1 General Requirements

1 General Requirements
1.1 Introduction

In recent years, a greater focus on improved clinical practices relating to infection prevention and
control (IPC) and significant advances in technologies has led to better outcomes for patients.

On-going construction practices however, in new build, renovation, or the maintenance of health
care facilities can impact on the well-being of patients. Any risks associated with all forms of
construction therefore need to be managed in a recognised and formal manner.

Lack of risk identification or not having appropriate practices in place to control risks, can lead to
serious environmental issues within a health care facility.

There is a need to identify the “at risk” population, which may include patients, staff and visitors;
the geographical location of the potential risk, and the possible transmission source/s at an early
stage of planning and development. This process is aimed to be all-inclusive so as to educate and
bring greater awareness of infection control related issues.

A formalized risk management methodology that includes sound infection control procedures
should result in an improved overall outcome, with minimized risks to patients and health facility
staff.

1.2 General

Infection control involves the prevention of the possible spread of infection by minimising the
transfer of micro-organisms from person to person.

A number of strategies contribute to the control of infection, such as hand washing, careful aseptic
technique and the observance of 'standard precautions' as determined by the operational policy of
the particular healthcare facility.

By far the most important of the infection control strategies is effective hand hygiene. Hand
hygiene facilities should be installed in all Patient Care Areas, and also in all areas where careful
attention to hygiene is essential - such as Kitchens, Laundries, Pharmacies and Laboratories. Staff
Amenities areas, such as Bathrooms, Toilets and Change Rooms should also be equipped with
hand-washing facilities. Refer to the heading 'Hand Hygiene' for further discussion and detailed
requirements.

Facets of construction and fit-out that contribute to effective infection control are covered in various
sections of these Guidelines. They include selection of materials, separation of dirty and clean
areas, adequate ventilation; floor coverings; waste management; provision for ease of cleaning;
provision for sterilisation and disinfection of equipment and instruments; provision for the isolation
of infectious patients, and provision for required facility cleaning regimes.

1.3 Planning

The Team responsible for IPC strategies should be consulted throughout each stage of a project.
Their considerations should be taken into account to ensure the design and physical layout of a
facility meets required infection control measures.

It is imperative that IPC measures are “built in” or incorporated at the very outset of the planning
and design of health care facilities – and that IPC inputs continue up to, into and beyond the
construction completion stage.

The design of facilities should also take into account the movement of people, equipment and
materials in ways that minimise the risk of infection transmission.

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1 General Requirements

To facilitate IPC measures, the team should:

 Determine a suitable and appropriate assessment of the IPC risks
 Identify the necessary steps to reduce or control infection risks
 Take records of findings based on the assessment and the necessary steps taken
 Implement the steps that have been identified
 Monitor and determine if further steps are needed to reduce or control infection risk

The objective of these control measures is to ensure the IPC advice is provided at the correct time
to prevent delays or costly mistakes.

1.4 Work Flows

General
While the cleanliness of people, tools and supplies within the facility is vital to infection prevention
and control, the spaces they enter and how they move between spaces is also critical. This means
that spaces must be designed with certain activities separated from others to avoid the risk of
infection and cross contamination. A carefully planned workflow is essential to minimising risk of
contamination.
Instrument Processing
The planning and design of a facility should provide separate clean and dirty working areas with a
defined unidirectional workflow to prevent cross contamination. The flow of instruments, equipment
and materials must be linear - from dirty to clean, to sterile, to store, to dispatch. To allow these
processes to occur, planning functions should be broken up into the following zones:

Zone Description
Soiled items are received from units throughout the facility and separated into
Receiving area
recyclable and non-recyclable items.

Waste disposal Non-recyclable items are disposed of appropriately.

All recyclable articles (including delivery trolleys) are sorted, rinsed, ultrasonically
Decontamination area
cleaned or mechanically washed and dried

Packing area Instruments and equipment are sorted, counted and packaged for sterilising

Sterilisers are loaded, operated, and unloaded

Sterilising / cooling areas
Sterilised items are allowed to cool while still loaded on steriliser trolleys
Sterile stock and distribution trolleys are held prior to dispatch to units of the facility. A
Dispatch area separate entrance for sterile stock being received from external suppliers should be
provided
Sterile stock is distributed to the units of the facility as required and disposed of or
User areas
returned to the receiving area after use.
Table 1: Zones for Instrument Processing

Activities carried out within this process must be performed in designated zones to maintain the
workflow pattern and thus prevent contamination. Each zone should have sufficient work space to
permit the required activity to be performed without the need for any “back tracking”. Clean items
should not re-enter contaminated areas. Refer to ‘Functional and Decontamination Areas’ in this
section for further discussion and information.
Staff Facilities
Eating and recreation areas for staff must be separate from work areas and patient treatment
areas.

Utensils must not be washed in hand basins and hand washing should not occur in sinks for
washing equipment.

Refrigerators for staff food storage must be separate from refrigerators for clinical specimen,
medical products such as drugs, vaccines and blood, and other treatment materials.

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1 General Requirements

Operating Rooms (ORs)

A one-way flow of sterile supplies into the operating room with soiled goods and waste out of the
operating room by a separate exit is required.

Shared use of the corridor for staff and patient access in the OR is acceptable such as in single
corridor designs. However the delivery of sterile supplies and removal of waste to provide
sufficient separation needs to be carefully considered in this model. It is recommended that sterile
supplies/ equipment have a separate, dedicated access way into the OR without this conflicting
with staff or patient traffic.

