Medicine

Hospitals - medical-preventive institutions intended for granting to the population stationary medical care

HYGIENICAL ESTIMATION OF CONDITION FOR PATIENTS AND OCCUPATIONAL HYGIENE OF MEDICAL WORKERS IN MEDICAL ESTABLISHMENTS.

MEDICAL-SANITARY SUPERVISION AFTER ORGANIZATION OF FEED IN MEDICAL ESTABLISHMENTS (AN INSPECTION OF FEEDING BLOC IN A HOSPITAL WITH REGISTRATION OF AN INSPECTION ACT

The work of the doctor should be referred to such kind of activity, which do not take part in production, creating material or spiritual values, at the same time ensures indispensable conditions for creation of such values, curing the people and reverting them to productive work.

The conditions and nature of labor activity of the doctors and other specialists of medical area require constant attention to protection of their health, because the activity of the medical worker bound with influencing both unfavorable working conditions, and dangerous factors of manufacturing environment on a workstation. These factors encounter a broad spectrum of manufacturing harmful factors.

а) Psychophysiological (psycho-emotional stress, specific work pose, excessive stress of analisator systems and other),

b) Physical (noncomfortable microclimate, poor illuminance of workstations, noise, chattering, ultrasonics, laser, radioirradiations,

Ionizing radiation),

c) Biological (promoters of ifection illnesses, parasite - insect, helminths,

Etc.),

d) Chemical (medical drugs, drug facilitiess and other).

It is known, that more than a half of professional diseases of the doctors - (59,8 % and more) is caused by physical and mental overstrain, and also the influence of the chemical factors.

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Hygienic features of the working conditions and state of health of the doctors of surgical specialties

Surgical specialties are: the general surgery, thoracic surgery, urinology traumathology and orthopedics, neurosurgery, obstetrics and gynecology, ophthalmology, oncology, facial surgery, surgical odontology, reanimation and anesthesiology. Except for enumerated, to surgical specialties referred anatomy, pathological anatomy, forensic medicine, surgical dermatology and other.

The professional feature of activity of the surgeons is multicomponent character of their working process. Except doing operations, as main activity of the doctors of a surgical profile, the considerable endurance of operating time is spent for inspecting patients, diagnostic, postoperative routines, morning conferences, planning how to do operations, filling in documentation (case history, protocols of operations), talking with the relatives of the patients, for the manager of departments, hospitals - administrative duties, and so on.

Operational loading of the doctors of a surgical profile, by countings of the explorers, compound: in communal surgery – more than 150 operations for one year, more than 3 for one week; in otolaryngology, accordingly, - more than 170 and to 4; in an obstetrics and gyneacology - 370 and 7 (including abortions, abrasions - 230 and 5). With improvement of professional skill of the surgeon increase both amount, and complication of operations. Operational, rentgenodiagnostical and reanimational loading increase also at daily duties of the emergency.

By physiological feature of work activity of the surgeon in operational is obliged working pose, with static stress of the muscle system. Is established, that 37,6 % of all period of the operation a trunk of the surgeon pitched forward and 27 % - with additional rotation in one or other side, and only 26 % of time its trunk is in vertical position. The blood pressure in legs is increased in 2 times, in the field of a basin - on 50 %. Takes place lack of blood supply of brain. From here - headaches,

The working area of the surgeon, occupies up to 60 cm in diameter, which causes to hold arms forward in one position, thus the angle of a brachium from a trunk oscillates from 35 up to 1800. Among the unfavorable factors of the physical nature is warming microclimate. For example, at 3 hourly operations in conditions of absence of a forced ventilation are created such conditions, that temperature of air is increased till 26-28 ", relative humidity till 70-80 of %. The level of an infrared radiation of the nonshadowing lighting above an operating table reaches up to 442 W / м2, all this results in a stress of dodges of thermal control, reinforced sweating (up to 700 mls and will go away for the operation). Considerable sweating is also by high psycho-emotional stress for the surgeons and character of used clothes (cotton costume (suit) and sterile dressing gown, hat, gauze mask).

In the summer temperature of air in operation room can reach 30C and greater, that at small speed of movingair (0,01-0,02 m\s), high humidity and high levels of radiative temperature conditions of overheat of an organism of the surgeons. Even in the winter temperature of air in operation room is on 3-5С higher than norm.

At conducting operations in conditions of hyperbaric oxigenation the surgeons and their helpers will experience the effect of warming microclimate, heightened atmospheric pressure and heightened infiltration into an organism of azote. The pressure in hyperbaric operational room reaches З and more atmospheres, that is considered predrug, in relation to azote. But the poor cubage in an barocamera, sometimes necessity of pressure increase up to 7-8 atmospheres, can condition of nitrogen narcosis for terms of operational team. The unfavorable operating constructs also process of a compression and, in particular, decompressions. Under operating of azote for terms of operational crew occur euphoria, the behavior (groundless laughter, slowing-down of motive reactings, decrease of attention, clearness of manipulations) is inflected.

The feature of a compression is the rise of air temperature in barocamera from original, for example 20С, up to 27 and even 37 degrees. At a decompression, on the contrary, temperature is slashed till 17-15 C and even 12С.

The relative humidity at a compression is increased from 40-60% till 70-84%. At a radiodiagnosis, radiognostics, surgical manipulations in traumatology the doctors and their helpers will experience the influence of ionizing radiation.

It is necessary to mark, that on the participants of surgical crews, except the indicated physical factors, the toxiferous chemical agents affect. It, first of all, chemicals, which are used foringalation narcosis: dioxide of azote (Mine), Ftorotanum (fluotane, halotane), Aether ethanol, Chloroformium (three - chlorethanum), three-clorethilenum, cyclopropane, chlorethyl and other.

Concentration of Ftorotanum in air of operational room in different space from a mask of the patient compounds 80-216 мг/м3, nitrous oxide 234-1770 мг/m ', and their concentration is augmented proportionally to the duration of an operation, in particular at a semiopen circuit of breathing.

Concentration of inhalation narcotics in a zone of breathing of members of surgical crews depends on time of a surgical intervention (at the operation on lungs concentration to Ftorotanum reaches 1000-1500 мg/m ), cubage of operational room, activity of drugs.

From the point of view of hygiene of work the speed of elimination of drugs from an organism is also important. It was found, that diethyle Aether has rather quick output from an organism. The signs of Ftorotanum are discovered in exhaled air of the anaesthesiologist in 64 hours after operation. At once after the operation the concentration of Ftorotanum in exhaled air is equal 42мg/м3. It is considered, that takes place material cumulation of Ftorotanum at its repetitive inflow in an organism. Chloroformium is not stored in an organism, and the ethanol stays for two days.

During operations anaesthesiologists, surgeons, gyneacologists are in a state of a high mental and nervous - emotional stress. At continuous operations (3-6 hours) are degraded speed of oculomotorius reactings, the coordination of moves of a hand and fingers, slashed memory and attention, the brake processes in a CNS dominate.

The frequency of cardiac pumps of the surgeon, anaesthesiologist that are getting ready to the operation is higher on 5-10 pumps/min, reaching 88-110 pumps/min, increasing in accountable periods of the operation.

After operational interferences, depending on their endurance, for the surgeons the diameter of legs is larger on 0,5-0,8 cm, the feet increases on 2-4 %.

Among diseases of the surgeons with a temporary disability on the main place comes the acute respiratory diseases, influenza, illnesses of organs of blood circulation, digestion, nervous system.

Among chronic diseases of the surgeons, gyneacologists, which are discovered by results of the deepened medical browses, the greatest specific weight is borrowed by the diseases of the system of blood circulation, by nervosisms, which are interlinked with high psycho-emotional and physical stress. In them most often the pains are localized in the field of heart, high arterial pressure, considerable changes of ECG, dissonances of the nervous system. The high case rate on gyneacological diseases, failure of pregnancy are discovered in the women - surgeons, which is interlinked, except of a psycho-emotional stress, with effect of anestetics and drugs.

The greatest amount of occupational diseases of the medical workers recorded for the doctors, including surgeons, in age of the highest working activity - 25-50 years. Behind frequency the greatest amount of cases of occupational diseases of the medical workers beloongs to zymotic illnesses, of which one most often are sick, except for infectionists and ftiziatres, also surgeons, pathologists, stomatologists, otolaryngologists, doctors - laboratory assistants. In Ukraine, on a statistician, the tuberculosis of a professional genesis among medical staff occupies 23 %, hepatitis A, B - 15,4 %.

In Ukraine among occupational diseases of the surgeons of chemical ethyology the medicamental allergy occupies 15,0 %, urticaria - 15,0 %, dermatitises - 8,0 %.

The considerable and continuous loading on a nervous - emotional and intellectual orb of the doctor - surgeon assists forming for him(it) of an idiopathic hypertensia, ischemic illness of heart, neurotic dissonances. A veheto-vascular dystonia, nervosism are discovered in the anaesthesiologists in 30 %.

The series of occupational diseases of the doctors is occupied by illnesses, which one are developed from a forced position of a body, stress of separate muscle groups; a radiculitis, osteochondrosis, discynesias, epicondylites - for the orthopedist - traumatologists.

Among reasons of progressing of occupational diseases for the doctors - surgeons select: a hypersensibility of an organism, absence or inefficiency of individual means of protection, non-compliance of the safety regulations, sanitary regulations, irregularity and deterioration of medical engineering, instruments, rigging.

Among diseases, which one has reduced in physical inability, 60 % are necessary on destiny of illnesses of chemical ethyology, 20 % - on illnesses conditioned by the biological factors, and till 10 % - on illnesses aroused by the physical factors and an overstrain of organs and systems.

As a result of originating professional disease the doctors were forced to inflect a place of operation through illnesses of chemical ethyology in 80 % of cases, through illnesses aroused by the biological factors in 11 % of cases and in 9 % through a functional overstrain.

Hygienic features of the working conditions and state of health of the doctors of a therapeutic profile.

To specialities of a therapeutic profile are referred: therapy with its derivation (gastroenterology, pulmonology, cardiology), phthisiology, zymotic illnesses, dermatovenerology, neurology, psychiatry, pedonosology, emergency.

From the point of view of features of operation and influencing of the unfavorable factors on the doctors of the enumerated specialities it is necessary to arrange on polyclinical, with a local principle of service ill, and on working in a hospital.

Among unfavorable psycho-emotional factors, the influencings will experience one of the divisionals theraputists, the carrying role belongs to excessive physical loading, which one depends on a season of year (amount of calls), sizes of a medical lease, such as building (one – multistore building, availability or absence of lifts).

Besides the divisionals theraputists and pediatrists, ER doctors, doctors - psychiatrists, the neuropathologists score constant psycho-emotional stress. It is conditioned by gravity of illness of the patients, complication of diagnostic, boundedness of possibilities of the doctor to help ill, feature of contacts of the doctor with ill and their with close.

The particular unfavorable operating on the doctors of a therapeutic profile is done by modern facilitiess of a hardware of medical entities - X-ray equipments, source of a radoactive radiation, electronic, ultrahigh-frequency, superhigh-frequency, ultrasonics, laser sets, source of ultraviolet radiation, chemical factors - pharmacological drugs, which one operate on medical staff by the way of solutions, gases, vapors and aerosolums.

For the doctors of leprosoriums, infectionists, dermato-venerologists, helmintologists, laboratory assistants antiplague, bacteriological, virologic, helmintological labs, desinfectors, epidemiologists particular professional unfavorable factors – exciters of the applicable zymotic diseases.

Among diseases of the doctors - theraputists with a temporary disability on the main place the acute respiratory diseases, influenza, illnesses of organs of blood circulation, digestion, nervous system. Thus the doctors - theraputists are sick considerably frequently and lengthy in matching with the doctors - surgeons, which work in a hospital (accordingly 103,4 cases and 128 dawned and 48,4 cases and 76,9 dawned disabilities on 100 working).

In pattern of chronic diseases trough theraputists the main rank places occupied by illnesses of digestion organs - (chronic cholecystitis, gastrityes, peptic ulcer of a stomach, duodenum), illness of the nervous system and sense organs. Are then routed: an ischias, radiculites conditioned by often variation of stay in building and outdoor at service or at home. It is necessary to note, that the considerable proportion of the doctors are engaged in services of the colleagues without the applicable decor of disease in medical documents. This feature essentially influences quality and endurance of treatment, entirety of the registration and, accordingly on an index of a case rate, that is why officially, of taking medical advices up to 600 cases on 1000 working, and on retrospective interrogation - up to 1500 on 1000 register.

