings should be the following:

-         between the walls with wards and doctors’ rooms windows – 2.5 of the opposite building height but not less than 25 m;

-         between the radiological building and other ones – 25 m;

-         the morbid anatomical building and a household one – at the distance of 30 m from other buildings, residential including;

-         between the buildings’ flanks – not less than 30 m, from the polyclinic, women’s consulting center and health centre – not less than 15 m.

The admission department for somatic patients (in the central building) and the rooms for the patients’ discharge should be joined together and should include: the examination room, sanitary inspection room, the wards for temporary admitted patients’ stay, the resuscitation and intensive care room, sometimes – the X-ray room.

There should be separate admission and discharge departments for the children’s, obstetric, infectious, dermatovenerologic, tuberculosis and psychiatric departments.

The admission departments areas depend on the amount of patients supposed to be admitted during 24 hours.

The sanitary inspection room is planned according to the current principle and consists of: the examination room, cloakroom, bath-and-shower room, dressing room.

In the infectious, dermato-venerologic and tuberculosis departments the admitted patient’s clothing is referred to the disinfecting department which is situated in the separate building within the household zone.

The laundry, central nutrition unit, boiler-room, garages and other hospital premises are also situated within the household zone.

 

HYGIENIC REQUIREMENTS CONCERNING HOSPITAL DEPARTMENTS

 

Each hospital department is intended for patients with similar diseases. It should include: ward sections for 25–30 beds, with 6–8 wards for 2–4 beds with the area of 7 m2 per bed, not less than 2 wards for 1 bed with the area of 9-12 m2 for severe somatic and infectious patients, with the cubic capacity of 20-25 m3 for each patient and the ventilation volume – 40-45 m3/hour. Except the wards in the ward, sector there should be a room for patients’ day-time stay (area of 25 m2), glazed verandah (30 m2), and medical accessory premises: the doctor’s room (8-9 m2), the procedure and manipulation room (12-15 m2), the medical nurse’s station (4 m2), and in the surgical departments sections – dressing rooms (pure and purulent). Besides, there should be a bar with a canteen (for two ward sections with the area of 18 m2), a room for clean and dirty linen (each of 4 m2), a lavatory with a bathroom (10 m2), a lavatory for patients and for personnel, a sanitary room (6-8 m2), and a corridor. There can be two types of the corridor: a side one with windows facing towards the Northern points, or a central – with light gaps (halls).

The optimal ward windows orientation in the Northern hemisphere is the South-East or South. But there should be 1-2 wards with the orientation towards the Northern points for severely ill patients or patients with fever. Beds should be located parallelly to the light conductive wall for a patient to be able to turn back from the dazzling effect of the direct solar radiation. The natural lighting indices (near the internal wall) should be the following: the daylight factor – 1,3-1,5 %, the lighting coefficient – 1:4-1:6, the angle of incidence – not less than 27°, the angle of aperture – not less than 5°, the coefficient of depth of premises – not more than 2. The artificial lighting should be general, 30-60 lux, and the night light – 10-15 lux with lamps in the lower part of the walls.

The wards ventilation should be achieved by means of exhaust ventilation ducts, presence of window leaves and windows which can be opened; the modern hospitals should be equipped with air-conditioners.

In the infectious diseases units the following rooms should be equipped: box wards (with every bed isolation), semi-boxes (the isolated wards with common lavatory and bathroom), and absolute boxes (the isolated wards with lavatory and bathroom).

The operating block of a surgical department should be situated in the blind-ended projection or in the separate outhouse of the hospital. In the operating block there should be following rooms: the operating room – 30 m2 (on the basis of 30-50 surgical beds in the department; for the complex operations – 40-45 m2), the pre-operating room – 10-12 m2, the sterilizing room (one for two operating ones), the anesthetic room – 15 m2, the instrumental room, the surgeon’s room (for protocols), the laboratory of the express tests, the plaster dressing room, the room of the mobile diagnostic, resuscitative apparatuses and the anesthetic equipment, the premises for the sterile and used operating linen, the washing and shower room for the operating brigade, the postoperative resuscitative wards, the lavatories for personnel, the operating nurse’s room and others depending on the surgical department type.

In the surgical departments there should be pure and purulent dressing rooms.

There are some peculiarities of the children’s departments and hospitals, tuberculosis, psychiatric and other specialized patient care institutions’ planning; they are explained in the normative documents and can be learned if it’s necessary.

 

A regional hospital for 510 beds with a polyclinic for 1 000 visitors per shift*

(the project is worked out by the chair)

An explanatory note

A regional hospital group of buildings for 510 beds with a polyclinic for 1 000 visitors per shift is a center of providing population with a high qualified medical assistance; it is obliged to serve the district town and the district itself with a population of up to 100 thousand people taking into account other existing district hospitals.

The group of buildings consists of central building for 450 beds (9-storey one), the infectious one for 60 beds, the polyclinic or out-patient building (2-storey one) and accessory premises (1-storey building).

The polyclinic for 1 000 visitors per shift should provide the medical assistance to the population of up to 40 thousand and to provide them with the medial consultations.

The hospital is an organization, methodical and consulting centre for the patient care institutions of the entire district.

The hospital comprises 10 departments which are listed below.

The treatment and accessory premises of the hospital comprise the central building, the intensive care unit, the rehabilitation, X-ray, admission and administrative departments; there are the operating block and the clinical diagnostic laboratory. This project can be used within the I-B, II and III climatic zones.

To build the hospital group of buildings, a site with area of 7.3 hectares is required.

The hospital territory is divided into the following zones: the in-patient, the out-patient buildings (polyclinic), the infectious diseases unit, the household and accessory premises and landscape area (see fig. 44.1).