1.5 Air-Conditioning

Hospital air-conditioning and ventilation systems should be monitored regularly and serviced by
accredited service technicians. Maintenance schedules should always be documented and
appropriate access given to permit ongoing maintenance.

Air-conditioning or ventilation systems are required in critical areas such as Operating Rooms,
Birthing Rooms, Tuberculosis Isolation Rooms, Burns Units, Intensive Care Units, Emergency
Units, and special treatment or procedural areas. Regular maintenance should ensure that the
system will provide high quality air at all times.

Air conditioning in Sterile Supply Units should comply with the relevant local standards. Ventilation
should be provided with a treated air supply where a Sterile Supply Unit is attached to Operating
Rooms. Air-conditioning should comply with Part E of these Guidelines.

Where there is a risk of airborne transmission of pathogens, there should be a sufficient number of
single rooms (at least one per 100 Beds) with adequately filtered air-conditioning and external
exhaust systems. No recirculation of air should be permitted.

For tuberculosis isolation and treatment rooms, negative pressure ventilation should be made
available in accordance with locally endorsed guidelines. A minimum of twelve air changes per
hour (ACH) or 145 litres per second per patient (whichever results in the largest quantity of air) is
advised. In addition, at least two outside air changes per hour plus good air circulation within the
room is recommended.

Refer to Part E of these guidelines for further reference.

1.6 Operating/ Procedure Rooms

Due to the invasive procedures undertaken in an operating /procedure room, infection control is a
key consideration in the design and planning process.

Where bronchoscopy is performed on persons who are known or suspected of having pulmonary
tuberculosis, the Operating/Procedures Room should meet the negative pressure Isolation Room
ventilation requirements. Air to a bronchoscopy suite/room should not be re-circulated, unless this
is done via a well-maintained HEPA filtration system. The air should exhaust externally and any
external vents should not be in proximity to other patient areas, or air intake locations.

All standard Operating Rooms (ORs) or Procedure Rooms are required to be positive pressure
rooms, relative to any adjacent area. The pressure gradient must provide an airflow direction from
the OR to the surrounding areas. Active control of pressure differentials is not necessary provided
supply air fans are selected so that constant airflow volume is maintained for the life of the filters.
Provision of increased filter resistance should be made in filter loading calculations.

Relative pressure gradients are represented diagrammatically below:

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1 General Requirements

Figure 1: Pressure Gradients for Operating Rooms and surrounding support rooms

In all cases, terminal filters at the point of entry to the OR should be HEPA filters, with provision for
testing filter integrity. HEPA filters should not be supplied with air diffusers, but be protected with a
removable, washable screen.

A minimum of four exhaust or return air intake grilles should be located in the corners of the OR,
approximately 200mm above floor level.

Anything that moves in or out of an OR, including the surgical suite as a whole, should be subject
to stringent control. Any moisture in this environment must be rigorously and aggressively
controlled by limiting the location and quantum of sources.

Accordingly, flash sterilization, or immediate-use steam sterilization (IUSS) where possible, should
be avoided as ideal infection control measures are not assured. It also introduces sources of
moisture into a sterile environment and may create cross-contamination where ORs/ Procedure
Rooms share the same flash sterilization area.

1.7 Functional and Decontamination Areas

A functional area is a zone or group of rooms within a healthcare facility that provides a specific
service. For example, functional areas within an Inpatient Unit include patient areas, support
areas and staff areas.

Separate and clearly defined functional and decontamination areas are required to maintain
effective barriers for infection control. Delineation of these areas facilitates easy identification of
surfaces that should be cleaned and disinfected between patients.

Functional areas can be categorized as extreme, high, medium and low risk. The classification of
the space reflects the frequency and intensity of cleaning required to meet infection control
standards; and will influence the design and material specification of the specific area.

Both functional and decontamination areas should have:

 Adequate lighting to minimize the risk of injury and enable inspection of cleaned areas and
equipment
 Good ventilation to reduce the risk of cross-infection from aerosols
 Smooth impervious work surfaces made from non-porous materials without crevices
 Slip resistant or non-slip, water-imperious flooring with sealed joints
 Correct bins for the disposal of hazardous waste.

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Decontamination areas should be divided into separate spaces where contaminated and clean
functions can occur. The clean-up/ processing area should be carefully defined and protected
from all vapours, splashing or aerosols that may be produced during operating, hand washing,
equipment washing, disinfection and ultrasonic cleaning that occurs in the decontamination area.

The area should comply with relevant local authority standards and include:
 adequate bench space for dismantling, cleaning and working on equipment
 adequate bench space for drying, processing and packaging cleaned equipment
 sufficient storage for materials and equipment used for cleaning and disinfecting; keeping the
work benches free from clutter
 handwash basin with soap and paper towel fittings
 at least one deep stainless steel sink or trough for manual cleaning of instruments and other
equipment. For smaller facilities where no surgical or dental procedures take place, (e.g.:
acupuncture clinics), a small dedicated basin or stainless steel bowl may be used as an
alternative. Cleaning sinks must be used only for the decontamination of equipment and
instruments and must be located separately to clinical hand washing basins to avoid cross-
contamination
 taps fitted with anti-splash devices to prevent splashing; where filters are fitted to taps in
place of anti-splash devices, filters should be cleaned regularly.
 a mechanical disinfector/ washer as required.

A sterilizing area, cooling area for sterile items awaiting storage and sufficient storage for
effectively covered or packaged cleaned, disinfected and/or sterilized instruments and equipment
will be required, ideally in a separate and collocated zone adjacent to the decontamination area.

International
Health Facility Guidelines © TAHPI Part B: Version 5 2017 Page 8
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