To occupational diseases of the doctors of a therapeutic profile belong:

- The zymotic and stray diseases, homogeneous with theme, ill on which one are handled by the doctor, medical sister, laboratory assistant, desinfectors, (lepra, tuberculosis, plague, cholera, malignant anthrax, rabies, brucellosis, helminthiases etc.);

- The diseases, which one can arise at service of sources of ionizing radiation - X-ray, gamma - therapeutic vehicles and installations, at the robot with opened radionuclides (acute, chronic radial illness, leukoses, radial cataract, carcinoma cutaneum, hyperceratosis, papillomas, dermatitises, eczema, toxicodermias, melanodermias etc.);

- The diseases, which are caused by service of physiotherapeutic rigging - oscillators a UHF, UV, hydrosulphuric, radon cabinets т of separations engine driven laundries, autoclave installations, etc. (radioundular illness, photo-ophthalmia, traumas, casualties);

- The diseases, which are caused by operation with medicines, drug, disinfectants, other chemical combinations (acute and chronic poisonings, medicamental allergy, dermatoses etc.);

- The diseases, which one are developed at continuous immediate service mentally ill - professional psychoneurosis),

- Disease conditioned by considerable constant psycho-emotional stress (an idiopathic hypertensia, stenocardia with their complications).

Hygienic features of the working conditions and state health of the doctors - stomatologists.

Stomatological of a speciality are divided on a therapeutic odontology. A surgical odontology, facial cosmetic surgery, etc.

By one of main professional unfavorables for the doctor - stomatologist is a forced position of a body, which one is tracked by static stress of separate muscle systems. Depending on a construction of stomatological seat for the patient the stomatologist works standing or sitting.

At usage of seats and instrumentation of vertical constructions the doctor - stomatologist works standing rakish trunks 34 % of operating time. At usage of seats of a horizontal construction - sitting rakish and bending of a backbone in the side of the patient 75 % of operating time, and with a strong tilt and bending of a backbone - 22 % of operating time.

The muscle loading of the stomatologists by operation in a pose costing increases in 1,6 times, and rakish trunks - almost in 10 times. By operation in a pose sitting rakish trunks the muscle loading is augmented in 4 times.

Operation with minor defects in dents, their restricted accessibility to examining predetermine a stress of the visual evaluator and excessive convergence of an eye owing to nearing an organ of vision to plant of distinguishing.

From among the essential physical unfavorable factors for the doctors - stomatologists there is a noise from operation of a drill, compressors, sucktions. In particular dangerous is local chattering from operation of a drill, which one is transmitted to arms of the stomatologist.

The applying of photopolymeric valves of local lighting predetermines influencing on the doctor of powerful visible and uv radiation, and usage of polymeric materials and know-hows is tracked inflow in a zone of breathing of toxiferous matters of a miscellaneous genesis.

The operation with mercurial amalgams is tracked by influencing on medical staff of vapors of metallical Hydrargyrum.

One of most relevant professional unfavorable for the doctor - stomatologist is hazard of a taint from the patient with diseases of the upper respiratory paths, which one flow past in mild, defaced, atypic to the shape, or are in a stage of incubation. Besides the potential hazard of originating of zymotic disease exists at implementation of manipulations, conducted with contact to a saliva, tissue an ash, blood of the ill or infected faces.

Medical examination of a state of health of the doctors - stomatologists has shown, that at continuous one way loading are expanded a tendon, owing to the joints, and bones are misplaced. The offset in a knee joint results in variations in coxofemoral, talocrural joints, progressing flat stops. The resistant variations of a backbone are step-by-step developed, there is a scoliosis, kyphosis, lordosis in cervical, thoracal, lumbar departments. Doctor working in a standing pose rakish trunks frequently results in disease of a gall bladder. The deduction od bile is degraded, the gallstones are gained, the internal organs are cramped, diaphragmal breathing becomes complicated.

By the studies of the german scientist Shebil (1971), in 70 % of the young specialists - stomatologists in 6-30 months after beginning of their activity there are this or that signs, which one testify to disease in them of a sceletal musculation.

The work of the stomatologist in a sitting pose near horizontal stomatological seat with deflection of a trunk from a vertical on 25-30 degrees with homing of a shoulder girdle on 28 degrees stagnation of a blood in organs of abdominal cavity, basin, progressing of a cholecystitis, less often than peptic ulcer, radiculitis, ischias. Thus take place (as well as for the doctors of a surgical profile) padding gains on upheaval and holding of arms in suspended position, which one assists even greater and is quick in occurring fatigue. Forced working outside of and the static stress of a locomotorium will call pains in a backbone, neuralgia in a shoulder girdle, necks, hemostasis in legs, platipedia, osteochondrosis.

Necessity of precise, thin manipulations during medical operation, stereotyped moves, statico-dynamic stress of muscles of fingers, hand

Arms, shoulder girdle, the holding of instruments not by gains of a fist, and fingers of arms (in a position – holding of a pencil), but with considerable physical gains, will call a hypertrophy of separate groups of muscles. Thus are so-called professional pains. Step-by-step accrueing, result to spastic contraction of all group of muscles, down to shoulder girdles.

Owing to operating local chattering from a drill occur of tag of percussive illness: tiredness, cramp and pain in fingers, feel of a numbness of arms, losses tactile and thermoesthesia.

As a result of a constant stamping of the hand lever metallical instruments on the same place can be developed contracture of Duipuirtene.

The stress of the visual evaluator can result in to a spastic stricture of accommodation and originating of a so-called artificial myopia, and the operation with photopolymeric valves can invoke a photo-ophthalmia, combustions of a cornea, clouding of crystalline. In this connection the characteristic complains on tiredness of vision, feel of “sand in eyes ", discomfort.

The operation with mercurial amalgams can be the reason originatings for the doctors - stomatologists, medical sisters, tooth techniques of micromercuralism.

The greater 25 zymotic diseases, including HIV, prion illness, hepatitises B and C passed through a saliva, tissue an opened wound. The often placer mining of arms by a sweeper can assist progressing micogenues eczemas, disgydrosis, epidermofitias.

Measures on environmental sanitation of the working conditions of the medical workers.

By one of main conditions of environmental sanitation and protection of operation of the medical workers, the creation of optimal conditions for effective conducting of the medical process is plane-architectual solution of treatment-and-prophylactic entity. The building of major hospitals (on 600-1000 beds) significally meliorates the working conditions of the medical workers. This building is carried out presently according to building norms. These norms stipulate the enumeration of indispensable buildings, according to assigning of hospital, separation, two corridor system, oversizes of main functional buildings, operational, minor surgery, procedural, manipulating. For the doctors foreseen " rooms of psychological discharging ", specialized gymnastics, room of personal hygiene of staff.

So, at budgeting surgical separations the insulated building of two surgery blocks - aseptic and septic, with airlock passes to department is stipulated. In a surgery block the gateway servers, supplementary puttings are guessed a floor broker, preoperational, sterylazing, narcosis, hardware, putting for a synthetic circulation of blood, putting for staff. The surgery block should be endured in the separate body, with the covered transferrings to the major body, to separation. Should be isolated clean and purulent Minor surgery. The floor space of a floor broker - at the rate of 36-48. М2 on one operating table, altitude not smaller 3,5г. The surgical department should be counted on 60-90 of beds, room section - for 20 beds. Norms of the floor space in 2 - 4 beds room not smaller 7м2, in one bed room - 9 м2.

The acceptance separation of the surgical departament, as against other, should be provided with rentgenodiagnostical facilitiess, operational (for immediate surgeries behind biotic indexs), antiseptic rigging and facilitiess, etc.

Designed separate special building both sanitary regulations and rules for tubercular, infectious diseases hospitals and separations, rentgenological cabinets, separations, labs, clinical-diagnostic, bacteriological, helmintological, virologic labs, hydrosulphuric, radon departments, psychiatric, antileprosoric hospitals, protesing labs, disinfectant servers engine driven laundries, boiler-houses, which one are esteemed in the applicable partitions of guidings from municipal hygiene.

The relevant value in environmental sanitation of the working conditions of the medical workers has rational arranging of medical furniture and machineries in the medical cabinet.

The sanitary regulations and norms - stipulate creations of optimal microclimatic conditions in separate functional buildings of hospital entities, ventilating system, conditioning of air, natural and synthetic lighting, sanitary - hardware (cold and ardent water facilities, communal and special water drain).

It is necessary to conduct systematic laboratory check of concentration of anestetics in operational with the purpose of debarment overflow them GDK: for a Aether - 300 мг/м3, Ftorotanum - 20 мг/м3, inhalanum - 200 мг/м3, Chloroformium - 5 мг/м3, cloraethilum - 50 мг/м3, Trilenum - 10 мг/м3.

At usage simultaneously several anestetics the total of ratioes of their actual concentrations to them GDK should not exceed unities.

However, the most effective preventive action against toxiferous operating of anaestetics on members of operational crew is transferring to intravenous narcosis and spinecord anaesthesia.

Concerning other chemical combinations, with which one the medical staff can work, first of all it is necessary to determine, that it is necessary to conduct operations with medicines, disinfectants, acids, meadows in fume hoods, for the patients - in inhalation cabs. Besides it is necessary to utillize individual means of protection - rubber gloves, defensive oculars, masks, respirators, film skirts and even an overalls. For arms with the purpose the preventing to progressing of allergic reactings is necessary to utillize defensive creams. With same purpose it is necessary to prefer tablet medicines.

Designed marginal levels of bacterial air pollution of hospital buildings. So, in operational up to 500 colony / м3 air to the operation, 1000 colonies / м3 after the operation is enabled; in chambers of reanimation and intensive care - not the greater 750 staffs / м3, and pathogenous of a staphylococcus -к 4-х/м3. In genitive halls - up to 2000 colony / м3, and staphylococcuses and streptococcuses - not greater 24-х/м3.

For support of purity air of hospital buildings, except for natural and the forced ventilation, will do air conditionaires ВОПР-09, ВОПР-1,5, which resolve to reduce dustivity and bacterial contamination of air during 15 minutes at 7-10 of time. In surgery blocks, minor syrgery, children's chambers, genitive halls rather effective uv radiation by germicidal lamps ЛБ-30, БУВ-ЗОП etc., straight light in absence of the people.

The UV radiation of hospital buildings in presence of the people, except for germicidal effect, assists a heightening of a resistance of an organism of the medical workers (as well as patients) to zymotic and other illnesses, do general stimulating, D-vitaminsynthesizing effect, pigmentsynthesizing effect. Nevertheless in this case there can be a hazard of a photo-ophthalmia, if the vision hits in a zone forward(straight) uv-radiation.

With the purpose of preventive measures of zymotic, catarrhal diseases of the medical workers the bacterination against acute respiratory diseases should be conducted in preepidemical period, and during epidemic - wearing of masks, wet retraction with usage desinfectants (Chloraminums etc.), other means of strife with intrahospital taints: 3 % solution of a lysol, 4-5 % solution of caustic, 2-3 % solution hypocloride of calcium etc.

The natural and synthetic lighting of puttings is ensured according to " Treatment-and-prophylactic entities. Norms of designing " and directional on supply of a high working capacity of the visual evaluator of the doctors, conservation of his(its) health. Coefficient of a daylight illumination, behind these norms, should be in chambers, puttings of communal assigning not smaller 0,8-1,0 %. In operational - 2.5 %.

The synthetic general lighting for the majority of hospital puttings (diagnostic, manipulations etc. of cabinets) should be ensured with cold light lamps on equal 500 lxose, in customary studies -300 luxose, in chambers, corridors - 150 luxose. The communal synthetic lighting operational should also be ensured with cold light lamps, behind a spectrum by close to day time, that ensures exact perception of colors, and to be not the lowest 500 lxose. The illuminance of a surgery field should reach 2000-3000 lxose for the score nonshadowing of lightings with a spectrum, also by close to day time, but to not invoke blinding effect on the surgeon and other members of operational crew, without lightshadows, influence a temperature schedule in operational (temperature in a zone of operation of crew should to be increased more as on 2-3С). It is necessarily necessary to provide availability of independent abnormal synthetic lighting.