The central building departments should occupy the next floors:

1st floor – the obstetric department, the children’s department for 30 beds for the children till 1 year old, the admission department and the central hospital entrance;

2nd floor – the rehabilitation, obstetric and children’s (for 30 beds for children till the age of 6) departments ;

3rd floor – the rehabilitation, intensive care and children’s (for 30 beds for children after the age of 6) departments;

4th floor – the therapeutic department consisting of 2 sections for 30 beds and rehabilitation (5th floor – the neurological department for 30 beds, the therapeutic section for 30 beds and the X-ray department;

6th floor – the functional diagnostics department, the gynecological department consisting of 2 ward sections for 30 beds;

7th floor – the chemist’s shop, the otolaryngological department for 30 beds and the ophthalmologic one for 30 beds as well;

8th floor – the surgical department consisting of 2 ward sections for 30 beds and the clinical diagnostic laboratory;

9th floor – the trauma unit for 30 beds and the operating block

*The chair can prepare another variant of the study (or real) project of the hospital institution.

The treatment and diagnostic departments are situated on each floor near the in-patient departments and are interconnected with them.

The ward sections have a short main corridor, lighted on each side. At the place where the corridors are crossed there should be projected halls of the day-time stay and the nurses on duty stations .

The infectious diseases unit for 60 beds is projected in the U-shaped 1-storey building, where the boxes’ section for 30 beds (one flank) and the semi-boxes’ section for 30 beds (another flank) are situated.

The morbid anatomical department is projected in the separate isolated building.

The household block is projected as an isolated building and household yard where central heat post, boiler house, garage, workshop, laundry and nutrition unit are located.

The hospital is projected in the skeleton bearing-wall constructions of II-04 series.

The hospital buildings are provided with the central water heating system, the tidal-exhaust mechanical ventilation, hot water supply from the boiler room, the electricity supply from the transformer substation and low current from the district telephone station and internal ATS.

 The quality of water has to allow State Standard "Drink water". The system of hot water supply is projected with circulation.

         Table 7.5 Hygienic requirements for water supply (daily needs)

Health facility

Cold water

Hot water

OPD

15 l per1 visit

 

Hospitals:

- rural

- town

 

150 l per bed

250 l per bed

 

 

150 l per bed

Infection & TB hospitals

250 l per bed

250 l per bed

Spa therapy

- bath

- subaquatic bath

- shower

- hydropathy unit

- hydro massage

- vertical extansion bath

500 l per bed OR

900 l per hour

700 per hour

200 per hour

3000 per hour

500 per hour

800 per hour

 

For waste treatment from hospital catering service in hospitals they establish fat-catching device. The treatment of waste from hospitals including infectious is carried out by municipal sewer system. At absence of municipal sewege systemthey use system of local waste treatment.

          For all health facilities should be provided reserve (emergency) hot water supply. They could use electrical boilers or second input of hot water supply. For heating it’s used water heating system with maximal water temperature in heating devices 85oC (Using water steam heating in the hospitals is prohibited).

         The heating radiating concrete panels can be used in following premises: operation, preoperation, resuscitation wards, narcosis, delivery, premises of electrolight treatment, psychiatric departments of hospitals, therapy rooms, rooms for premature babies, injured children, little children and newborns infection wards, combustiological wards, complete and incomplete boxes, premises of blood bank, storerooms for sterile materials and medications, x-ray rooms, laboratories and experimental - biological clinics (vivaria).

          The toilets for the patient should be equipped with cabins, hangers, drying devices for hands, mirrors. In lavatories of female ward sections there should be equipped cabins of women hygiene with ascending shower (bidet).

          The quantity of sanitary devices (toilet pans) for the patient in ward departments of hospitals should be accepted at the rate of  1 device per 15 men and per 10 women, but not less than 1 device. The quantity of pissuare in male lavatories has to equate to quantity of another sanitary devises. The sizes of lavatory cabins for the patient should be not less than 1,5 (1,1) m with obligate opening of doors outside. In sanitary - household premises for the attendants it is necessary to accept:

1.     Quantity of sanitary devices for the medical staff - not less than 2 devices for the women and 1 device for the men; but not less than 1 sanitary unit on each department

2.     Quantity of shower cabins -  1 shower cabin per 10 employees in infectious and phthysiatric departments, in other departments - 1 shower cabin on 15 employees in the largest shift. If less number of the personnel it is necessary to provide 1 shower cabin on department.

         Lavatory for the patient in ward departments for hundicapped patients should have special equipment (racks, folding ), that the seriously ill patient can use of sanitary devices.

          The houses of medical and patrimonial houses should be equipped with systems of balanced ventilation, except for infectious departments. In the last should be established the exhausting ventilation. The exhausting ventilation from chambers has to be carried out through individual channels, which prevents of air movement by the vertical.

         They use exhausted from operational, narcosis, resuscitation, patrimonial and X-ray rooms, as a rule, from two zones: 40 %- from upper zone (10 cm. from a ceiling), 60 %- from the bottom zone (on 60 cm from a floor) in view of allocation in these premises of gases and steams, which can form explosive mixes, or difficult positively charged ions.

Ventilation systems in operation, narcosis, resuscitation, maternity and other wards with severe sanitary should be equipped with  bacterial filters.

Table 7.6 Hygienic demands to hospital environmnet

Premise

Air t°

AEH

AEH for natural air exchange

Germ pollution

 

GMN

Str.

