Effects of indoor environmental parameters related to building heating, ventilation, and air conditioning systems on patients' medical outcomes: A review of scientific research on hospital buildings

Prenatal risk factors of indoor environment and incidence of childhood eczema in the Japan Environment and Children's Study

The quality of indoor environment is a risk factor for early childhood eczema and atopic dermatitis; however, its influence during pregnancy on childhood eczema in Japan has not been investigated. In this study, we aimed to determine the indoor environmental factors that are associated with eczema in children up to 3 years of age, using national birth cohort data from the Japan Environment and Children's Study (JECS). Information on indoor environments and eczema symptoms until 3 years of age was collected using self-administered questionnaires to the mothers. A total of 71,883 and 58,639 mother-child pairs at 1.5- and 3-years-old, respectively, were included in the former analyses. To account for prenatal indoor risk factors, 17,568 (1.5-years-old) and 7063 (3-years-old) children without indoor mold and/or ETS exposure were included in the final analysis. A higher mold index, gas heater use, parquet flooring use, and frequent insecticide use showed significantly increased risks for childhood eczema up to 3 years of age. These associations were consistent after stratification analysis among children whose parents did not have a history of allergies. The updated WHO guidelines on indoor air quality should be implemented based on recent findings regarding the effects of prenatal exposure to indoor dampness on health effects of children further in life, including asthma, respiratory effects, eczema, and other immunological effects.

Prevalence of occupational heat stress across the seasons and its management amongst healthcare professionals in the UK

Occupational heat stress (OHS) is an issue in healthcare facilities (HCFs) in the United Kingdom (UK). The aims of this study were to evaluate perceived levels of OHS during two seasons and its perceived consequences on healthcare professionals (HCPs) and to assess the efficacy of heat stress management (HSM) policies. An anonymous online survey was distributed to HCPs working in HCFs in the UK. The survey returned 1014 responses (87% women). Descriptive statistics and content analysis of survey data identified that OHS in HCFs is frequently experienced throughout the year and concerned most HCPs. Over 90% perceived OHS impairs their performance and 20% reported heat-related absenteeism. Awareness of HSM policies was poor and 73% deemed them not adequate. To help reduce the financial loss and impact on staff performance, health and well-being and patient safety, it is recommended that revisions and widespread dissemination of HSM policies are made.

Numerical Analysis of Indoor Air Characteristics and Window Screen Influence on Particulate Matter Dispersion in a Childcare Center Using Computational Fluid Dynamics

Indoor exposure to outdoor pollutants adversely affects health, varying with building dimensions and particularly ventilation that have critical role on their indoor dispersion. This study assesses the impact of outdoor air on indoor air quality in a child care center. Computational fluid dynamics was utilized to analyze the dispersion of particulate matter, with a specific focus on window screens featuring 6 distinct pore sizes ranging from 0.8 mm to 2 mm and 2 different thicknesses of 0.5 mm and 0.1 mm. Results indicate that the presence of a window screen offers significant advantages in controlling particle infiltration compared to scenarios without a screen, as larger particles tend to pass directly through the window within the breathing zone. The scenario without window screens minimizes pressure drop but lacks enhanced particle capture capabilities. However, for effective particle reduction, the window screen with a pore size of 0.8 mm (R0.8T2) and a thickness of 0.5 mm proves to be the most beneficial, achieving the particle filtering efficiency of approximately 54.16%, while the larger window screen with a pore size of 2 mm and a thickness of 1 mm exhibits the lowest efficiency at about 23.85%. Nonetheless, screens with very small sizes are associated with a high-pressure drop, impacting energy efficiency, and overall window performance. Larger pores with smaller thicknesses (0.5 mm) reduced particle count by approximately 45.97%. Therefore, the significance of window screen thickness beyond pore size for particle reduction efficiency is highlighted, emphasizing screens' role in indoor air quality and health protection.

A Systematic Review of Research Gaps in the Built Environment of Inpatient Healthcare Settings

OBJECTIVE

This study utilized the evidence-gap map method and critically examined the scope, methodologies, and focus of the studies that investigated the influence of the built environment on inpatient healthcare settings over a decade (2010-2021).

METHODS

We conducted a systematic review per the preferred reporting items for systematic reviews and meta-analyses guidelines and surveyed 406 articles, primarily from North America and Europe.