For security against ionizing radiation, electromagnetic radiations a UHF, UV, irradiations will be provided by methods grounded on physical methods of slackening radiating - by limitation of power radiating (security by an amount), limitation of periods beaming (security from time to time), spacing interval, screening. By operation with opened sources of ionizing radiation, besides is keeping a radiative asepsis and antiseptics.

Security by an amount from ionizing radiation gobed up in Norms of a radiation safety of Ukraine (NRBU-97) and Sanitary regulations of operation with radioactive matters and other sources of ionizing radiations (SMALLPOX - 99). These statutiry documents regulate limits of doses for categories And і (20 and 2 м3в, accordingly), admissible equal inflows of radionuclides through organs of breathing and admissible concentrations in air of workrooms for each radionuclide separately, admissible amounts of radionuclides on a workstation with allowance for of class of hazard admissible equal impurities by radionuclides of working surfaces, clothes and arms working. The security is from time to time reached by acquisition of habits exactly and speed of manipulations with "cold" moulages and analogs of radioactive drugs, and for the roentgenologists - keeping of a condition dark adaptings of vision before X-ray examination.

The preventive measures of fatigue from a forced position of a body are reached by a rational construction of furniture, with allowance for the ergonomical requirements. The working chair (by operation sitting, for example, otolaryngologist, oculist, gyneacologist) should be jacking, rotating, backrest according to the configuration of a backbone, semi-upholstered sitting, round, whether rounded. There should be a foreseen place for legs.

The preventive measures of fatigue power up also autogenous, which resolves to reduce a nervous stress, to remove a headache, to normalize bloody stress, cerebral circulation of blood, to construct feel of freshness, vivacity; a complex of exercises of manufacturing gymnastics for putting off(taking out) of static fatigue, periodic(batch) breath holding for gymnastics of bulbs of a brain (operating of an excess С02), deep diaphragmal breathing.

The rooms of psychophysiological discharging, with usage of music, videotape recorders, semilying seats of rest, douche in elderly period and etc are recommended also. Positive there is an architecture of mild second lunch, which reflectory will activate activity of a major brain, refills power resources of an organism a /ardent meat broth with a pie, sandwich, ardent tea or coffee with sweetness / .

The redoxon increases a mental and physical working capacity, adaptive possibilities of an organism, his(its) wear hardness to taints, intoxications, oxygen deficiency, and etc. The daily dose of redoxon should not exceed 600 мg, rutin - 0,15 мg.

The major value has professional culling of the doctors, medical sisters for operation in subsections and separations with the parasitic working conditions. Absolutely counterindicative in this respect there is an availability for the challengers of organic diseases a CNS, epilepsy, mental deviations, neurosises, nervosism, and also troubles of sceleton.

To security of shortening of operating time for this category of the medical workers is from time to time referred also.

Security of spacing interval most effective, as the radiation dose is slashed proportionally to quadrate of spacing interval, and is reached by definition of zones of inaccessibility for sources X-ray and gamma-ray, usage of positioning devices by operation with enclosed and opened sources of ionizing radiation, rational budgeting of buildings and sufficiency of their sizes.

The security by screening is reached by operation with X-ray and gammas - radiatings with the help of lead screens by the way of pods, screens, antiradiation rubber skirts, etc. Shields for sources of a beta radiation are aluminum, organic glass. For security of terms of surgical crew against X-ray beaming at traumatological, orthopedic operations will be provided by new rentgenodiagnostical staff, roving defensive screens.

The relevant value has psychophysiological culling for specialities with theme or other professional risk factors. In a ground(basis) of such culling there should be trusted to morally - ethical, physiological, psychological performances of the person, speed and fidelity sight and hearing reactings, stability of attention, speed of waste-handling of the information, and etc.

In the system of public health services of the medical workers the relevant place borrow(occupy) precursor, at employment with unhealthy conditions, and periodic(batch) medical browses of the doctors, medical sisters, laboratory assistants, other specialists, architecture of the qualified treatment-and-prophylactic help on a place of their operation, or in specialized medical entities; a dispensary observation, in-depth analysis of a case rate of the medical workers, their examination LSEC, LKK, transistorizing temporarily or permanently on one more mild or more safe operation, exclusion for them of night duties and etc.

The special place in the system of public health services of the medical workers borrows(occupies) the sanitarian and legal legislation. So, the precursor and periodic(batch) medical browses are regulated by the Order MOZ USSR № 555 since 29.09.1989 years and Order MOZ of Ukraine № 45 from 31.03.1994., according to which one the precursor and periodic(batch) browses should be obligatory for the medical workers of treatment-and-prophylactic entities of miscellaneous assigning.

In Ukraine waste strong statutiry and normative base on protection of operation. Since 1992 gated in I shall do the progressive Law of Ukraine " About protection of operation ". The constitution of Ukraine has locked behind each medical worker the right on safe operation. But is far from being in each medical entity, not on each workstation, these laws will be realised. On it is much both objective, and subjective reasons.

With the purpose of preservation of health of the medical workers and pharmacists working in parasitic conditions, the legislation establishes(installed) the abbreviated working day:

- Hourly - in zymotic, tubercular separations of hospitals, children's entities, in psychiatric, psychoneurological, narcological entities and separations, in physico-theraputical, radon, balneal separations, in sanitary - epidemiological departments both separations and labs, which one work with the parasitic factors (doctors - bacteriologists, epidemiologists, hygienists, parasitologists, toxicologists, sanitarian doctors, desinfectors) etc.

The night duties of the doctors and medical sisters, duty on days off, according to the legislation should to be countervailed: by operation without the right of dream hour in an hour, and with the right of dream - 0,5 hours in an hour. By the legislation is stipulated also limitations of norms loading of the doctor at the rate of on 1 business hour; out-patient reception - surgeons - 9 ill, ophthalmologists, otolaringologists, dermatovenerologists - 8, traumatolog-orthopedist - 7, theraputist, infectionist, endocrinologist, hematologist, urologist , oncologist, pediatrist, surgeon - stomatologist - 5 ill, children's psychiatrist - 2,5, theraputist-stomatologist - 3, prosthetic odontology, forensic psychiatry - 2 ill.

- 5,5-hour the working day is established for the doctors out-patient - polyclinical entities, LSEC, LKK. Psychoneurological tubercular dispancers, stomatologists , doctors and nurses, working with oscillators a UHF, or irradiation in polyclinics.

- 5-hour the working day is established for medical staff, immediately working in rentgenodiagnostics, rentgenophotography, on rotatory roentgen - therapeutic, hamma theraputical installations, for the pathologists, prosectors, anatomists, other specialists working with a corpse material, for medical workers, handling children's entity for mentally retarded children, with a defect of CNS.

- The 4-hourly working day is established for the doctors, mean and low medical staff immediately which was taken up with opened radionuclides.

At transferring for 5-day's working week the week uptime is saved by reallocating working hours of 6-th day 5 day working week.

Nevertheless, certain problems with telecommunications exist: legal and some organizational questions remain unclear; there is no standardized scientific method or basis for telemedical consults. Establishing a standard methodology, and addressing legal concerns will help expand the use of modern telemedical technologies, hastening their implementation in the sphere of occupational and environmental health.

Nosocomial infections (i.e., infections acquired in the hospital) have become acute problem in human medicine because of increases in drug-resistant microbial strains and increases in the use of invasive procedures for patient support and monitoring. Compliance with handwashing protocols is perhaps the most important means of preventing nosocomial infection. Careful attention to aseptic technique and judicious use of antibiotics are also essential.

Nosocomial infections (NI) -infectious diseases connected to stay, inspection and treatment in medical-preventive institutions or reference (manipulation) in these for the help.

The concept "hospitalismus", which quite often use as a synonym of the term "hospital infection ", is wider and unites all diseases caused by specificity of environment of medical institutions. There are traumatic hospitalismus, mental (psychogenic) and infectious hospitalismus (NI). Joining to the basic disease, nosocomial infections worsen its decursus and prognosis.

On the data of the American authors, in USA NI occur between 5 % of the patients, (average level in the advanced countries 5-12 %), taking place on stationary treatment. Mortality reaches 25 %, so nosocomial infections are the basic reason of mortal cases in the hospitals. Nosocomial infections considerably increase the term of stay of the patients in medical institutions, that is the reason of the huge expenditures (in USA: 5-10 USD billions per year). The large urgency have got NI in connection with distribution so-called hospital strains of bacteria, as a rule poliresistent to antibiotics and chemiopreparations. You know, obviously, the principal mechanisms of development resistence to antibiotic, such as chromosomal, plasmid etc. The mechanisms work concerning those or other antibiotics.

Chromosomal resistance is characterized by sudden change such as sensitivity of one or several strains to an antibiotic (as a rule, this kind of stability is inducted with carbeniclline, streptomycine, levomycetine, aminoglicosides, tetracycline and sulfonamides). This type of the resistance is characteristic for Klebsiella, Enterococci, Pseudomonas aeruginosa, Neisseria, Staphylococci (in particular - Staphylococcus aureus (MRSA)).

Plasmid resistance is characterized by gradual change of types of sensitivity of many kinds of microorganisms for one or several antibiotics (tetracycline, ampicilline, cephalosporines etc.), and it’s typical for Enterobacteriaceae and Acinetobacter, Pseudomonas, H. influenzae. The resistance trasfer factor is conjugative plasmid. Sudden or gradual change of types cross resistance of one kind of microbs to two antibiotics (aminoglicoside + b-lactam antibiotic, tetracycline and aminoglicosides) characterizes stability connected to permeability. Last type of resistance is realized for Pseudomonas, Serratia, Staphylococci, Enterococci. Poliresistent strains are especially dangerous for children and weak persons, especially elderly people and patients suffering from immunodeficites of any origin. They represent group of risk.

The transfer of microorganisms can occur:

1. by an aerogenic way.

2. by fecal-oral way

3. by parenteral introduction

4. by the contact

Table 7.7 Risk factors of hospital environment decreasing the resistance of organism to infecting:

Infringement of protective barriers

-constant cateter

-dialysis

-drainage

-tracheostoma

-wounds (especially combustions)

-operations

-punctions of skin: injections and venepunctions

Neutropenia

Antibiotic treatment

Marrow disease

Decreased activity of neutrophylic white blood cells

-chronic granulematous diseases (TB, MFD, lues, actinomycosis)

-acydosis

Cell immunity supression

Hodgkin disease

Swiss type of α-immunoglobuline

Sarcoidosis (Kashine-Beck disease)

Etc

Hypoimmunoglobulnaemia

Treatment with steroides, antibiotics

Lymphosarcoma

other

NI can occurs during stay in medical-preventive institutions, and after a discarging from hospital. They are various on the clinical displays and can proceed as the located forms or generalized septic processes, and also as symptomless carriage of an activator. The diseases of the medical workers arising during treatment and a care for the infectious patients are concerned also to hospital infections.

There are some modern classifications of nosocomial using now:

I. Based on ethyology:

Viral NI:

1. HIV (AIDS)

2. Mixoviridae (influenza)

3. RSV (respiratory-syntitial infection)

4. Rhinovirus (" common cold ")

5. Paramixoviridae (paragryppus, measles)

6. Herpeviridae (herpetic infection)

7. Adenoviridae (adenoviral infection)

8. Cytomegalovirus

9. Enteroviridae (Coxaki, ECHO, polio)

10.vira HA, HB, HC, HE.

chlamidical: epidemic conjunctivitis, (very seldom - ornithosis or trachoma)

bacterial:

1. Staphylococci (Gr +)

2. Streptococci

3. Klebsiella (Gr-)

4. Pseudomonas

5. Neisseria

6. Legionella

7. Lysteria

8. Clostridia

9. Proteus

10.Serratia

11.Enterobacterioceae

12.Mycoplasma

Mycobacterià

1. Candida

2. Actinomyceta

3. Nocardia

protozoic: Pneumocysta carinii

By the transmission way

I. With aerogenic spreading:

1. · adenoviral infection

2. · cytomegaloviral infection

3. · Influenza

4. · paragryppus

5. · measles

6. · rubeolla

7. · pneumonia (for example: Fridlender pneumonia or disease of Legioners)

8. · dyphtheria

9. · pertussis etc.