Categoria of pureness

 

inlet

 

exhaustion

Before

work

 

Before

work

 

1

2

3

4

5

6

7

8

9

10

Adult and children wards

 

20°Ñ

 

80 m3/h per one bed

100%

 

2

 

 

3500*5000

 

 

to 16*

to 36

 

P

 

 

 

 

 

 

 

 

TB wards

20°Ñ

80 m3/h per 1 bed

2

 

—»—

 

—»—

D

 

80%

100%

 

 

 

 

 

 

Wards for hypothyreotic patients

24°Ñ

80 m3/h per 1 bed

100%

2

 

—»—

 

—»—

P

Wards for hyperthyreotic patients

15°Ñ

—— » ——

2

 

—»—

 

—»—

P

1-2 beds room, IT rooms, cobustiological rooms

22°Ñ

> 10 eph

-

 

—»—

 

—»—

VP

 

100%

 

80% - aseptic

 

 

 

 

 

 

80%

100% - septic

 

 

 

 

 

Operation room

22°Ñ

—— » ——

—»—

500

1000

 

< 4

VP

 

 

*1)

*2)

 

 

 

 

 

 

Delivery room

22°Ñ

—— » ——

—»—

750

2000

 

< 24

VP

 

 

 

 

 

(in delivery -1000)

 

 

 

Premature children wards

25°Ñ

:

—»—

500

1000

 

< 4

VP

 

100%

80% - aseptic

 

 

 

 

 

 

100%

100% - septic

 

 

 

 

 

 

Newborn wards

25°Ñ

—— » ——

—»—

 

3000

 

44

 

Boxes

22°Ñ

2,5 (from corridore) 100%

2,5

2,5

 

3500

7000

 

16

36

Á

Infection wards

20°Ñ

80 m3/h

80 m3/h

——

 

3500

7000

 

16

36

Á

Wards for patients with scarlet fever

20°Ñ

—— » ——

——

 

3500

 

75-100

Á

Sterilization rooms

18°Ñ

 

3

3 - septic

— -aseptic

2

 

2

 

 

 

 

Á

 

4

Dressing rooms

22°Ñ

2

2

2

750

1500

 

á³ëüøå 4 (äî 16)

4

Therapy room

22°Ñ

2

2

2

 

2500

 

32

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes:                   *   — summer / winter

                            *1) — 20% through neighbor premises

                            *2) — inlet with sterile air

 

Reception ward of hospital has following functional tasks:

        Reception, registration and distribution of patients

        Previous diagnostics

        The decision of a question about necessity of in-patient or out-patient treatment

        Sanitary treatment of patients

        Prevention of communicable diseases

        Shifting needed patients to other health facilities

        Discharging the patient and distribution of an information.

The number of patients are receipted by the reception ward depend on the number of beds in the hospital and its specialization::

        2 %  of beds number - in TB, mental and rehab hospitals

        15 %- in emergency hospitals and maternity houses

        10 %- in other hospitals.

The number of the patient flows should be accepted from the ratio:

        1 flow per 800 beds- TB and rehab hospitals

        1 flow on 600 beds- in mental hospitals

        1 flow on 150 beds- in emergency care facilities

        1 flow on 200 beds- others hospitals.

         For each flow in hospitals (excepting infectious, children and obstetric hospitals) they provide one examination room/box and one sanitary treatment unit. In infectious hospitals and infectious departments of general hospitals they provide reception wards with examination boxes, their quantity depends on quantity of beds in department:

        up to 60 beds - 2 boxes.

        100 -3 boxes

        more then 100 beds-by the formula X=3*x, where x - 1 additional box for every 50 beds of department.

The similar boxes are organized in children hospitals.

          In obstetric departments the reception premises (examination room, sanitary treatment unit) should be provided as combined for physiological department and department of a pathology of pregnancy and separately for observation and gynecologic departments. The movements the patient of all departments, including stairs and elevators, should be isolated one from one.

         If it’s necessary they organize traumatological shifts, their offices should be placed on the ground floors of houses.

          For reception of the infectious patient they provide isolator room which connected to examination room of the ward.

         Ward department is the basic functional structural element of in-patient medical institutions. The basic types of ward departments is: noninfectious department (for adult and children) and infectious departments, maternity department

          If children departments has 60 or more beds they should be placed in separate buildings. Infectious and TB departments are placed only in separate buildings.

          Ward department consists of ward sections and general premises located between the sections. The general premises include the medical and diagnostic offices, catering service premises etc.

          The ward section represents the isolated complex of rooms and medical-auxiliary premises providing care for patients with homogeneous diseases. The quantity of beds in ward section, as a rule, is not less 20 and no more than 30 (except for psychiatric).

          The quantity of 1 bed rooms in observation obstetric department, department of a pregnancy pathology and also in hematological, neurosurgical and urologic departments for adult persons and children should be not less than 15 %, and in others departments - not less than 7 % of quantity of beds in department.

          The quantity of 2 beds rooms  in the specified departments has to make not less than 15 %. In all other departments project not less than two 3 bed rooms in each section.

The  best ratio is 20%of one-bed, 20% for two-bed and 80% for three and four-bedrooms.

In infectious stationary basic structural unit of ward department could be not  a ward, but complete or uncompleted box or boxed room. Boxes provide a complete isolation of the patient. There are 1-2 bed boxes using in Ukraine.

Isolator has two exits: to the department and to outdoor environment. The patient never leave  Isolator through the department door, they pass only through external exit with tambour. The access of the medical personnel to Isolator is provided from a "conditionally clean" corridor through sluices, where medical staff should change their gowns, wash and disinfect hands. The doors in the sluices should be placed on the slanting line. Isolator department have the largest maneuverability and carrying ability, it is important for small departments.