RESULTS

Our findings revealed a dominant focus on architectural features (73%), such as room design and ward layout. Comparatively, there was less emphasis on interior-, ambient-, social-, and nature-related features. Most previous studies explored multiple environmental features, which indicated the intricacy of this field. Research outcomes were diverse, with person-centered care (PCC) being the most frequently investigated, followed by safe care, emotional well-being, activity, and behavior. Furthermore, research methods varied considerably based on the study's outcomes and features. Clinical outcomes and safe care favored quantitative methods, activity and behavior favored mixed methods, and PCC favored qualitative research.

CONCLUSION

This review provides an in-depth overview of the existing studies on healthcare design research and sheds light on the current trends and methodological choices. The insights garnered can guide future research, policy-making, and the development of healthcare facilities.

In Vitro and In Vivo Testing of Microbe Growth on Antimicrobial Nursing Scrubs

Around 5% to 10% of hospitalized patients develop a hospital-acquired infection (HAI). Scrubs are a potential vector of HAIs. To compare the antimicrobial characteristics of scrubs with and without an antimicrobial fabric coating, as tested in the laboratory (in vitro) and hospital (in vivo) environments. Two protocols were conducted to address the purpose. The in vitro protocol was a laboratory study that involved observing the microbe growth after inoculating coated and uncoated scrub fabric swatches with S. aureus and then processing them in moist and dry environments. The in vivo protocol was a clinical trial that measured microbe growth on coated and uncoated scrubs prior to and following nursing staff completing a 12-hr shift on an acute care unit, as measured by colony forming units (CFUs). For high-humidity environments, the in vitro study indicated that swatches treated with an antimicrobial coating exhibited minimal microbe growth, while untreated swatches exhibited significant microbe growth. For low-humidity environments, coated and uncoated swatches were all found to exhibit minimal microbe growth. In the in vivo study, the CFUs increased on scrubs worn by nurses over a 12-hr shift with no significant difference in CFUs for coated and uncoated scrubs. For bacteria in a warm and moist environment, the antimicrobial coating was found to be important for inhibiting growth. For bacteria in a warm and dry environment, both coated and uncoated fabrics performed similarly as measured at 24 hr, with minimal bacterial growth observed. In a hospital environment, microbe growth was observed, but no significant difference was detected when comparing coated and uncoated scrubs. This may have been due to the short time between exposure and culturing the scrubs for analysis immediately at the end of the shift not allowing for enough time to kill or inhibit growth. Contact time between the bacteria and scrub fabric (coated or uncoated) in the in vivo study more directly correlated with the 0-hr observations for the in vitro study, suggesting that the ineffectiveness of the treated scrubs in the clinical results may be due in part to short residence times before collection.

Investigating the effectiveness of a new indoor ventilation model in reducing the spread of disease: A case of sports centres amid the COVID-19 pandemic

The ventilation of buildings is crucial to ensure indoor health, especially when demanding physical activities are carried out indoors, and the pandemic has highlighted the need to develop new management methods to ensure adequate ventilation. In Spain, there are no specific ventilation regulations to prevent the spread of pathogens such as the coronavirus. Therefore, it is necessary to have a theoretical tool for calculating occupancy to maintain sports facilities in optimal safety conditions. The proposed theoretical method is based on the analysis of mathematical expressions from European standardisation documents and uses the concentration of CO2 as a bioeffluent. It is also based on the concept of background and critical concentration, which allows its application to be extrapolated to future crises caused by pathogens. This study presents a unique and novel dataset for sports centres. For this purpose, the calculation methods were applied to the data set provided by Mostoles City Council, Spain, during the pandemic years with the highest incidence of COVID-19, when the government introduced the assimilation of COVID-19 sick leave to occupational accidents. The data on this type of sick leave provided by the City Council correspond to the period between March 2020 and February 2022. Similarly, the data on the average use of sports facilities by activity, provided by the Sports Department, correspond to the years 2020 and 2021. In this way, it was possible to verify the effectiveness in preventing the spread of any type of coronavirus. In conclusion, the implementation of a theoretical occupancy calculation method based on the concentration of carbon dioxide as a bioeffluent can be an effective tool for the management of future crises caused by pathogens or hazardous chemicals in the air, and demonstrated its effectiveness in sports centres such as gyms, sports fields, and indoor swimming pools during the COVID-19 pandemic.