II With a fecal-oral way of transfer:

1. · poliomyelitis

2. · viral hepatites A and E

3. · toxicoinfection, bacteriotoxicoses (microbic food poisonings)

4. · dysenteria

5. · salmonellosis etc.

III. With the parenteral transfer:

1. HIV-infection

2. Virus of hepatites B, C, D etc.

IV. With a contact way of transfer:

1. · wound infection

2. · implantation infection

By localization:

1. generalized forms:

1. sepsis

2. meningitis

3. osteomyelitis

2. Located forms:

Infections of a skin and hypoderma:

1. abscess

2. phlegmona

3. mastitis

4. conjunctivitis

5. otitis

6. endometritis

Urogenital infections: uretritis, custitis, pyelonephrites

Respiratory infections:

1. ARVI

2. legioners’ disease (Pitsburg fever, fort Pontiac fever)

3. gastro-intestinal path: - gastroenteritis

4. enteritis

5. colitis

6. wound infection (including postinjection complication):

7. erysipelas

8. pyogenesis

Other: viral hepatites

About "iatrogenic" nosocomial infections they speak, when the direct reason of disease is the rough infringement of medical technology by the personnel .

For last years the ethyologic structure of NI has undergone significant changes. In the last streptococci were the main reason of NI. Now the main ethiological factors are staphylococci (up to 60 %) and large group of gram - negative microorganisms (Esherichia, Pseudomonas aeruginosa, Klebsiella, Enterococci etc.). In the intensive therapy wards the most often activators of NI are staphylococci, Pseudomonas aeruginosa, Esherichia coli, enterococcus (streptococci of group D). The increasing role at the hospital pneumonias play legionellae and also Añinebacter, Añhromatobacter, - last meet mainly at the persons with immunodeficite condition.

The basic precondition for occurrence NI is the non-observance of sanitary-epidemiologic and antiepidemic mode in medical-preventive institutions. Distribution of an infection promote presence of the obscure sources of an infection among the personnel and patients, infringement by the personnel rules of aseptics, antiseptics, personal hygiene, mode of the current and final disinfection, mode of cleaning, linen mode, infringement of a mode of sterilization and disinfection of medical tools, devices. The greatest importance have aerial and intestinal infections (especially in childrens MPI), capable to form mass flares.

Among directions of preventive maintenance of NI it is possible to allocate two basic:

1. Unspecific preventive maintenance - covers architectural - planning measures, sanitary - antiepidemic measures, sanitary - technical measures;

2. Specific prevention (immunization) - will be carried out in the scheduled order. It’s used an active immunization (vaccine, anatoxines less often; more often - passive immunization (immunoglobulini).

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 ofmaximising the role and status of the individual trust. We have,however, observed over the past two years an increasing trendfor groups of hospitals to work more collaboratively, and a softening,or even abandonment, of the competitive ethos, in line with thegovernment'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 ishow to plan for an area where a number of hospitals form a potentialnetwork 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 collectivewill. The recent acute strategy for Scotland is an early exampleof what seems to be a growing trend towards planning on a system-widebasis.

This development reflects the view that some services must be organised on a scale larger than any one hospital, for someservices for populations as large as one million. However, asthe Calman Hine report recognised for cancer care, the amountof evidence bearing on such large scale issues is limited.⁷Furthermore, neither the Calman Hine report nor the Scottish strategyreport⁸ adequately deals with the relation between servicesorganised in this way, as they do not allow for the impact oftheir proposals on the way other services are providedeven thoughthe 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 communitybased services such as rehabilitation facilities and out of hourscooperatives formed by general practitioners. They also dependon the way in which potential users, particularly of emergencyservices, decide whether and how to access care. Although thephrase "whole systems approach" has now found its way into officialdocuments, 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 recentreview by the York Centre for Reviews and Dissemination⁹ andPosnett's article in this series¹⁰ have shown, high qualityevidence on the benefits of this process of centralisation andspecialisation is limited. Nevertheless, the recent recommendationsfor hospitals by the BMA and the Royal Colleges of Physiciansand Surgeons envisage a continuation of this process.¹¹ Furthermore,the colleges are issuing guidance that will put managers in aposition in which they will have to close or reduce the role ofsomehospitals.

This is in direct opposition to the high value placed on access by the public, and unless models can be developed to overcomethis it is possible that the accountability of the colleges willbe questioned, and they may come into direct conflict with politicians.The problem is particularly acute in more rural areas, where eventhe revised minimum populations suggested in the most recent documentby the BMA and the royal colleges may be hard to achieve. A compromisewill need to be developed between the requirements of educationand training and the development of local services, and some hospitalsmay not be able to continue to function as educational establishmentsresponsible for training juniordoctors.

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

The results of this are apparent in the current crisis in the recruitment of nursing staff. Although many other factors playa part, one element is the lack of research on the number andtype of nurses that hospitals require and the contribution ofnursing to patientoutcomes.
The research agenda

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

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

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

Even though this initiative is welcome, it will not be enough. An additional problem is that the time lag in implementationmeans that evaluation may become history rather than researchand, given the pace of change, the past may not be a reliableguide to the future. No substantial sources of funding have beenavailable to support this type of research. Moreover, many ofthe questions for which planners, managers, and policymakers needanswers are not easily answered with traditional methods of researchinto the healthservice.

Secondly, new research techniques are required to support planning for the hospitals of the future, including the developmentof scenario planning and modelling, and simulation techniquesto identify uncertainties and the sensitivity of plans to forecastingerrors. There should be more evaluation of completed plans andmuch better systems to exchange knowledge about innovations. Somenationally led experiments are also neededin the developmentof service modelsfor example, for rural areas where the trendsreferred to above are undermining existing patterns ofprovision.

Little research has been done that highlights the central issues of hospital planning: how many hospitals we need, what serviceseach should offer, how they should relate to each other, and how,once these issues are resolved, they should be organised, staffed,andmanaged. 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 shouldbe that whatever is planned should be robust in as many possiblefutures as are conceivable. Research should be directed at understandinghow flexibility can be incorporated into hospital design at lowcost. In this respect there is perhaps some reason to be concernedabout the impact of the private finance initiative. These schemeswill have fewer beds but may not incorporate design ideas thatallow flexibility since, in many cases, the costs associated withthe planning will fall on theNHS.

This failure of research reflects a larger failure to take the planning of hospitals seriously, which has been particularlymarked since regional health authorities were abolished. Althoughgeographical 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 consultationdocument on acute hospital services to respond to this challenge.

It is known, that more than a half of professional diseases of the doctors - (59,8 % and more) is caused by physical and mental overstrain, and also the influence of the chemical factors.

Hygienic features of the working conditions and state of health of the doctors of surgical specialities.

Surgical specialities are: the general surgery, thoracal surgery, urinology traumathology and orthopedics, neurosurgery, obstetrics and gynecology, ophthalmology, oncology, facial surgery, surgical odontology, reanimation and anesthesiology. Except for enumerated, to surgical specialities referred anatomy, pathological anatomy, forensic medicine, surgical dermatology and other.

The professional feature of activity of the surgeons is multicomponent character of their working process. Except doing operations, as main activity of the doctors of a surgical profile, the considerable endurance of operating time is spent for inspecting patients, diagnostic, postoperative routines, morning conferences, planning how to do operations, filling in documentation (case history, protocols of operations), talking with the relatives of the patients, for the manager of departaments, hospitals - administrative duties, and so on.

Operational loading of the doctors of a surgical profile, by countings of the explorers, compound: in communal surgery – more than 150 operations for one year, more than 3 for one week; in otholaryngology, accordingly, - more than 170 and to 4; in an obstetrics and gyneacology - 370 and 7 (including abortions, abrasions - 230 and 5). With improvement of professional skill of the surgeon increase both amount, and complication of operations. Operational, rentgenodiagnostical and reanimational loading increase also at daily duties of the emergency.

By physiological feature of work activity of the surgeon in operational is obliged working pose, with static stress of the muscle system. Is established, that 37,6 % of all period of the operation a trunk of the surgeon pitched forward and 27 % - with additional rotation in one or other side, and only 26 % of time its trunk is in vertical position.The blood pressure in legs is increased in 2 times, in the field of a basin - on 50 %. Takes place lack of bloodsupply of brain. From here - headaches,

The working area of the surgeon, occupies up to 60 cm in diameter, which causes to hold arms forward in one position , thus the angle of a brachium from a trunk oscillates from 35 up to 1800. Among the unfavorable factors of the physical nature is warming microclimate. For example, at 3 hourly operations in conditions of absence of a forced ventilation are created such conditions, that temperature of air is increased till 26-28 ", relative humidity till 70-80 of %. The level of an infrared radiation of the nonshadowing lighting above an operating table reaches up to 442 W / м2, all this results in a stress of dodges of thermal control, reinforced sweating (up to 700 mls and will go away for the operation). Considerable sweating is also by high psycho-emotional stress for the surgeons and character of used clothes (cotton costume (suit) and sterile dressing gown, hat, gauze mask).

Concentration of Fortnum in air of operational room in different space from a mask of the patient compounds 80-216 мг/м3, nitrous oxide 234-1770 мг/m ', and their concentration is augmented proportionally to the duration of an operation, in particular at a semiopen circuit of breathing.

From the point of view of hygiene of work the speed of elimination of drugs from an organism is also important. It was found, that diethyle Aether has rather quick output from an organism. The signs of Ftorotanum are discovered in exhaled air of the anaesthesiologist in 64 hours after operation. At once after the operation the concentration of Ftorotanum in exhaled air is equal 42мg/м3. It is considered, that takes place material cumulating of Ftorotanum at its repetitive inflow in an organism. Chloroformium is not stored in an organism, and the ethanol stays for two days.

After operational interferences, depending on their endurance, for the surgeons the diameter of legs is larger on 0,5-0,8 cm, the feet increases on 2-4 %.

Among diseases of the surgeons with a temporary disability on the main place comes the acute respiratory diseases, influenza, illnesses of organs of blood circulation, digestion, nervous system.

In Ukraine among occupational diseases of the surgeons of chemical ethyology the medicamental allergy occupies 15,0 %, urticaria - 15,0 %, dermatitises - 8,0 %.

Hygienic features of the working conditions and state of health of the doctors of a therapeutic profile.

To occupational diseases of the doctors of a therapeutic profile belong:

- The diseases, which are caused by operation with medicines, drug, disinfectants, other chemical combinations (acute and chronic poisonings, medicamental allergy, dermatoses etc.);

- The diseases, which one are developed at continuous immediate service mentally ill - professional psychoneurosis),

- Disease conditioned by considerable constant psycho-emotional stress (an idiopathic hypertensia, stenocardia with their complications).

Hygienic features of the working conditions and state health of the doctors - stomatologists.

Stomatological of a speciality are divided on a therapeutic odontology. A surgical odontology, facial cosmetic surgery, etc.

The operation with mercurial amalgams is tracked by influencing on medical staff of vapors of metallical Hydrargyrum.

Necessity of precise, thin manipulations during medical operation, stereotyped moves, statico-dynamic stress of muscles of fingers, hand

Owing to operating local chattering from a drill occur of tag of percussive illness: tiredness, cramp and pain in fingers, feel of a numbness of arms, losses tactile and thermoesthesia.

As a result of a constant stamping of the hand lever metallical instruments on the same place can be developed contracture of Duipuirtene.

The operation with mercurial amalgams can be the reason originatings for the doctors - stomatologists, medical sisters, tooth techniques of micromercuralism.

Measures on environmental sanitation of the working conditions of the medical workers.

The relevant value in environmental sanitation of the working conditions of the medical workers has rational arranging of medical furniture and machineries in the medical cabinet.

At usage simultaneously several anestetics the total of ratioes of their actual concentrations to them GDK should not exceed unities.

However, the most effective preventive action against toxiferous operating of anaestetics on members of operational crew is transferring to intravenous narcosis and spinecord anaesthesia.

The uv radiation of hospital buildings in presence of the people, except for germicidal effect, assists a heightening of a resistance of an organism of the medical workers (as well as patients) to zymotic and other illnesses, do general stimulating, D-vitaminsynthesizing effect, pigmentsynthesizing effect. Nevertheless in this case there can be a hazard of a photo-ophthalmia, if the vision hits in a zone forward(straight) uv-radiation.

To security of shortening of operating time for this category of the medical workers is from time to time referred also.