Incomplete Isolatores distinguish from boxes  because they have no an external exit. They also are provided on 1 and 2 beds. The mode  of non- Isolator department differs from boxed one by that the patients are brought in incomplete isolatores through a general corridor department. In isolator departments it is recommended to use 25 % of all beds in isolatores per 1 bed, other - in 2 bedsisolators. In everyone ward section should be provided two incomplete boxes on 1-2 beds.

In noninfectious departments for children  older one year and for adults they use rooms having not more than 4 beds. Capacity of rooms for infants, and also for newborns in observation obsteric department should be not more than on 2 beds each.

Recommended percent of boxes in section for children younger 3 years is 100 %.

          At presence of the gynecological departments in structure of health institution it should be isolated from obstetrics and other “clean” departments. Women in the childbirth and pregnant women are divided into 2 flows in the filter of reception department . One  flow is made  by women in childbirth and pregnant women, which are directed at department of a pathology of pregnancy and physiological department, other - in observation department.

The reception in observation department of the maternity house is for the pregnant women and women in the childbirth who have:

        a fever (temperature of a body 37,6 o and more without other expressed symptoms)

        long waterless interval (waters break in 12 and more  hours before the reception in hospital)

        trombophlebitis of any localization (acute or chronic form in a stage of an exacerbation)

        inflammatory diseases of kidneys and urine tracts (acute stage, an exacerbation of chronic process during pregnancy, symptomless bacteriuria- 100000 CCU/ml and more)

        signs of any urogenital infection  (colpitis, cervicitis,  choriamnionitis etc)

        clinical or laboratoric data about TORCH infection (TORCH - toxoplasmosis, rubeola, cytomegalovirus, herpes, listeriosis, veneral diseases (STD))

        intrauterinal death of fetus

        acute respiratory disease (influenza, tonsillitis), signs of inflammatory diseases (pneumonia, otitis)

        skin diseases of infectious ethyology

        Tuberculosis (closed forms of any localization at absence of specialized hospital). (Pregnant women and women in the childbirth with the open form of a tuberculosis are should be hospitalized in the specialized maternity houses (department); if there are not presented  - in boxes or isolators of observation department with the following transferring in tuberculosis dispensary)

And also:

        skin diseases (noninfectious)

        at absence of the medical documentation

        for an abortion on medical and social indication in ²² the period of pregnancy

        malignant tumors

        women have the anomalies of development of a fetus, which revealed during pregnancy (at absence of specialized hospitals)

        women in the childbirth (in terms 24 hours after deliveries in case of childbirth outside of medical institution)

They transfer the pregnant women, women in the childbirth and women recently delivered if these women have:

        increase of temperature of a body 38oÑ and higher (at three times measuring)

        fever with not clear genesis (temperature of a body up to 37,5oÑ), that lasts more than 1 day

        postpartum inflammatory disease (endometritis, mastitis, wound infection ò. ³.)

        extragenital infectious diseases which do not require transferring in specialized in-patient department (ARVI, herpes etc.)

          The pregnant women, women in the childbirth  and women recently delivered, which suffer on infectious diseases, are subject to hospitalization and transferring in the appropriate infectious hospitals. The observation department should be placed or in the separate house, be isolated, above it there should not be an obstetric department.

          At presence of gynecological department to it the separate reception is provided. Gynecologic department is necessary completely isolated from obstetric departments.

The operational block

          The operational block is structural unit of hospital using for surgical operations.

          The operational blocks are divided into general and specialized (traumatologic, cardiologic, neurosurgical). By an attribute of presence one department (aseptic) or two (aseptic and septic) operation room are divided on aseptic and combined.

          The operational block has such functional zones:

 ². The sterile zone: an operational room

²². A zone of restrictions

        group of premises for preparation to operation: preoperation, wardrobe for overalls, narcosis room,

        group of premises for the equipment: apparatus room (AABC, hypotemia)

        group of premises of postoperation wards

        group of auxiliary premises, which contain also sluice at an entrance to operational room

²²². A zone of the limited access:

        group of premises for diagnostic researches

        group of premises for preparation tools and equipment for operation: sterilization, instrumental-material (instrumental-financially)

        group of premises of the personnel: offices of the surgeons, office of the doctor - anaesthesiologist, room of the nurses-anaesthesiologists, room of attendants

        auxiliary premises: sluices at an entrance in septic and aseptic of department, room to the central board, plasters ³ and that similar

        warehouse premises:  blood bank etc

 

Fig. The operational block

 

          It is necessary to accept quantity operational in CR, interregional and urban regional hospitals: 1 on everyone 30 beds to a surgical structure and 1 on 25 beds in hospitals of emergency care. The ratio of septic and aseptic operational in operational blocks of general hospitals is necessary 1:3, but it is not less than one septic operational room per block.

          The quantity of beds in post-operation ward is accepted as 2 bed per operation room. At presence of departments of anaestasiology and reanimation or the reanimations and ²Ò department, postoperation wards are not provided, and their quantity is taken into account of beds of department of anaestesiology and reanimation.

         Postoperation room are being placed in separate isolated section at the operational block, or in structure of branch anaestasiology and reanimation or the reanimations and ²Ò department or it's isolated in structure of surgical department.

          For maintenance of free transportation the patient width of door apertures is necessary to be not less than 1,1 m. A floor in operation room should have antistatic covering. The ventilation in operation and dressing room provides conditioning of air. Than inflows of air from system of conditioning - in the top zone of a premise (is not lower 2,5 from a floor), exhaustion - from two zones: top and bottom (0,4 from a floor). Air, which is showed in operational has to be cleaned with  the bilaterial circuit (rough and thin clearing).