Heating, ventilation, and air-conditioning systems in healthcare: a scoping review

Guidelines for heating, ventilation, and air-conditioning systems have been developed for different settings. However, there is a lack of up-to-date evidence providing concrete recommendations for the heating, ventilation, and air-conditioning systems of an isolation room, which is essential to appropriately guide infection control policies. To highlight the guidelines for heating, ventilation, and air-conditioning systems in isolation rooms to inform relevant stakeholders and policymakers. A systematic search was performed based on Joanna Briggs Methodology using five databases (CINAHL, Embase, Joanna Briggs Institute, Medline, and Web of Science) and websites. Eight articles published by government departments were included in this review. Most studies recommended controlled airflow without recirculation, 12 air changes per hour, high-efficiency particulate air filtrate to exhaust contaminated air from the airborne isolation room, humidity ≤60%, and temperature in the range of 18-30 °C. This review provides further evidence that there is a need for interdisciplinary collaborative research to quantify the optimum range for heating, ventilation, and air conditioning system parameters, considering door types, anterooms, and bed management, to effectively reduce the transmission of infection in isolation rooms.

Relationship Between Airborne Fungi Presence and the Position of the High Efficiency Particulate Air Filter in the Heating, Ventilation, and Air Conditioning System

AIM

Establish the influence of the terminal or nonterminal position of High Efficiency Particulate Air (HEPA) filters in the Heating, Ventilation, and Air Conditioning (HVAC) system on the presence of airborne fungi in controlled environment rooms.

BACKGROUND

Fungal infections are an important cause of morbidity and mortality in hospitalized patients.

METHODS

This study was realized from 2010 to 2017, in rooms with terminal and nonterminal HEPA filters, in eight Spanish hospitals. In rooms with terminal HEPA filters, 2,053 and 2,049 samples were recollected, and in rooms with nonterminal HEPA filters, 430 and 428 samples were recollected in the air discharge outlet (Point 1) and in the center of the room (Point 2), respectively. Temperature, relative humidity, air changes per hour, and differential pressure were recollected.

RESULTS

Multivariable analysis showed higher odds ratio (OR) of airborne fungi presence when HEPA filters were in nonterminal position (OR: 6.78; 95% CI [3.77, 12.20]) in Point 1 and (OR: 4.43; 95% CI [2.65, 7.40]) in Point 2. Other parameters influenced airborne fungi presence, such as temperature (OR: 1.23; 95% CI [1.06, 1.41]) in Point 2 differential pressure (OR: 0.86; 95% CI [0.84, 0.90]) and (OR: 0.88; 95% CI [0.86, 0.91]) in Points 1 and 2, respectively.

CONCLUSIONS

HEPA filter in terminal position of the HVAC system reduces the presence of airborne fungi. To decrease the presence of airborne fungi, adequate maintenance of the environmental and design parameters is necessary in addition to the terminal position of the HEPA filter.

Risk Influence of Some Environmental and Behavioral Factors on Air Contamination in the Operating Room: An Experimental Study

Air contamination in operating rooms (ORs) depends on the conditions of the room and on activities therein performed. Methodologies of air quality assessment in ORs are often inadequately described in the scientific literature, and the time required for a change in status in air quality is never taken into account. The purpose of this study was to determine the influence of the state and the presence of human operators on air quality by implementing a precise measurement protocol that also took into account the time required for changes in the room to affect air pollution. As the main indicators of air pollution, bacterial load and concentration of airborne dust were measured. The results showed that: the use of surgical masks by operators in the OR did not significantly affect bacterial load within a distance of 2 m; keeping OR doors open did not induce a significant increase in bacterial load and of 5 μm particles while 10 μm particles concentration was positively affected; and air pollution measured with open doors was not significantly different from that due to the presence of two staff members, whether or not they were wearing masks. The results clarified the role of some factors on air pollution in ORs.

The Effectiveness of Active External Warming of Patient Concurrently With Ice Application on the Incision Site on Post-Thoracotomy Pain and Analgesic Consumption

The aim of study is to investigate the effects of active external warming of patient concurrently with application of ice to incision site on thoracotomy pain and analgesic consumption. The research is a quasi-experimental design with control and study groups. The study was conducted in 2018 and 2019. A total of 70 patients were included in the study: 35 in the control group and 35 in the study group. The mean verbal pain scale values were significantly lower in the intervention group (2.85 point) than in the control group (4.57 point; p < .001). Opioid consumption rate was high in control group patients (77.1% tramadol 30 mg; 45.7% morphine sulfate 5 mg) In contrast, the rate of opioid consumption was lower in patients in the intervention group (40% tramadol 30 mg; 17% morphine sulfate 5 mg). Active external warming and ice application on the incision area, could reduce the intensity of thoracotomy pain.