With the purpose of preservation of health of the medical workers and pharmacists working in parasitic conditions, the legislation establishes(installed) the abbreviated working day:

- 5-годинннй the working day is established for medical staff, immediately working in rentgenodiagnostics, rentgenophotography, on rotatory roentgen - therapeutic, hamma theraputical installations, for the pathologists, prosectors, anatomists, other specialists working with a corpse material, for medical workers, handling children's entity for mentally retarded children, with a defect of CNS.

- The 4-hourly working day is established for the doctors, mean and low medical staff immediately which was taken up with opened radionuclides.

At transferring for 5-day's working week the week uptime is saved by reallocating working hours of 6-th day 5 day working week.

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.

FUNCTIONS OF DIFFERENT DEPARTMENTS UNDER THE ADMINISTRATIVE SERVICE

ADMINISTRATIVE OFFICE – Directs and supervises the activities and functions of administrative units to effectively deliver quality support services.

1. PERSONNEL SECTION - Development and administration of a comprehensive manpower development program which includes recruitment and selection, promotion, training, employee welfare and benefits, manpower planning and research.

2. PROPERTY AND SUPPLY SECTION - Procurement, storage, inventory, distribution and disposition of hospital supplies, materials, and equipment.

3. HOUSEKEEPING SECTION - Develop and maintain clean, safe and sanitary environment for patients and hospital personnel.

4. LINEN AND LAUNDRY SECTION - Ensure adequate supply of clean linens for patients and hospital units.

5. ENGINEERING AND MAINTENANCE SECTION - Installation, operation and maintenance of electrical, mechanical and communication equipment and allied facilities including buildings and vehicles.

6. MOTOR POOL SECTION (TRANSPORT) - Convey transport patients, hospital officials and personnel to their destination.

7. SECURITY FORCE - Ensure safety of hospital patients, facilities and personnel, maintain peace and order, and enforce hospital rules and regulations.

8. MEDICAL SOCIAL SERVICE -The Medical Social Service function Is to see to it that patients attain emotional equilibrium as they are assisted with other needs which interfere in hospitalization and treatment.

9. MEDICAL RECORDS - Process, maintain, analyze and safe keep all medical records created in this hospital; prepares hospital statistical reports; and formulate and develop effective policies, systems and procedures for the efficient operations of the section.

10. PHARMACY SECTION - Ensures continuous supply of drugs and medicines to patients by maintaining an adequate quantity in stocks of those approved by the Pharmacy Therapeutic Committee. Dispenses, compound drugs for in and out patients. Controls the purchasing, requisitioning, safekeeping and issuing of drugs. Maintains records and files of dangerous drugs and other pharmaceuticals as required by law. Serves as the Drug Informant Center

11. DIETARY SERVICE – Maintain or enhances the health of the patients and personnel by providing them with high quality and nutritious food through an efficient Dietary Service; Provides or serves safe, nutritious and attractive food through careful planning, wise procurement and proper preparation of balanced and satisfying meals within budgetary limits; Implements diet prescription in coordination with physician and nurse; Provides nutrition consultation and education services to patients as well as in-service training to both dietary personnel and other related fields; Promotes and maintains cooperation with other department in the hospital towards total patient care.

12. ACCOUNTING SECTION - Systematic recording of all financial transactions, preparation of financial statements and relevant reports, and maintenance and safekeeping of the hospital’s Book of Accounts.

13. BUDGET SERVICE - Prepares the Work and Financial Plan and provision of fund estimates for hospital programs and projects.

14. CASHIER SERVICE - Receipt, deposit, custody and disbursement of cash/collection of the hospital (Cash Management)

15. MEDICARE AND BILLING SECTION - Admits, classifies Pay and Medicare Patients, orients patient with regard to privileges, obligations, responsibilities during the course of confinement. Prepares statement of account on service and bills rendered to patient. File records, bills and statement of account.

16. INFORMATION AND ADMITTING SECTION

FUNCTIONS OF THE NURSING SERVICE

1. Plans, organizes, and directs the overall nursing service activities in all clinical and special areas in the health fields of maternal and child nursing, medical and surgical nursing.

2. Defines the philosophy, goals, objectives and policies of the hospital, and interprets them to the nursing staff, patients, and the community.

3. Develops the basic, functional and position organization chart that will allow for an open communication horizontally and vertically to ensure smooth operations of the service.

4. Develop program methods of the major functions of the service.

5. Formulates qualification standards, job specifications and job descriptions of various categories of nursing personnel in line with the hospital policies and Civil Service Commission rules and regulations and the Nursing Law.

6. Delegates assignments with commensurate authority to ward supervisors and follows this up.

7. Determines and makes recommendations concerning hospital wards’ facilities, equipment and surgical supplies affecting nursing care, and plans for allocation and utilization of space and equipment to ensure safe environment for patients and working personnel.

8. Formulates and implements nursing care policies and standards operating procedures as guides for the nursing personnel and initiates periodic revision of some as need arises.

9. Determines the staffing needs based on patients’ conditions ranging from the minimally-ill, moderately-ill or critically-ill to ensure smooth operations of the service.

10. Makes general nursing rounds weekly and as the need arises and look into patients nursing needs and ward conditions to ensure safe environment and safe care.

11. Cooperates in providing referral system between the hospital and community health centers and other agencies. Assigns and re-assigns nursing personnel periodically to meet the needs of nursing service. Provides opportunities for growth and development of personnel-recognizes personnel and professional abilities, maintains continuing staff development program. Develops and carries guidance and counseling program.

12. Cooperates with individual/group in other departments or services in carrying forward the work of the hospital as a whole.

13. Supervises and coordinates activities of nursing personnel engaged in specific nursing services such as Obstetrics, Pediatrics, Surgical or Medical, or from two or more clinical nursing divisions.

14. Supervises Senior Nurse in carrying out their responsibilities in the management of nursing care. Evaluates performance of Senior Nurse and nursing care as a whole. Inspects clinical nursing division to verify that patient needs are met.

15. Plans and organizes orientation for clinical nursing division staff members and participates in guidance and education programs. Interviews pre-screened applicants and makes recommendations for employing or for terminating employees.

16. Visit clinical nursing divisions to oversee nursing care and to ascertain condition of patients. Gives advice for treatments medications, and narcotics, in accordance with medical staff policies in absence of physician. Arranges for emergency operations and relocations of personnel during emergencies. Admits or delegates admissions of new patients.

17. Assigns duties to professional and ancillary nursing personnel based on patients’ needs, available staff, and service needs. Supervises and evaluates work performance in terms of patient care, staff relations and efficiency of service. Provides for nursing care and cooperates with other members of medical care team in coordinating patients’ total needs. Identifies and studies nursing service problems and assists in their solutions. Observes nursing care and visits patients to insure that nursing care is carried out as directed and treatment is administered in accordance with physician’s instructions and to ascertain needs for additional or modified services. Maintains safe environment for patients. Operates or supervises operation of specialized equipment assigned to unit and provides assistance and guidance to nursing team as required.

18. Accompanies physician on rounds to answer questions, receives instructions and notes patients’ care requirements. Reports to replacement on next tour on condition of patients or of any untoward or unusual actions taken. May render professional nursing care and instruct patients and members of their families in techniques and methods of home care after discharge.

19. Collects clinical data thru the process of interviewing observations using all senses and clinical instruments and utilization of diagnostic examination reports.

20. Implement nursing actions and legal orders of the physician.

21. Evaluates results of interventions and revise plan to cope with changing conditions of the patient.

22. Endorse patients and give attention to patients’ comfort and safety.

23. Assists the midwife in maintaining cleanliness and orderliness of the unit.

24. Delivers clean medical supplies to patient care units and collect used supplies, instrument sets, rubber goods, etc.

25. Reviews patient’s pre-operative preparation including spiritual.

26. Assists in emergency operations when other professional staff are not available.

27. Makes general assessment of patients in the recovery room and confers with head nurse nursing management of each patient.

FUNCTIONS OF THE MEDICAL SERVICE

TRAINING SERVICE:

1. Provides qualified individuals with practical and scientific knowledge in the diagnosis and treatment of diseases.

2. Installs a sense of responsibility, discipline and compassion in the management of surgical patients.

3. Develops adequate administrative ability and leader- ship qualities.

4. Trains qualified individuals to practice various clinical disciplines in areas where their expertise are needed within the context of national dispersal program.

5. Develops and implements a training strict and fair selection process the admission of resident physicians.

6. Maintains a good atmosphere for teaching and learning in the different clinical departments.

ANCILLARY SERVICE

Laboratory:

1. Prepares the medical graduate in the specialized practice of Clinical and Anatomic Pathology.

2. Prepares future teachers of Clinical and Anatomic Pathology.

3. Gives the physician sufficient skill and experience to practice the science and art of Clinical Pathology Independently and proficiently.

4. Supports the spirit of keeping abreast with the current trends of concepts and practice by reading, experience and research.

5. Imparts to the trainee the role of Clinical Pathology in relation to other fields of medicine.

6. Inculcates the ethic practice of Clinical Pathology.

Radiology

Develops knowledge, attitudes, and skills of professional radiologist at par with the standards of the Department of Health and Philippine College of Radiology and responsive to the country’s needs.

OUT-PATIENT SERVICE

1. Provides quality medical care services to as many out- patient as possible.

2. Provides the widest coverage of quality health care for the people not for curative only but also promotive and preventive health care to minimize the development of diseases.

3. Ensures that health services are always available to the people.

4. Provides health services that is within the financial capability of the people.

5. Provides health services based on what the people really needs and what the h

6. Provides facilities for training of health workers and initiate medical research for the improvement of the quality of health care.

EMERGENCY SERVICE

1. Provides a plan for the reception area and treatment of patients who need emergency services.

2. Provides a well organized with adequate facilities, adequate enough to assure prompt diagnosis and the institution of appropriate emergency attendance for care and management.

3. Checks the medicine cabinet in the Emergency Room if the necessary emergency medicines are available for the next 24 hrs.

IN-PATIENT SERVICE

1. Provides, develops and adopts a patient care system of its own befitting appropriately its particular needs.

Emergency Physician Rights and Responsibilities

Emergency physicians typically practice in a hospital-based setting. In nearly all cases, such practice is pursuant to a contractual arrangement on which practice at the hospital is based. The legitimate purpose of such contracts is to ensure the efficient and reliable staffing of the emergency department (ED). However, such contracts also often limit or eliminate the rights physicians otherwise have under the medical staff bylaws and contain other provisions that may compromise the professional autonomy of physicians. Consequently, such contracts may harm the public interest.

The American College of Emergency Physicians (ACEP) believes that high-quality emergency care is best provided when emergency physicians practice in a fair and equitable environment. To provide guidance to physicians and others with respect to contractual arrangements involving the practice of emergency medicine in a hospital-based setting, ACEP hereby adopts this statement of Emergency Physician Rights and Responsibilities.

This guidance should be of value to hospitals, physicians, and professional or business entities contracting with individual physicians or groups of physicians for the provision of emergency care in hospitals. It is anticipated that these guidelines will benefit the profession and the public. These guidelines are not intended to dictate individual contracting practices; rather, ACEP members must make independent determinations regarding their employment and contractual relationships with hospitals, practice groups, and other entities based on their individual circumstances.

Rights of Emergency Physicians

Emergency physician autonomy in clinical decision making shall be respected and shall not be restricted other than through reasonable rules, regulations, and bylaws of his or her medical staff or practice group.

Emergency physicians have a right to expect adequate staffing and equipment to meet the needs of the patients seen at the facility and to have the institution provide support to improve patient safety. Emergency physicians shall be provided such support and resources as necessary to render high-quality emergency care in the ED setting and shall not be subject to adverse action for bringing to the attention of responsible parties deficiencies in such support or resources when done in a reasonable and appropriate manner.

Emergency physicians shall be reasonably compensated for clinical and administrative services and such compensation should be related to the physician qualifications, level of responsibility, experience, and quality and amount of work performed.

Emergency physicians shall not be required to purchase unnecessary, unneeded, or excessively priced administrative services from a hospital, contract group of any size, or other parties in return for privileges or patient referrals.

Emergency physicians shall be provided periodic reports of billings and collections in their name and have the right to audit such billings, without retribution.