For control on the hospital environment they use following indicator of air pureness:

        Oxygen: 20-21 %. Very stable size, does not decrease even at intensive consumption (restoration for the infiltration).

        Carbonic gas:

        · very clean air < 0,05%

        · rather clean air < 0,07%

        · satisfactorily clean air < 0.1%

        Dust pollution:

        It is no more than 500 particles in 1 cm3

        ·clean air < 0,1 ìã/ì3

        dirty air > 0,15 ìã/ì3

        Oxydation of air:

        clean air - up to 6 mg Î23

        · is moderate - polluted - up to 10 ìã Î2/ì3

        · dirty - up to 12 ìã Î2/ì3

Hospitals produce about 230 kg of sold wastes per bed annually (0,63 g/day). Nowadays they use for waste treatment in the hospitals some modern schemes:

In canalized dwelling place there are:

1.     complex of local treatment units with thermal decontamination in liquid and solid phase of waste. It has high effectiveness of decontamination. Power is about 100 m3/day

2.     complex of local treatment units with septic-dehelminthizator. (25 m3/day)

3.     complex of local treatment units with a septic (25 m3/day)

4.     complex of local treatment units with the contact defenders (10-15 m3/day)

5.     complex of local treatment units with a 2-level septic (100-150 m3/day). It's used in Odessa infectious hospital, for example.

6.     complex of local waste buildings with a aerotank of continued aeration and mechanic aerator (400 (!) m3/day)

7.     complex "Rapid Lock" (to 840 (!) m3/day)

8.     complex of local treatment units with circular oxygenation channel (COC). It's used for waste treatment of tuberculosis hospitals if volume of waste is up to 700 m3/day

9.     complex of local treatment units with emsher and biofilter. They use it for waste treatment of tuberculosis hospitals if volume of waste is up to 500 m3/day

10. complex of local treatment units with septic and biofilter ( for small tuberculosis hospitals, waste to  50 m3/day)

For canalized areas they use:

11. complex of local treatment units with ground fields of filtration (irrigation). The scheme are being used if volume of wastes is 50-100 m3/day and there is sandy soil.

12. complex of local treatment units with underground fields of filtration. Waste pipes (drenas) is placed on the depth 3 m, loading is about 15-20 l/day The scheme are being used if volume of wastes is 50-100 m3/day

13. complex of local treatment units with sand-gravel filters

14. complex of local treatment units with filtering trench

For waste treatment in tuberculosis hospitals they use two-stages of biologic purification.

Fig. Ward section of teraputic department

 

Fig. Ward section of children department

 

Fig. Ward section of infection department

 

 

 

Fig. Typical ward section

 

You know that on the hospital area they provide some functional zones. The infectious departments should be isolated from non-infectious. The currents of movement for "pure" and "dirty" (suspicious for communicable diseases) patient should be also isolated from each other according to a principle of one-way flow. It’ very important how departments are distributed by the floors. Departments requiring aseptic conditions (surgical, maternity, neonatological) should be placed on the first floors of a hospital building. At the arrangement of operation - reanimation complex septic operations have to be placed above aseptic. In infectious cases of departments intended for hospitalization of the homogeneous patients they place them by the floors, thus the most contagious patients (with aerial infections) are placed in the top floors.

            Sanitary - antiepidemic measures provide health promotion activity among the patients and personnel, monitoring of an epidemic situation, including revealing vira- and bacteria carriers. With this purpose the system of the previous and periodic (current) medical surveys is introduced. So, pupils of medical schools, the students of medical high schools during  practice should pass obligatory physical examination with participation of physician, dermatovenerologist, they have to make fluorography (if this research was not taken during the previous 6 months), analysis feces on carriage of intestinal infections and helmints eggs, and the persons are more senior than 18 years - on HIV, RW and urethral (for women also vestibular and vaginal) smear on Neisseria gonorrhoeae.

          Before practice in maternity houses, newborn wards, children's hospitals (departments), surgical departments etc. it is necessary to pass inspection of stomatologist, otholaringologist with an obligatory capture smears on staphylococci tests (from a nose and fauces)

          Prior to the beginning work in maternity houses, children's hospitals and other MPI medical workers should to pass inspection including fluorography (6 months), RV and tests on gonorrhea, analysis on HIV they repeat every year, carriage of pathogenic staphylococcus and RW -too, tests on gonorrhea and analysis on HIV - 1 time per 6 months, on carriage - 1 time per 6 months will be carried out.

All hospitals should be supplied with a linen - accordingly of sheet of equipment at enough. Change of a linen by the patient should be carried out in process of its pollution, regularly, but not less once for one week. Polluted linen should be changed immediately. The change of bed-clothes for delivered women should be carried out 1 time per 3-4 days, body linen and towels - daily, under napkins - by the necessity. Change of a linen by the patient after operation should be carried out regularly to the discontinuance of exudation from wounds.

In maternity hospitals (patrimonial blocks and other premises with aseptic mode for newborn) should be used a sterile linen.

          The temporary (not more than 12 hours) preservation of dirty linen in departments could be provided in the shut container (metal, plastic boxes, dense boxes, and other capacities, which are subject of disinfecting). For work with a dirty linen the personnel should be supplied sanitary clothes (dressing gown, cap, mask, glove).

The clean linen should be stored in the special premises, deduced for it. In departments they should have a daily stock of a linen. Linen and container should be marked.

The washing of a hospital linen should be carried out by centralized way in special laundries at the hospitals. The washing of a linen in medical institutions is carried out in conformity with the instruction on technology of processing of a linen of medical establishments at factories – laundries.