Investigation on the effectiveness of ventilation dilution on mitigating COVID-19 patients' secondary airway damage due to exposure to disinfectants

Chlorine-containing disinfectants are widely used in hospitals to prevent hospital-acquired severe acute respiratory syndrome coronavirus 2 infection. Meanwhile, ventilation is a simple but effective means to maintain clean air. It is essential to explore the exposure level and health effects of coronavirus disease 2019 patients' inhalation exposure to by-products of chloride-containing disinfectants under frequent surface disinfection and understand the role of ventilation in mitigating subsequent airway damage. We determined ventilation dilution performance and indoor air quality of two intensive care unit wards of the largest temporary hospital constructed in China, Leishenshan Hospital. The chloride inhalation exposure levels, and health risks indicated by interleukin-6 and D-dimer test results of 32 patients were analysed. The mean ± standard deviation values of the outdoor air change rate in the two intensive care unit wards were 8.8 ± 1.5 h^-1 (Intensive care unit 1) and 4.1 ± 1.4 h^-1 (Intensive care unit 2). The median carbon dioxide and fine particulate matter concentrations were 480 ppm and 19 μg/m³ for intensive care unit 1, and 567 ppm and 21 μg/m³ for intensive care unit 2, all of which were around the average levels of those in permanent hospitals (579 ppm and 21 μg/m³). Of these patients, the median (lower quartile, upper quartile) chloride exposure time and calculated dose were 26.66 (2.89, 57.21) h and 0.357 (0.008, 1.317) mg, respectively. A statistically significant positive correlation was observed between interleukin-6 and D-dimer concentrations. To conclude, ventilation helped maintain ward air cleanliness and health risks were not observed.

Innovation for infection prevention and control-revisiting Pasteur's vision

Louis Pasteur has long been heralded as one of the fathers of microbiology and immunology. Less known is Pasteur's vision on infection prevention and control (IPC) that drove current infection control, public health, and much of modern medicine and surgery. In this Review, we revisited Pasteur's pioneering works to assess progress and challenges in the process and technological innovation of IPC. We focused on Pasteur's far-sighted conceptualisation of the hospital as a reservoir of microorganisms and amplifier of transmission, aseptic technique in surgery, public health education, interdisciplinary working, and the protection of health services and patients. Examples from across the globe help inform future thinking for IPC innovation, adoption, scale up and sustained use.

Airborne transmission of biological agents within the indoor built environment: a multidisciplinary review

The nature and airborne dispersion of the underestimated biological agents, monitoring, analysis and transmission among the human occupants into building environment is a major challenge of today. Those agents play a crucial role in ensuring comfortable, healthy and risk-free conditions into indoor working and leaving spaces. It is known that ventilation systems influence strongly the transmission of indoor air pollutants, with scarce information although to have been reported for biological agents until 2019. The biological agents' source release and the trajectory of airborne transmission are both important in terms of optimising the design of the heating, ventilation and air conditioning systems of the future. In addition, modelling via computational fluid dynamics (CFD) will become a more valuable tool in foreseeing risks and tackle hazards when pollutants and biological agents released into closed spaces. Promising results on the prediction of their dispersion routes and concentration levels, as well as the selection of the appropriate ventilation strategy, provide crucial information on risk minimisation of the airborne transmission among humans. Under this context, the present multidisciplinary review considers four interrelated aspects of the dispersion of biological agents in closed spaces, (a) the nature and airborne transmission route of the examined agents, (b) the biological origin and health effects of the major microbial pathogens on the human respiratory system, (c) the role of heating, ventilation and air-conditioning systems in the airborne transmission and (d) the associated computer modelling approaches. This adopted methodology allows the discussion of the existing findings, on-going research, identification of the main research gaps and future directions from a multidisciplinary point of view which will be helpful for substantial innovations in the field.

The Influence of Transient Changes in Indoor and Outdoor Thermal Comfort on the Use of Outdoor Space by Older Adults in the Nursing Home

