Essential ventilation in healthcare premises; extraction of odours, aerosols, gases, vapours, fumes and dust (toxic, infectious, corrosive, flammable, or otherwise hazardous); airborne pathogenic material; ultraclean ventilation; Clostridium difficile; antibiotic-associated diarrhoea; probiotics; 'green hospital' design

Reply_14_09_2006_vs_0.3
from the Department of Health to Designs For Wellbeing

Our ref: DE000000135025

Dear Ms Filby,

Thank you for your emails of 24 and 25 August to the Department of Health and the Chief Nursing Officer about air hygiene.

I am sorry if you found my previous reply unhelpful. I hope that you will find the following information useful.

My colleagues in the Department's Infection Control Team have confirmed that there is little evidence to show that air plays a significant role in the transmission of most healthcare associated infections. People are the main source of infections. In those cases where airborne transmission is thought to be important, both dilution of pathogens in the air and controlling airflow into, or out of, a room are mechanisms for reducing risk. However, this will only be one part of a strategy to reduce infection rates.

The NHS Guidelines on ventilation are enshrined in Health Technical Memorandum (HTM) 2025: Ventilation in healthcare premises; which is recognised internationally as an industry standard. This comes in 4 volumes of which the first is Design Considerations. The following appears under general considerations:

Reasons for ventilation:

2.1 Ventilation is essential in all occupied premises. This may be provided
by either natural or mechanical means. The following factors determine the
ventilation requirements of a department or area:

a. human habitation (fresh air requirements);
b. the activities of the department, that is, extraction of odours, aerosols, gases, vapours, fumes and dust – some of which may be toxic,
infectious, corrosive, flammable, or otherwise hazardous (see Control of
Substances Hazardous to Health (COSHH) regulations);
c. dilute and control airborne pathogenic material;
d. thermal comfort; and
e. the removal of heat generated by equipment (for example in catering,
wash-up and sterilizing areas and in some laboratory areas).

The document proceeds to discuss filtration, humidity and air changes for the various types of settings within the health service.

Your original letter mentioned orthopaedic infections. This is one area where airborne transmission in the operating theatre has been known to have a role and special precautions are taken in the design of theatres for this type of surgery (ultraclean ventilation). However, the use of enhanced air systems may not be suitable for other specialties. Orthopaedic infection rates are low but because these infections can have severe effects for patients, the health service is working to reduce rates even further. The measures used to control infections will vary according to local circumstances but can include air filtration systems and patient screening for MRSA.

Clostridium difficile, the main cause of antibiotic-associated diarrhoea, is a spore forming micro-organism and the spores can survive for long periods in the environment on surfaces. Consequently, enhanced cleaning of the environment rather than air filtration is more important for preventing these infections.

Finally, I should explain that if you wish to contact the Department by email, it would be best to use the email address dhmail@dh.gsi.gov.uk. This is the Department’s central mailbox for correspondence. As all incoming mail must be logged centrally and is not necessarily answered by the same member of staff, this is the quickest and most effective way for queries to receive a response.

I hope this reply is informative.

Yours sincerely,

Shelley Wilson
Customer Service Centre

----- Original Message -----

From: Grace Filby

Sent: Thursday, September 14, 2006 5:07 PM

Subject: Re: Response to your Query : - Ref:DE00000135025 - TO00000131070

Dear Shelley Wilson and the Dept of Health

Thank you for this further information - it is rather odd that your colleagues can claim yet again that there is little evidence to show that air plays a significant role in the transmission of most healthcare associated infections. My colleagues will be intrigued by your response.

After all, if that is the case, then whyever did the NHS Guidelines on ventilation (that are, as you remind me, enshrined in the HTM document) state very firmly that

"Ventilation is essential in all occupied premises. ..."

and why would it specifically itemise airborne pathogenic material?

Consider for a moment the slightest possibility that healthcare associated infections and airborne pathogenic material are the same thing. Is there any evidence that they are not the same thing? We would like to know.

Regarding C.diff and antibiotic-associated diarrhoea, I would like to mention to you that the 111-page official HCC investigation report completely skidded over a very significant point regarding probiotics. This is important because deaths could have been prevented. The official line is that nurses were apparently too busy to administer probiotics recommended by the dieticians. Further details are available of course but otherwise you can contact Dr Heather Wood (HCC) and also refer to the relevant internet pages.