Emergency physicians shall be accorded due process before any adverse final action with respect to employment or contract status, the effect of which would be the loss or limitation of medical staff privileges. Emergency physicians' medical and/or clinical staff privileges shall not be reduced, terminated, or otherwise restricted except for grounds related to their competency or professional conduct.

Emergency physicians who practice pursuant to an exclusive contract arrangement shall not be required to waive their individual medical staff due process rights as a condition of practice opportunity or privileges.

Emergency physicians shall not be required to render anything of value in return for referral of patients by a hospital (e.g., through the awarding of an exclusive contract) other than assurances of reliability and high-quality care; nor shall emergency physicians receive anything of value in return for referrals of patients to others.

Emergency physicians, both independent contractors and physician employees, shall be represented in the contract negotiation process between hospitals and those payers providing reimbursement for emergency services. Emergency physicians are entitled to fair rights and reimbursement pursuant to such contract agreements.

Emergency physicians shall not be required to agree to any restrictive covenant that limits the right to practice medicine after the termination of employment or contract to provide services as an emergency physician. Such restrictions are not in the public interest.

Responsibilities of Emergency Physicians

Emergency physicians bear a responsibility to practice emergency medicine in an ethical manner consistent with contemporary emergency medicine principles. Emergency physicians must maintain current emergency medicine knowledge and skills through independent study and continuing medical education (CME) activities.

Emergency physicians should exhibit professionalism in the ED in regard to behavior, attire, and reliability.

Emergency physicians should participate in medical staff and/or hospital affairs with the support of the ED medical director.

Emergency physicians should gain knowledge of the basic principles of documentation, coding and reimbursement, recruiting costs, coding and billing costs, practice expense costs, and other applicable physician administration costs, to assist in accurate billing for their services and to properly interpret practice revenue and expense information which they receive.

Emergency physicians must maintain knowledge of and compliance with major federal and state regulations that affect the practice of emergency medicine, such as the Emergency Medical Treatment and Active Labor Act (EMTALA).

Emergency physicians who are employees, contractors, or principals of a practice group, during the course of the relationship, have certain duties and responsibilities to the group. Active efforts, during the relationship, to interfere with or acquire a contractual relationship of the practice group may expose the individual to legal liability.

On-Call Responsibilities for Hospitals and Physicians:

USA Today and the Los Angeles Times recently reported on the refusal of specialists to come to the hospital when called to care for emergency room patients. The newspapers alleged that specialized treatment sometimes isn't available because doctors won't come in when called, won't volunteer to be on call in the first place, or simply are not available.

While these cases appear to be isolated, they strike at the heart of the public's confidence in what hospitals do. They are part of a larger concern about both caring for and being accountable to our communities. That's why it's important to continue to make sure your organization is doing everything it can to provide all patients with the care they need when they need it.

Make sure you're following the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) and its regulations. Be aware that a number of jurisdictions have state-based EMTALA laws that should be followed with the same rigorous attention to detail. EMTALA is intended to ensure that all patients who come to the emergency department receive appropriate care, regardless of their insurance or ability to pay. Hospitals are required to provide patients with a medical screening examination to determine if they have an emergency medical condition and, if so, to stabilize their condition. The law prevents hospitals from transferring patients until they're stable, unless the expected benefits of transfer outweigh the risks or the patient has made a request to be transferred. Violations carry penalties of up to $50,000 per incident and possible exclusion from Medicare and Medicaid.

After reviewing this advisory, check off the following items from your to-do list:

Make sure your hospital's medical staff bylaws and emergency department policies regarding on-call physician responsibilities are consistent with EMTALA's requirements.

Review EMTALA with your medical staff (including residents and interns), governing boards, senior managers, nurses and key personnel. Share copies of hospital emergency department policies and procedures with them. Determine when medical staff had its last training session on EMTALA. Consider whether it's time for a "refresher" course.

Engage your community on this issue. Have your community and media relations' teams speak candidly to community leaders and local media about your policies...your procedures...your commitment to ensuring quality care.

Encourage your medical staff, nurses, and other health care professionals to consult your hospital's risk manager for assistance and advice on EMTALA and its on-call requirements.

Background

In the vast majority of communities, the "on-call" system works well. It's largely invisible to the public, but is one of the cornerstones of good hospital care. Physicians respond night and day - take time from family and other activities - to be there for patients who are brought to their community hospital.

"On-call" duties come with the privilege of practicing in a hospital. They are a covenant between physician and hospital as part of their mutual responsibility to all patients who come to the hospital door. Physicians who break that covenant call into question their medical staff privileges. Every hospital should have policies to ensure appropriate "on-call" coverage of the emergency department by specialists and sub-specialists.

Hospital and Physician Requirements

Hospitals and physicians, including on-call physicians, who violate EMTALA may face stiff penalties. They could include civil fines of up to $50,000 per violation or exclusion from participating in the Medicare and Medicaid programs. Specifically:

§ Hospitals must maintain a list of physicians, including specialists and sub-specialists, who are on call to evaluate and treat patients in the emergency department.

Hospitals are responsible for ensuring that on-call physicians respond within a reasonable period of time.

The medical staff bylaws or policies and procedures must define the responsibility of on-call physicians to respond, examine, and treat patients with emergency medical conditions.

Although physicians are not required to be on call at all times, hospitals must have policies and procedures that are followed when a particular specialty is not available or on-call physicians cannot respond because of situations beyond their control (for example, if the physician is performing another surgery).

In most cases, on-call physicians must come to the hospital to examine the patient when a request is made for their services. If, however, their offices are located in a hospital-owned facility on contiguous land or on the hospital campus, the patient may be seen in the physician's office.

If a hospital transfers a patient to another facility because an on-call physician fails or refuses to appear, it must give the on-call physician's name and address to the receiving hospital. Failure to provide this information would violate EMTALA.

House staff responsibilities include the following:

Provide initial medical care to assigned patients in ambulatory/outpatient or inpatient settings appropriate to the resident's experience and ability.

Patient care responsibilities assigned to residents will be commensurate with their level of training, according to ACGME Special Requirements for the training program, and the judgement of the program director and the attending physician.

Where appropriate, formulate a plan of care based on a thorough assessment of the patient's history, current condition, and needs.

Write orders for the implementation of the plan of care.

Coordinate consultations with physicians and other members of the multi disciplinary health team.

Facilitate communications regarding the plan of care with the patient, family, attending physician(s), and any other involved member(s) of the health team.

Perform and/or assist in procedures according to the level of delegation appropriate to the resident's experience and ability.

Adhere to the duty hour regulations and policies of the School and submit hours worked as mandated by the School and/or program.

Participate in education, research, and patient care experiences required by the particular program within which he/she is a trainee.

Supervise and teach other house staff and medical students as appropriate.

Adhere to the affiliated hospitals' policies and procedures for the medical staffs including the "Bylaws, Rules, and Regulations for the Medical Staff" of each hospital and the School of Medicine "Personal Information for House Staff."

Before rotating to another assignment, complete and sign all medical records, charts, and reports assigned to him/her in a timely fashion.

Participate in institutional orientations, relevant committees, projects, and other leadership assignments and activities involving the clinical staff.

Demonstrate the knowledge and skills necessary to provide care, based on physical, socioeconomic, psychosocial, educational, safety and related criteria, appropriate to the age of patients served in the assigned service area.

Reflect a fundamental concern with and respect for patients' rights.

Develop an understanding of ethical and medical/legal issues surrounding patient care, hospitals' policies governing these issues, and structures available to support ethical decision making.

Sensitive to and apply cost containment strategies while caring for patients.

Conduct him/herself professionally, ethically, and personally in a manner consistent with the standards and aims of the medical staff of the affiliated hospitals and the School of Medicine.

Develop and participate in a personal program of self study and professional growth with guidance from the teaching staff.

Participate in the evaluation of the program and its faculty.

Nosocomial infections (NI) -infectious diseases connected to stay, inspection and treatment in medical-preventive institutions or reference (manipulation) in these for the help.

The transfer of microorganisms can occur:

1. by an aerogenic way.

2. by fecal-oral way

3. by parenteral introduction

4. by the contact

Table 7.7 Risk factors of hospital environment decreasing the resistance of organism to infecting:

Infringement of protective barriers

-constant cateter

-dialysis

-drainage

-tracheostoma

-wounds (especially combustions)

-operations

-punctions of skin: injections and venepunctions

Neutropenia

Antibiotic treatment

Marrow disease

Decreased activity of neutrophylic white blood cells

-chronic granulematous diseases (TB, MFD, lues, actinomycosis)

-acydosis

Cell immunity supression

Hodgkin disease

Swiss type of α-immunoglobuline

Sarcoidosis (Kashine-Beck disease)

Etc

Hypoimmunoglobulnaemia

Treatment with steroides, antibiotics

Lymphosarcoma

other

There are some modern classifications of nosocomial using now:

I. Based on ethyology:

Viral NI:

1. HIV (AIDS)

11. Mixoviridae (influenza)

12. RSV (respiratory-syntitial infection)

13. Rhinovirus (" common cold ")

14. Paramixoviridae (paragryppus, measles)

15. Herpeviridae (herpetic infection)

16. Adenoviridae (adenoviral infection)

17. Cytomegalovirus

18. Enteroviridae (Coxaki, ECHO, polio)

19. vira HA, HB, HC, HE.

chlamidical: epidemic conjunctivitis, (very seldom - ornithosis or trachoma)

bacterial:

1. Staphylococci (Gr +)

2. Streptococci

3. Klebsiella (Gr-)

4. Pseudomonas

5. Neisseria

6. Legionella

7. Lysteria

8. Clostridia

9. Proteus

10. Serratia

11. Enterobacterioceae

12. Mycoplasma

13. Mycobacterià

fungal:

1. Candida

2. Actinomyceta

3. Nocardia

protozoic: Pneumocysta carinii

By the transmission way

I. With aerogenic spreading:

1. · adenoviral infection

2. · cytomegaloviral infection

3. · Influenza

4. · paragryppus

5. · measles

6. · rubeolla

7. · pneumonia (for example: Fridlender pneumonia or disease of Legioners)

8. · dyphtheria

9. · pertussis etc.

II With a fecal-oral way of transfer:

1. · poliomyelitis

2. · viral hepatites A and E

3. · toxicoinfection, bacteriotoxicoses (microbic food poisonings)

4. · dysenteria

5. · salmonellosis etc.

III. With the parenteral transfer:

1. HIV-infection

2. Virus of hepatites B, C, D etc.

IV. With a contact way of transfer:

1. · wound infection

2. · implantation infection

3. STD (??)

By localization:

1. generalized forms:

1. sepsis

2. meningitis

3. osteomyelitis

2. Located forms:

Infections of a skin and hypoderma:

1. abscess

2. phlegmona

3. mastitis

4. conjunctivitis

5. otitis

6. endometritis

Urogenital infections: uretritis, custitis, pyelonephrites

Respiratory infections:

1. ARVI

2. legioners’ disease (Pitsburg fever, fort Pontiac fever)

3. gastro-intestinal path: - gastroenteritis

4. enteritis

5. colitis

6. wound infection (including postinjection complication):

7. erysipelas

8. pyogenesis

9. (Cr??)

Other: viral hepatites

About "iatrogenic" nosocomial infections they speak, when the direct reason of disease is the rough infringement of medical technology by the personnel .

Among directions of preventive maintenance of NI it is possible to allocate two basic:

1. Unspecific preventive maintenance - covers architectural - planning measures, sanitary - antiepidemic measures, sanitary - technical measures;

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

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.

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.

INTRAHOSPITAL INFECTION

The world every year millions of people go for treatment. More people go to ambulatory treatment-prophylactic establishments. The main aim of medical workers is full and fast recovering of patients’ health. Not less important is formation of favourable conditions for people’s being in medical establishments and liquidation of influence on them pathogenic factors of hospital environment. There is action on the organism of many factors of physical, chemical, biological and social nature which condition dveelopment of intrahospital infections (hospitalism), appearance of new suffering, increase of their staying in the hospital, severity of disease course, additional economical and work payments.

Hospitalism in wide understanding is a disease caused by hospital factors. This notion is used everywhere where are sick people or people who need treatment, get medical help, for example, in hospital, polyclinic, at home, in health puncts etc. Hospitalism is considered to be any psychical or physical disorders of human health, caused by specialities of medical service (Pic. 1). The term “intrahospital infection” means different infectious diseases which patients have due to treatment in the hospital or people which have diseases due to medical activity. The synonim of this term is “nosocomial infection” meaning the infection got by patient in the hospital.