The washing of hospital linen in urban municipal laundries on a condition of allocation on them of special technological lines is supposed which exclude an opportunity of contact of hospital linen with not hospital. The linen in infectious, observation and purulent - surgical departments before washing should give in disinfecting in special premises by processing of disinfecting solution in washing machines.

After recovery of the patient, his death, and also for the prevention of pollution a mattress, pillow, the blankets should be changed and a disinfected.

At the reception ward all in-patients will pass special sanitary processing in acceptance branch (acceptance soul or baths, the cutting of nails and other procedures) by the necessity. It depends on results of the examination.  They give to each patient soap and wiping  bast for personal use. After sanitary care the complete set clean body linen, pajamas, shoes (slippers) is given out to the patient. They keep the personal clothes and the footwear for safety in special container with hangers (polyethylenic bags, covers with a dense fabric etc.) or it is transferred to preservation to its relatives or familiars.

Washing of the patient is carried out not less than 1 time per week with marking in the case history. Hygiene of the seriously ill patients (washing, wiping of a skin of the person, parts of a body, rinsing oral cavity etc.) will carry out constantly after the meal and at pollution of a body. It should be organized a hair dressing and shaving for the patient. Each patient should be supplied with a personal towel and soap. 

The serving medical personnel of hospital, patrimonial houses and other medical institutions should be supplied complete sets of the replaceable worker (sanitary) clothes: dressing gowns, caps, replaceable shoes (slippers) in quantities, that provides daily change sanitary clothes. All medical personnel of medical or patrimonial institutions have to be faultlessly tidy and accurate, edge of the worker (sanitary) clothes should completely close personal (home) clothes. The hair should completely be covered with caps. Change of footwear of the personnel of operational, patrimonial blocks, resuscitation, dressing rooms and newborn departments should be with non-fabric material, suitable for desinfecting.

The doctors, nurses should wash hands before the examination of each patient or performance of procedures, and also after "dirty procedures " (cleaning of premises, change of the patient linen, visiting of a lavatory etc).

 

HOSPITAL SYSTEMS

The development of the internal market and creation of trusts has produced incentives for hospitals to plan on the basis of maximising the role and status of the individual trust. We have, however, observed over the past two years an increasing trend for groups of hospitals to work more collaboratively, and a softening, or even abandonment, of the competitive ethos, in line with the government's white paper The New NHS.6

The result of this is that the type and range of options that are considered to be available change when the objective is how to plan for an area where a number of hospitals form a potential network of complementary provision, rather than how to compete. Joint plans are increasingly likely to be followed by mergers, the ultimate surrender of individual aspirations to the collective will. The recent acute strategy for Scotland is an early example of what seems to be a growing trend towards planning on a system-wide basis.

This development reflects the view that some services must be organised on a scale larger than any one hospital, for some services for populations as large as one million. However, as the Calman Hine report recognised for cancer care, the amount of evidence bearing on such large scale issues is limited.7 Furthermore, neither the Calman Hine report nor the Scottish strategy report8 adequately deals with the relation between services organised in this way, as they do not allow for the impact of their proposals on the way other services are provided---even though the same staff and facilities may beinvolved. 
The wider system

Both the demands placed on hospitals and their efficiency as providers depend on the nature and effectiveness of community based services such as rehabilitation facilities and out of hours cooperatives formed by general practitioners. They also depend on the way in which potential users, particularly of emergency services, decide whether and how to access care. Although the phrase "whole systems approach" has now found its way into official documents, virtually no research has been commissioned at the "whole system" level. 
Staffing and medical specialisation

One of the most powerful factors making for change in hospitals has been increasing medical specialisation. As the recent review by the York Centre for Reviews and Dissemination9 and Posnett's article in this series10 have shown, high quality evidence on the benefits of this process of centralisation and specialisation is limited. Nevertheless, the recent recommendations for hospitals by the BMA and the Royal Colleges of Physicians and Surgeons envisage a continuation of this process.11 Furthermore, the colleges are issuing guidance that will put managers in a position in which they will have to close or reduce the role of some hospitals.

This is in direct opposition to the high value placed on access by the public, and unless models can be developed to overcome this it is possible that the accountability of the colleges will be questioned, and they may come into direct conflict with politicians. The problem is particularly acute in more rural areas, where even the revised minimum populations suggested in the most recent document by the BMA and the royal colleges may be hard to achieve. A compromise will need to be developed between the requirements of education and training and the development of local services, and some hospitals may not be able to continue to function as educational establishments responsible for training junior doctors.

Changes in the way that hospitals provide care have implications for clinical training and the working environment of clinical staff as well as for future staffing requirements, and vice versa. Because responsibility for these different areas is divided among the professions, training organisations, the Department of Health, and the NHS Executive, the links between them have been persistently neglected.

The results of this are apparent in the current crisis in the recruitment of nursing staff. Although many other factors play a part, one element is the lack of research on the number and type of nurses that hospitals require and the contribution of nursing to patient outcomes. 
The research agenda

The previous sections have focused on the areas where we believe that more research is required. Two general points need to be made.

Firstly, research relevant to hospitals has tended to concentrate on single interventions and less frequently on some models of service delivery such as hospital at home. It tends not to address issues about the planning of whole systems, and it is rare for the results of hospital reconfiguration to be evaluated. Although there is a requirement for large capital schemes to be evaluated after completion, this does not seem to happen routinely, and where such evaluations are carried out the results are often not in the public domain. Politicians and policymakers may find the critical evaluation of previous decisions uncomfortable, but unless it is carried out mistakes will be repeated and there will be no collective learning within the NHS about how to plan such schemes.