Thank you for your note about quick and effective ways to receive a response. I don't seem to have done too badly by replying to Norman Warner by fax or contacting Chris Beasley by email, as advised officially by my MP, the HPA and other official bodies. You too have replied informatively when I have written to you.

Please note I have been asked by some American researchers for some suggestions on technology for the future, and I have just put forward a proposal for a 'green hospital'. It would be equally applicable for office buildings, leisure centres etc., and would fit in very well with the recommendations sent to me by a former health minister a few months ago.

Perhaps these concepts are way beyond the DoH and NHS but they rely on very simple microbiology. As always you are welcome to contact me if ever the DoH wake up to some new ideas from time to time.

Yours sincerely

Grace Filby

For further reference on airborne pathogens please see www.relax-well.co.uk/good_luck.html

http://fengsrv1.leeds.ac.uk/cpd/documents/Prog_060718b_000.doc

http://www.engineering.leeds.ac.uk/cpd/SVHP.shtml

http://www.relax-well.co.uk/summary.html

Continuing Professional Development (CPD) Unit
Professional Development Programme in
Pharmaceutical Technology and Quality Assurance

PTQA

Course Programme

Specialised Ventilation in Healthcare Premises 18 – 20 July 2006, Weetwood Hall

Day 1

Tuesday

18th July 2006

Chairman for Day:

Malcolm Thomas

Time

Session

Speaker

0930 – 1015

1015 – 1045

Introduction & Current Relevant Legislation

Malcolm Thomas

1030 - 1045

HTM 03 - the new guidance

Malcolm Thomas

1045 – 1145

Hospital Acquired Infections

1145-1200

Coffee

1200 – 1245

Ventilation Concepts

Malcolm Thomas

1300 – 1400

Lunch

Buffet Lunch

1400 – 1445

The Operating Department

1445 – 1630

Workshop 1 – Design of an Operating Suite (Tea/Coffee Taken during workshop)

Craig Mackintosh, Margaret Barrows, Tim Sizer

1630 – 1700

Workshop Feedback Session

1730 – 1800

Theatre Design in Practice – a users view

Margaret Barrows

1800 – 1815

Malcolm Thomas

1930 –2030

Evening Meal at Weetwood Hall

Day 2

Wednesday

19th July 2006

Chairman for Day:
Craig Mackintosh

0900 – 0905

Introduction to Day 2

Craig Mackintosh

Air Handling Units (The Revised Guidance)

Air Filtration

Malcolm Thomas

0945 – 1030

Air Quality Assessment and Validation

Craig Mackintosh

1030 – 1035

Introduction to Workshop 2

1045 –1315

Demonstrations of monitoring techniques (Tea/Coffee Taken during Equipment Circus)

1315 – 1400

Lunch

Buffet Lunch

1400 – 1430

1430 –1445

Richard Gatley

1445 – 1545

Workshop 3 - Specification for Premature

1545 –1600

13a

1600 –1630

1630 – 1700

Pathology Areas

Iain Banks

1700 –1730

Mortuary Suites

Iain Banks

1730 –1745

Craig Mackintosh

1930

Evening Meal at Weetwood Hall.

Course Programme

Specialised Ventilation in Healthcare Premises 18 – 20 July 2006, Weetwood Hall

Day 3

Thursday

20th July 2006

Chairman for Day:
Malcolm Thomas

Time

Session

Speaker

0915 – 0930

Introduction to Day 3

Malcolm Thomas

Clean Rooms for Pharmacy / CSSD

Tim Sizer

1015 – 1100

Isolation Rooms – the new standards

Malcolm Thomas

1100 – 1115

Tea/Coffee

1115 – 1200

Monitoring & Control of Systems & User interaction

Richard Knight

1200 – 1245

Tim Sizer

1245 -1345

Lunch

1345 – 1415

MCQ Answers and Review of Exam Paper

Tim Sizer, Malcolm Thomas, Craig Mackintosh

1415 – 1500

Case Study “A failure of Theatre ventilation”

Tim Boswell

1500-1530

Malcolm Thomas

1530 –1535

Malcolm Thomas

1535