Hospitalism

Physical Chemicall

Accident in the Hospital

Hospital infection

Adapted hospital Not adapted hospital

Stammes stammes

Sporadic Endemic

Among pathogenic factors of hospital environment the first place has intrahospital (hospital, nosocomial) infection. Last years it had important meaning for all countries in the world. It appears in more than 5% of surgical patients, and in 25% of them it is the reason of death. Health and life of people motly depends on state of fight with intrahospital infection. Doctors should also be protected from them.

Table 1. Frequency of hospital infections in USA

Medicine branch

Frequency of infection, %

Therapy

Surgery

Gynecology

Pediatrics

Obstetrics

5,9

5,4

4,9

1,8

1,5

Special attentio should be paid to that medical establishmetns should not be teh source of infection spreading among population. Prophylaxis of hospital infection requires not only large money expands connected with building, buying of equipment personal and organizing measures, but also high level of general and professional preparation of medcial staff on prophylaxis of infections during treatment and patients’ care. Workers and patients should know about connection between hygienic way of behaviour and correct nutrition and health. Rich experience of medical staff influences on it.

Hospital infection are diseases:

1. which have appeared after polycinic visit

2. abscesses ofrmed after operation

3. cystitis and urethritis adn catheterization and cystoscopy

4. infectious hepatitis

5. conjunctivitis and keratitis

6. purulent and fungal infections

7. infections appeared due to not keeping of aseptic during prophylactic observations

8. trichomonadous colpitis

9. trachoma

This group includes also:

1. additonal infections (mastitis in mothers, sepsis in newborns, pneumonia during measles etc.)

2. superinfections (for example, patient with scarrlet fever gets salmonelosis, pneumonia in measles etc.)

3. Cross infections when there is a transmittance of infection from one patient to another

4. Infections which appear due to activetion of own flora (ofr example, in patient with viral infection of upper respiratory tract might develop pneumonia, after operation – tetanus, gangrene)

Localization of hospital infections is reflected in Table 2. Localization of hospital infections in patients in USA hospitals

Localization

Quantity of infectious diseases, %

Generally medical

Children

Respiratory tract

Urinary tract

Wounds

Eye, throat, nose, pharynx

Skin

Primary bacteriemia

GIT

1,67

1,62

0,78

0,32

0,31

0,19

0,05

0,78

0,79

0,78

–

0,48

–

0,15

There may be cases when a man suffering from some disease gets to the hospital in incubation period of some other disease or gets out of the hospital in incubation period of acqiured disease.

For spreading of hospital infections the important meaning have transmitters and recipients. Transmitters may be people (sick, bacterial carriers, personnel, visitors), animals (bugs, mice) or materials (subjects, dust, water, food). See Pic. 2

In hospital conditions spreading of infection may be by such ways:

1. Infection of skin, mucosal membranes adn wounds as a result of direct contact;

2. Oral infection through dirty subjects by alimantary way or through medicines;

3. Through skin infication, mostly during injections, more rarely by bugs’ bites;

4. Aerogenic infection with dust or droply;

5. Transplacentar infication

Very often the same causative agent is transmitted by differetn ways and different causative agents are transmitted by the same way. In case if this revealing of these processes becomes harder.

The most epidemic meaning have contact infections through dirty subjects and iatrogenic infections. The main link of epidemic chain in hospitals are hands of patients, hair, shoes, robes adn other subjects.

Aerogenic infections have 10% from all hospital infections. Only in catar of nasal pharynx drop infection has big meaning. Aerogenic infection mostly develops in aptients with weakened protective function of upper respiratory tract, newborns and people with tracheotomia.

There is possible infication of the organism by:

1. the same kind and type of causative agent

2. the same kind, but different type of causative agent;

3. The same kind of microbes aand the same type of causative agent, but with different resistance;

4. Another kind of causative agent.

Hospital infections as a rule depend on;

1. quantity of microbes;

2. intensity of contact;

3. temporary interval.

They must be blocked after 3-5 persons. But there should be taken into account that every contact person may be source of infection. As to newborn infections there is no one thought about who is the main in transmittance of infection, mother or child.(Pic.3)

The special kind of hospital infection is autoinfection (endogenic, autogenic), It appears due to weakening of natural organism’s immunity. Autoinfection is caused by microbes which in particular conditions are situated on skin or mucosa during months or even years or are a part of local flora. The spcail role in developemtn of autoinfection belongs to bacteroides and clostridia (more often in patients who had abdominhal operations), b-haemolytic streptococcus of A group and other microorganisms.

Sources of hospital infection are different:

1. infectious patients got into the hospital with mixed infection

2. soamtic patients who didn’t keep the time og quarantine

3. carriers of pathogenic staphylococci, streptococci, intestinal infections, poliomyelitis.

Causative agents of hospital infections are:

1. air-drop infections (influenza, scarlet fever, measles)

2. staphylococcal and intestinal infections

3. transfusional (serum hepatitis).

1. We might notice that due to selection medical establishments are with microbes of particular kind or type. Those stammes are called problemic or hospital microbes. They are microbes living everywhere adn having very high possibility to spreading. The reason of this is relativelt high resistance to injuring physical and chemical factors of environment, not needing of particular growth and reproduction conditions; closeness to microbes with normal microflora.

In 1969-1970 center of infection control in USA hospitals registered 29 epidemies: 9 caused by salmonella, 4 - by hepatitis virus, 3 – by staphylococci, streptococci and pseudomonas, 2 – by klebsiella.

There is no causative agent not taken into hospial and not caused any infection. Viruses of hepatitis and cytomegalia are widely spread in hospitals. It may be that viral epidemies in most cases are transmitted by patients. The question about selection of viruses in medical establishments is shortly studied.

Reservoir of intrahospital infection are bacillar carriers.Causative agent might be situated on different parts of human body. On skin of patients and personnel there are found staphylococci, E.coli, enterococci, chlamidia, mycoplasma, anaerobes, salmonella, adn fungi-dermatophytes. Hair is also a reservoir of staphylococci. Nasal cavity is an important reservoir of infection, especially in wards of newborns. In personnel and grown up patients in 70% cases there was found St. aureus. During epidemies there were found rhinoviruses, viruses of influenza, paragrippe, measles, adenoviruses.

Oral cavity can also be an infection reservoir, especially staphylococci. In newborns on 5^th day the number of staphylococci carriers reaches 60%.

In newborns eyes and umbilicus are especially sebsitive to infection. Thus, on 2-3 day of life in 70% eyes are filled with staphylococcus aureus. That’s why for prophylaxis and treatment in newborns on 1^st week of life it is necessary to take smears from eyes every 2 days.

There is a possibility of newborn infection through milk of own mother. Gathered breast milk is even more dangerous. It may be used only in constant bacteriologic and mycologic control. In other cases such milk must be pasterized.

The big meaning for contact infection and autoinfection of patients in urology, gynecology, obstetrics, surgery of abdominal cavity, in burn centers has intestinal flora. In feces of patients being in medical establishments there are found: enteroviruses, E. Coli, shigellas, salmonellas, St. aureus, fungi.

In hospital ward microbes are situated on baths, electrical turners, doors, floors, beds, shaving sets and food.

The most massive inseminated by microbes are hats, robes, shoes and pants of medical staff. Sometimes the environment of microbes localization are injectional solutions in broken ampules, washing and desinfecting solutions, solutions for keping of instruments and thermometers. Microbes may be situated in distilled water (to 10⁸ per ml)

To risk factors of developemtn of hospital infection belong:

1. time of operation

2. infication of the wound

3. length of incision

4. usage of drenages

5. old age of patients

6. time of hospotalization before the operation

7. usage of antibiotics

8. presence of diabetes mellitus

9. malignant formations.

Number of hospital infections in all clinics stayes in average 5-10%. The first role in appearance of hospital infections belongs to:

1. infecting dose

2. resistance of causative agent

3. organism resistance

4. accepting of human organism

5. ways of transmittance of causative agent

6. physical factors of environment.

Reasons of spreading of hospital infections are very different which makes their treatment harder. On one hand, these are changes of living environment and properties of microbes, presence of mroe virulent stammes resistant to antibiotics and different desinfecting agents. On the other hand, it is appearance of more difficult operations, wide, and often not rational and not systemic usage of antibiotics, not lkekeping of sanitary regime in hospitals (overloading of wards, disorders in ventilation system etc.). The special role in this belongs to aseptics rules.

Very important is education of “prophylaxis feeling” in doctors and middle medical staff. Aimless work in stationar leads to loss of attention to necessity of correct execution of instructions from aseptics.

Hospital infections give also big economical losses. In Britain 7-10% of patients transmit hospital infection. Connected with purulent processes duration of patient’s being in the hospital increases from 13 to 36 dyas, mortality among adults increases from 4 to 23%, among children – from 10 to 33%, adn in septical states – in 14 times. In USA hospital infections lead to diseases of 2 mln people (6.3% of all patients being treated in hospitals). Economical losses are 10 billion dollars every year.

Children being in the hospital get many infections. The nore the child stays in the hospital, the more antibodies to more viruses he (she) has in blood. During children’s being in the hospital from 1 to 10 days staphylococci carrying is found in 38%, from 11 to 20 days – in 62%, more than 3 weeks - in 73.6% of observed.

Presence of strangers in departments may be dangerous for patients, especially for children. It is proved that in children and their mothers there is high titer of antibodies to the same viruses. It says about cross infection of children and mothers. Staying of the child in hospital is prolonged for 14.2 days.

Fight with hospital infections is difficult, because causative agents as a rule circulate in intrahospital environment, have high resistance to external influence, and mechanisms of transmittance are different. Thus sure methods of specific prophylaxis of hospital infections are absent, it is necessary to provide complex of non specific and specific measures (Pic.4).

Non specific methods of prophylaxis are architecture-plannig measures to preventthe cusative agents’ spreading by isolation of ward sections from operation blocks. They include isolation of patients in wards. It can be strict, standard and warning.

Strict isolation: separate room, the patient should not go out of there. There are needed protective robes, gum gloves, repiratory masks with filter, hands are desinfected before going out of the room.

Standard isolation: separate room, the patient should not go out of the room, it is needed only in aerogenic infection. Protective robes are used only in dirct contact with patient, it is not necessary to protect mouth and nose (excluding people with high predisposition to infections which use respiratory mask with filter), gum gloves are not needed too (excluding those cases when it is necessary to contact with infected body surface).

Preventive isolation: separate ward, the patient should not go out of it, protective robe which should be put on in going in, there must be protection of mouth and nose, desinfection of hands in going out of the room, gum gloves during medical and sanitary care of the patient.

Such instructions are relative, because antiepidemic measures depend on the way of patient’s getting into the hospital – because of infectious disease, whe ther it was a hospital infection. There also must be known if the infection was hospital or not.

Effecttiveness of sanitary-hygienic measures is provided by keeping of every require, sanitary culture of patients and medical staff, correct providing of bacteriologic control, revealing among the personnel and patients the carriers of pathogenic bacteria and their sanation .

The second important chain of prophylaxis of hospital infections are specific measures aimed on increase of organism’s resistance to hospital infections. Effective specific prophylaxis includes measures aimed on prevention of disease development in people in case of their infication. Its aim is formation of organism’s resistance in limits of incubation period. For example, with the aim of specific prophylaxis of purulent inflammatory diseases in mothers and newborns there is provided planned active immunization of pregnant women by purified staphylococcal anatoxin.

Depending on the character of measures urgent prophylaxis may divided onto specific and general. For specific prophylaxis there are used preparations of direct action (staphylococcal absorbed anatoxin, antistaphylococcal gamma-globulin, staphylococcal bacteriophage), for general – antibiotics of wide action spectrum, general st renthening preparations.

Desinfecting and sterilizatory measures are directed on elimination of causative agents on subjects, materials, instruments. With this aim there are many physical and chemical methods and measures.

In differents cases depending on department’s specificity they increase this or that method of prophylaxis or it is done by complex way.

In adenoviral infection the big meaning belongs to personal hygiene: you must not cough or sneeze to the side of the other person, to keep perfectly the rules of aseptics during eyes’ investigation (desinfect tonometer, to use sterile eye drops), standard isolation with epidemic conjunctivitis in separate ward or section, to provide periodic and final desinfection.