In the past, funding to support this type of research has been limited. The new research into service delivery and organisation to be commissioned by the NHS Executive offers the potential for many of these areas to be investigated.

Even though this initiative is welcome, it will not be enough. An additional problem is that the time lag in implementation means that evaluation may become history rather than research and, given the pace of change, the past may not be a reliable guide to the future. No substantial sources of funding have been available to support this type of research. Moreover, many of the questions for which planners, managers, and policymakers need answers are not easily answered with traditional methods of research into the health service.

Secondly, new research techniques are required to support planning for the hospitals of the future, including the development of scenario planning and modelling, and simulation techniques to identify uncertainties and the sensitivity of plans to forecasting errors. There should be more evaluation of completed plans and much better systems to exchange knowledge about innovations. Some nationally led experiments are also needed---in the development of service models---for example, for rural areas where the trends referred to above are undermining existing patterns of provision.

Little research has been done that highlights the central issues of hospital planning: how many hospitals we need, what services each should offer, how they should relate to each other, and how, once these issues are resolved, they should be organised, staffed, and managed. http://www.bmj.com/cgi/content/full/319/7221/1361

Plans for the future of hospitals need to recognise our lack of knowledge, and, if there is to be central guidance, this should be that whatever is planned should be robust in as many possible futures as are conceivable. Research should be directed at understanding how flexibility can be incorporated into hospital design at low cost. In this respect there is perhaps some reason to be concerned about the impact of the private finance initiative. These schemes will have fewer beds but may not incorporate design ideas that allow flexibility since, in many cases, the costs associated with the planning will fall on the NHS.

This failure of research reflects a larger failure to take the planning of hospitals seriously, which has been particularly marked since regional health authorities were abolished. Although geographical variations rule out a "one size fits all" approach, we have identified a range of issues that require a central response. The professions have begun with the publication of a consultation document on acute hospital services to respond to this challenge.12 We can only hope that the Department of Health will do so too

HOSPITAL AND HOSPITALISM

The medicine is one of the most abundant spheres of labor activity of society. It calculates more than 170 medical specialties. In the system of public health services of Ukraine more than 200 thousand doctors are employed, including dentists, over 500 thousand of nurses.

DUTIES AND RESPONSIBILITIES OF EACH SERVICES

FUNCTIONS OF THE HOSPITAL

Hospital administration functions can be classified into three broad categories:

1. Medical - which involves the treatment and management of patients through the staff of physicians.

2. Patient Support - which relates directly to patient care and includes nursing, dietary diagnostic, therapy, pharmacy and laboratory services.

3. Administrative - which concerns the execution of policies and directions of the

hospital governing discharge of support services in the area of finance, personnel, materials and property, housekeeping, laundry, security, transport, engineering and board and the maintenance.

MAJOR FUNCTIONS OF THE ADMINISTRATIVE SERVICE

1. Provide service related to accounting, billing, budget, cashiering, housekeeping, laundry, personnel, property and supply, security, transport, engineering, and maintenance; and

2. Render support services to hospital care providers, clients, other government, and private agencies, and professional groups.

RESPONSIBILITIES

1. To plan, direct and coordinate financial operations of the hospital;

2. To prepare work and financial plan and provide fund estimates for programs and projects;

3. To manage the receipt and disbursement of cash/ collections;

4. To administer personnel development programs, policies and standards;

 

5. To give advice on matters affecting policies, enforcement and administration of laws, rules and regulations;

6. To procure, store, manage and issue the inventory and disposal of unserviceable hospital equipment and materials; and

7. To provide general services such as repairs and maintenance, housekeeping, laundry, transport and security.

NOSOCOMIAL INFECTION

 

An infection that can be acquired in a hospital. ABPA is a nosocomial infection.

Risk factors for nosocomial infection

·        Duration of hospital stay

·        Indwelling catheters

·        Mechanical ventilation

·        Use of total parenteral nutrition

·        Antibiotic usage

·        Use of histamine (H2) receptor blockers (owing to relative bacterial overgrowth)

·        Age—more common in neonates, infants, and the elderly

·        Immune deficiency

 

 

 

Invasion and multiplication of microorganisms in body tissues, as in an infectious disease. The infectious process is similar to a circular chain with each link representing one of the factors involved in the process. An infectious disease occurs only if each link is present and in proper sequence. These links are (1) the causative agent, which must be of sufficient number and virulence to destroy normal tissue; (2) reservoirs in which the organism can thrive and reproduce; for example, body tissues and the wastes of humans, animals, and insects, and contaminated food and water; (3) a portal through which the pathogen can leave the host, such as the respiratory tract or intestinal tract; (4) a mode of transfer, such as the hands, air currents, vectors, fomites, or other means by which the pathogens can be moved from one place or person to another; and (5) a portal of entry through which the pathogens can enter the body of (6) a susceptible host. Open wounds and the respiratory, intestinal, and reproductive tracts are examples of portals of entry. The host must be susceptible to the disease, not having any immunity to it, or lacking adequate resistance to overcome the invasion by the pathogens. The body responds to the invasion of causative organisms by the formation of antibodies and by a series of physiologic changes known as inflammation.





The spectrum of infectious agents changes with the passage of time and the introduction of drugs and chemicals designed to destroy them. The advent of antibiotics and the resultant development of resistant strains of bacteria have introduced new types of pathogens little known or not previously thought to be significantly dangerous to man. A few decades ago, gram-positive organisms were the most common infectious agents. Today the gram-negative microorganisms, and Proteus, Pseudomonas, and Serratia are particularly troublesome, especially in the development of hospital-acquired infections. It is predicted that in future decades other lesser known pathogens and new strains of bacteria and viruses will emerge as common causes of infections.