Actinomycosis, anabiosis, teniidosis. There isn’t needed patient’s isolation. But because the excretions are contagious, tehgre must be provided periodic and final desinfection.

Brucellosis. Standard isolation of the patient in ward-isolator or in isolatory section.There is possible aerogenic way of infection, doctor must be careful in purulent injuries.

Candidosis. Infection of patients with normal immunity is hardly possible. Patients with high predisposition to infectious diseases and newborns must be separated from patients with candidosis. Propylaxis of newborn candidosis: smears from vagina in third trimester of pregnancy, in positive results – group isolation of newborns with periodical and final desinfection.

Coxaciviral diseases. Periodical and final desinfection.

Diarrhea of not found origin. The patient is isolated in the ward or section during the disease, periodical and final desinfection.

Diphtheria. The patient is isolated in infectious hospital even in suspection on the disease till they get negative bacteriologic result. People who excrete the causative agent for a long time are hospitalized for 8 weeks, carriers of atoxigenic causative agent – for 6 weeks, people with presence of chronic bacteriocarrying must be sanated through tonsilectomia. The important thing is providing of periodical and final desinfection. People who were in contact with sick with diphtheria are injected with immune serum. Personnel being in contact with sick patient are isolated for 7 days from the medical establishment for abcteriologic and clinical control; prophylactic injection is provided obligatory.

Vaccinary eczema. There must be strict isolation of patient in infectious hospital in isolator during all period of the disease till desquamation.

Coli infection. There is provided standard isolation of patients in section, periodical and final desinfection. All rooms, equipment, instruments should be clean.Wet cleaning of rooms must be provided not less than 2 times per 24 hours using washing and disinfecting solutions.

Usage of synthetic washing powders is not allowed. All the equipment for cleaning must have clear marks, where rooms and kind of washing is indicated. It must be used only by instructions and kept separately.

General cleaning of wards and other functional rooms must be provided according to the timetable not less than 1 time per month with cleansing of walls, floor, all equipment, wardrobes, lamps from dust. General cleansing of operation blocks, delivery halls is provided 1 time for a week with freeing from equipment. There must be 3 months storage of cleaning and disinfecting solutions. There must be special dishes for trash in corridors, toilets and other rooms.

Rooms which require special regime of sterility, aseptics, antiseptics (operation rooms, reanimation wards, wards of newborns and not carried children to 1 year, procedure rooms, infectious boxes) must be radiated by ultraviolet of mobile bactericidal lamps (1Wt for 1 m3 of room).

Every week rooms should be cleaned (washing of walls, cleansisng of glass from dust) using washing and desinfectory solutions.

Air regime of the hospital should be kept too. Wards and other rooms which need coming of fresh air must be ventilated not less than 4 times per day.

Every year (or even more often) there is provided “refreshing” of rooms. Elimination of different defects should be provided without any waiting.

Providing of hospitals with clothes is according to norms in enough quantity. In obstetrics sterile clothes are used. Dirty clothes from the patients is gathered into special gum or polyethylene bags and is kept in special rooms. Its sorting in departments is prohibited.

Medical personnel of hospitals, delivery houses must be provided with complects of hcangable work clothes: robes, hats, shoes. Clothes should be kept in individual wardrobes. Washing of robes is provided centralizely and separately from patients’ clothes. Medical personnel of hospitals should be perfectly clean. Changeable shoes and clothes is also to be for medical staff of other departments which give consultations and other help.

It is prohibited to be in special clothes and shoes out of medical rooms. Students should also be provided with special clothes and shoes.

Special attention is paid to regime of dish washing. Things for dish washing and tables’ cleaning are boiles during 15 minutes or stay in 0.5% solution of calcium hydrocarbonate during 60 minutes, then they are dried and kept in special places.

Special attention is paid to keeping of sanitary-antipidemic regime in the hospitals.

Giving of qualified methodical help to sick newborns is provided in specialized departments of children’s hospitals and perinatal centers. Ther is strict isolation of infectious patients from somatic. With this aim in departments for patients with purulent-septic pathology, acute respiratory infections and pneumonias, acute intestinal infections there must be boxed rooms which work as infectious stationar. Consultations of patients with infectious and somatic pathology are to be provided in different rooms.

The most oten pathologies in newborns are omphalitis, pyodermia, pneumonia, acute respiratory diseases, diseases of skin and subcutaneous fat, acute intestinal (gastroenteritis, colitis, enteritis) and generalized infections (sepsis, osteomyelitis, meningitis), The main sources of hospital infection are newborns with purulent inflammatory and other infectious diseases, and also mothers and medical personnel.

For prophylaxis of hospital infections consultations for children are provided in special rooms which consist of not less than 2 boxes where newborns are taken. Observation of newborns is provided on special table covered by easily cleaned material.

After observation of every child the covering of the table is washed or two times cleaned by dust with desinfecting solution. Before and after child’s observation medical staff washes hands with soap and dries them and hand dryer.

If the newborn child has infectious pathology of skin, then hands are treated with wet cotton with deesinfecting solution: 2.5% (0.5% by active substance), water solution of chlorhexidine bigluconate; 1% (by active iodine) solution of iodopirone or 0.5% (0.13% by acrive chlorine) solution of chloramine during 2 minutes. After cleaning hands are washed with soap.

After observation the child is clothed and moved to particular department. Used during observation wood stick is put into special closed dish, and then destroyed, and dish is desinfected. Metal sticks are desinfected. Thermometers are put into desinfecting solution. Used clothes are put into polyethylene bags.

After finishing of change the room must be cleaned. During this walls, equipment and floor is treated with usage of desinfecting solutions. During 60 minutes is radiated with bactericidal lamp after this. Then it is cleaned one more time, radiated duirng 30 minutes more, after that it is ventilated.

If the child was taken into the hospital with the mother, the odctor must look also the mother. He looks her throat, skin, hair, measures her temperature. If he reveals infectious disease or suspects it, increase of temperature, pediculosis, she is not hospitalized and should not visit the child in the hospital.

Hygienic and Sanitary regime in surgical profile. After every patient the wardrobe is to be desinfected, clothes (which were under treating for vegetative forms of microbes) on bed are to be changed. If there is such possibility, the cyclicity of wards’ filling is kept. In case of dirtiness clothes are to be changed not rarer than 1 time for 7 days.

Dirty clothes are gathered into special bags made of wool or into closable dishes. It is prohibited to put dirty clothes on the floor or directly into gatherers. Sorting of dirty clothes is provided in special buildings out of the department. After clothes change subjects in the ward are treated with desinfecting solution.

The patient gets individual subjects of care which are gathered and washed just after usage. After delivery of patient subjects of individual care are desinfected.

It is absolutely prohibited to take into surgical department soft toys and other subjects that cannot be desinfected.

Patients with purulent septical diseases adn postoperational purulent complications are to be isolated into separate wards where are ultraviolet bactericidal radiators of closed type. In such wards staff works in robes, masks, hats that after work are to be changed. Independent moving of patients from ward to ward and outside is prohibited.

Delivery of patients is provided in separate room. Shoes after delivery of patient’s death is cleaned by 25% solution of formaline or 40% soltuion of acetic acid or treated from aerosol ballon “Sapozhok 74” till full wetting of inner surface. Then shoes are gathered into polyethylene bag for 3 hours. After that it is put out and ventilated during 10-12 hours.

There should be operation rooms for clean and purulent operations. In case of absence of those conditions o0perations in case of purulent processesare provided in specially marked days with future desinfection of operation block and all equipment.

Sterilization adn desinfection of subjects of medical usage consists of presterilization cleaning, sterilization and desinfection.

With aim of elimination of protein, lipid and mechanical dirties all medical equipment are to be cleaned before sterilization. Cleaning is provided by hand of mechanized way using surface active substances. Cleaning solutions are prepared on drinking water. There may be used different desinfecting solutions allowed by Ministery of Health Care. For presterilizatory cleaning it is allowed to use hydrogenium oxide (medical or technical, marks “A” or “B”).

Using washing solution with 0.5% of hydrogenium oxide 0.5% SWS “Lotos” there must be obligatory added 0.44% sodium oleate – corrosium inhibitor.

Instruments with blood directly after operation or procedure ar put for 60 minutes into solution of corrosium inhibitor in temperature 22±5 oC. After that they are well washed with water and kept for 15 minutes in synthetic washing solution in temperature 40-50oC. Every instrument is washed with the help of brush or cotton ball, washed in water for 3-10 minutes, then in distilled water and dryed by hot air (temperature 85oC) to complete elimination of water.

Surgical instruments from steel after washing in water are kept in solution of acetic acid (5 g) and sodium chloride (1 g) in distilled water (to 100 cm3) during 2-6 minutes in temperature 20oC.

All instruments that have contact with wound surface, blood, injectional preparations or mucosa and may cause its damage are to sterilized.

Instruments from glass and metal after drying are packed into special bag paper, sterilized in sterilizatory camera in temperature 180oC during 60±5 minutes. Sterilized instruments may be kept during 3 days, without package should be used immediately. Sterilization may be provided by saturated watery air under residual pressure: 2 kg?cm2, temperature 132oC, 1.1 kg/cm2, temperature 120oC, 45 minutes.

Instruments used during purulent operations ro operative procedures in infectious patient before presterilizatory treating and sterilization are desinfected. There should be desinfeted also instruments after operation, injection in patients who had hepatitis B or viral hepatitis, and also those who are the carriers of HB5-antigen.

Desinfection of instruments from glass, metal, thermic polymer materials and gum is proveded by boiling, hot steam, air, chemical method. Boiling is provided in distilled water or in 2% solution of sodium hydrocarbonate (drinking soda) during 30±5 minutes. Desinfection by steam is provided in pressure of steam 0.5 kg/cm2, temperature 110oC during 20±5 minutes.

Sterilization by dry hot air is provided in temperature 120oC druing 45±% minutes and is recommended for instruments from glass and metal inspecial dishes without package.

Chemical sterilization is provided for instruments from glass, corrosium resistant metal, polymeric materials, gum. During this there are used such chemical solutions as trial solution (formalin-2%, phenolum-0.3%, sodium hydrocarbonate-1.5%); 1% solution of chloramine, 3% solution of hydrogenium peroxyde, 3% solution of formalinum, 2.5% solution of gibitan, 1% sol of dichlor-1, 0.5% sol of chlorcinum, 0.25% sol of dezamum, 0.25-1% sol of calcium hypochlorite. Time of exposition in different solutions is different and varies from 15 minutes (in dezoxane-1) to 60 minutes (hydrogenium peroxyde).

For prophylaxis of hospital infections the big meaning has keeping by medical personnel of rule of personal hygiene. All workers going to work in hospital have obligatory medical observation. In future workers of kitchen and medical staff who directly cares for patients have medical observation every month, and one time in a year – investigation for bacilli carrying of intestinal infections and diphtheria.

Workers having diseases dangeous for patients are not allowed to work. With this aim all medical personnel has X-ray investigation fro tuberculosis, veneric and skin diseases.

Every day starting to work medical personnel should take off the clothes, wash hands with soap, put special clothes (robe, hat, mask for nose and mouth). Special clothes should be perfectly clean, ironed, of needed size.

Every time after dirty work personnel should wash hands with hot water and soap, and if needed, to treat them with desinfecting solution,m such as 0.2% lightened solution of chlorinated calcium hydrocarbonate, 1% solution of chloramine. It must be done after service of infectious patients providing of medical procedures, visiting of toilets.It is necessary the staff to have short nails, clean appearance, because the personnel is an example for patients in keeping rules of personal hygiene. Technical personnel busy with cleaning of rooms is not allowed to work in kitchen, giving of food.

In every hospital medical staff after work must jave a possibility to take a shower. Personnel of infectious and desinfecting departments must also have a shower.

With the aim of evaluation of measures’ providing level on fight with hospital infections there are provided investigation og air for bacterial number, oxidity and content of carbon dioxide, sterlity of surgical instruments and bandage material, investigation of smears from personnel’s and patients’ hands, from clothes, furniture, subjects of constant usage for presence and degree of insemination by E.coli. Data of investigation are written into special journal. Depending on necessity there are provided special measures.

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