The development of resistant strains of pathogens can be limited by the judicious use of antibiotics. This requires culturing and sensitivity testing for a specific antibiotic to which the identified causative organism has been found to be sensitive. If the patient has been receiving a broad-spectrum antibiotic prior to culture and sensitivity testing, this should be discontinued as soon as the specific antibiotic for the organism has been found. It would be helpful, too, if the general public understood that antibiotics are not cure-alls and that there is danger in using them indiscriminately. In some instances an antibiotic can upset the normal flora of the body, thus compromising the body's natural resistance and making it more susceptible to a second infection (superinfection) by a microorganism resistant to the antibiotic.

Although antibacterials have greatly reduced mortality and morbidity rates for many infectious diseases, the ultimate outcome of an infectious process depends on the effectiveness of the host's immune responses. The antibacterial drugs provide a holding action, keeping the growth and reproduction of the infectious agent in check until the interaction between the organism and the immune bodies of the host can subdue the invaders.

Intracellular infectious agents include viruses, mycobacteria, Brucella, Salmonella, and many others. Infections of this type are overcome primarily by lymphocytes and their products, which are the components of cell-mediated immunity. Extracellular infectious agents live outside the cell; these include species of Streptococcus and Haemophilus. These microorganisms have a carbohydrate capsule that acts as an antigen to stimulate the production of antibody, an essential component of humoral immunity.

Infection may be transmitted by direct contact, indirect contact, or vectors. Direct contact may be with body excreta such as urine, feces, or mucus, or with drainage from an open sore, ulcer, or wound. Indirect contact refers to transmission via inanimate objects such as bed linens, bedpans, drinking glasses, or eating utensils. Vectors are flies, mosquitoes, or other insects capable of harboring and spreading the infectious agent.

Patient Care. Major goals in the care of patients with threatening, suspected, or diagnosed infectious disease include the following: (1) prevent the spread of infection, (2) provide physiologic support to enhance the patient's natural curative powers and resources for warding off or recovering from an infection, (3) provide psychologic support, and (4) prepare the patient for self-care if this is feasible.

Special precautions for prevention of the spread of infection can vary from strict isolation of the patient and such measures as wearing gloves, mask, or gown to simply using care when handling infective material. No matter what the diagnosis or status of the patient, handwashing before and after each contact is imperative.

Unrecognized or subclinical infections pose a threat because many infectious agents can be transmitted when symptoms are either mild or totally absent.

In the care of patients for whom special precautions have not been assigned, gloves are indicated whenever there is direct contact with blood, wound or lesion drainage, urine, stool, or oral secretions. Gowns are worn over the clothing whenever there is copious drainage and the possibility that one's clothes could become soiled with infective material.

When a definitive diagnosis of an infectious disease has been made and special precautions are ordered, it is imperative that everyone having contact with the patient adhere to the rules. Family members and visitors will need instruction in the proper techniques and the reason they are necessary.

Physiologic support entails bolstering the patient's external and internal defense mechanisms. Integrity of the skin is preserved. Daily bathing is avoided if it dries the skin and predisposes it to irritation and cracking. Gentle washing and thorough drying are necessary in areas where two skin surfaces touch, for example, in the groin and genital area, under heavy breasts, and in the axillae. Lotions and emollients are used not only to keep the skin soft but also to stimulate circulation. Measures are taken to prevent pressure ulcers from prolonged pressure and ischemia. Mouth care is given on a systematic basis to assure a healthy oral mucosa.



The total fluid intake should not be less than 2000 ml every 24 hours. Cellular dehydration can work against adequate transport of nutrients and elimination of wastes. Maintenance of an acid urine is important when urinary tract infections are likely as when the patient is immobilized or has an indwelling urinary catheter. This can be accomplished by administering vitamin C daily. Nutritional needs are met by whatever means necessary, and may require supplemental oral feedings or total 
parenteral nutrition. The patient will also need adequate rest and freedom from discomfort. This may necessitate teaching her or him relaxation techniques, planning for periods of uninterrupted rest, and proper use of noninvasive comfort measures, as well as judicious use of analgesic drugs.

Having an infectious disease can alter patients' self-image, making them feel self-conscious about the stigma of being infectious or “dirty,” or making them feel guilty about the danger they could pose to others. Social isolation and loneliness are also potential problems for the patient with an infectious disease.

Patients also can become discouraged because some infections tend to recur or to involve other parts of the body if they are not effectively eradicated. It is important that they know about the nature of their illness, the purposes and results of diagnostic tests, and the expected effect of medications and treatments.

Patient education should also include information about the ways in which a particular infection can be transmitted, proper handwashing techniques, approved disinfectants to use at home, methods for handling and disposing of contaminated articles, and any other special precautions that are indicated. If patients are to continue taking antibacterials at home, they are cautioned not to stop taking any prescribed medication even if symptoms abate and they feel better.

 

Practical methods for preventing nosocomial infection

What's in

·        Hand washing:

o        as often as possible

o        use of alcoholic hand spray

o        removing jewellery before washing

·        Stethoscope: cleaning with an alcohol swab at least daily

·        Gloves: supplement rather than replace hand washing

·        Intravenous catheter:

o        thorough disinfection of skin before insertion

o        changing administration sets every 72 hours

What's out

·        Hand washing: using a brush

·        Mask:

o        routine use in theatre

o        during wound dressing

·        Gowning: routine use in neonatal units

·        White coats: enforced use in clinical units

·        Intravenous catheter:

o        routine removal of peripheral catheters after 72 hours

o        use of impermeable, transparent dressings

o        in-line bacterial filters