Recently, the requirements regarding the environment of nursing homes are high, because the elderly are a vulnerable group with limited adaptive capacity to respond to transient environmental change. This paper presents a field investigation on the influence of transient thermal comfort changes between the indoor and outdoor spaces (i.e., air temperature (Ta), solar radiation (SR), relative humidity (RH), wind speed (WS), and the thermal comfort indices of Universal Thermal Index (UTCI)) on the willingness of the elderly to use outdoor spaces of the Wanxia nursing home of Chengdu City. Results indicated that, in summer, the mean UTCI values of indoor and corridor spaces corresponded to the level of moderate heat stress, while those of road and garden corresponded to the strong heat stress level. Road and garden spaces even showed moderate heat stress in spring. Approximately 28.93% (139) of the elderly living here used outdoor spaces every day. The morning period (from 9:00 a.m. to 10:00 a.m.) was the elderly’s favorited period for using outdoor spaces in seasons. The microclimatic transient differences between indoor and outdoor spaces ranged from 0.47 °C to 2.93 °C (|ΔTa|), from 86.09 W/m2 to 206.76 W/m2 (|ΔSR|), from 5.29% to 14.76% (ΔRH), from 0.01 m/s to 0.07 m/s (|ΔWS|), and from 0.25 °C to 2.25 °C (ΔUTCI). These big microclimate differences could cause enormous health risks for the elderly in the process of indoor and outdoor space conversion. The minimal transient change occurred between corridors and indoors. Pearson correlation analysis indicated ΔTa and ΔRH between indoor and outdoor spaces were the primary meteorological factors that influenced the elderly’s willing to use outdoor spaces. The elderly preferred to live in a constant Ta and RH environment. Only when the ΔTa and ΔRH are small enough to resemble a steady-state (ΔUTCI ≤ 0.5 °C), ΔWS and ΔSI could affect the elderly’s choice of using outdoor space. Optimal design strategies were put forward for reducing the transient differences between indoor and outdoor microclimates to inspire the elderly to use outdoor spaces safely, including improving outdoor canopy coverage and indoor mechanical ventilation.

A Review of Recent Literature on Systems and Methods for the Control of Thermal Comfort in Buildings

Thermal comfort in indoor environments is perceived as an important factor for the well-being and productivity of the occupants. To practically create a comfortable environment, a combination of models, systems, and procedures must be applied. This systematic review collects recent studies proposing complete thermal-comfort-based control strategies, extracted from a scientific database for the period 2017–2021. The study consists of this paper and of a spreadsheet recording all the 166 reviewed works. After a general introduction, the content of the papers is analyzed in terms of thermal comfort models, indoor environment control strategies, and correlation between these two aspects. Practical considerations on scope, required inputs, level of readiness, and, where available, estimated cost are also given. It was found that the predicted mean vote is the preferred thermal comfort modeling approach, followed by data-driven and adaptive methods. Thermal comfort is controlled mainly through indoor temperature, although a wide range of options are explored, including the comfort-based design of building elements. The most popular field of application of advanced control strategies is office/commercial buildings with air conditioning systems, which can be explained by budget and impact considerations. The analysis showed that few works envisaging practical implementations exist that address the needs of vulnerable people. A section is, therefore, dedicated to this issue.

An Edge Computing and Ambient Data Capture System for Clinical and Home Environments

The non-contact patient monitoring paradigm moves patient care into their homes and enables long-term patient studies. The challenge, however, is to make the system non-intrusive, privacy-preserving, and low-cost. To this end, we describe an open-source edge computing and ambient data capture system, developed using low-cost and readily available hardware. We describe five applications of our ambient data capture system. Namely: (1) Estimating occupancy and human activity phenotyping; (2) Medical equipment alarm classification; (3) Geolocation of humans in a built environment; (4) Ambient light logging; and (5) Ambient temperature and humidity logging. We obtained an accuracy of 94% for estimating occupancy from video. We stress-tested the alarm note classification in the absence and presence of speech and obtained micro averaged F1 scores of 0.98 and 0.93, respectively. The geolocation tracking provided a room-level accuracy of 98.7%. The root mean square error in the temperature sensor validation task was 0.3°C and for the humidity sensor, it was 1% Relative Humidity. The low-cost edge computing system presented here demonstrated the ability to capture and analyze a wide range of activities in a privacy-preserving manner in clinical and home environments and is able to provide key insights into the healthcare practices and patient behaviors.

Monitors to improve indoor air carbon dioxide concentrations in the hospital: A randomized crossover trial

BACKGROUND

Ventilation has emerged as an important strategy to reduce indoor aerosol transmission of coronavirus disease 2019. Indoor air carbon dioxide (CO₂) concentrations are a surrogate measure of respiratory pathogen transmission risk.

OBJECTIVES

To determine whether CO₂ monitors are necessary and effective to improve ventilation in hospitals.

METHODS

A randomized, placebo (sham)-controlled, crossover, open label trial. Between February and May 2021, we placed CO₂ monitors in twelve double-bed patient rooms across two geriatric wards. Staff were instructed to open windows, increase the air exchange rate and reduce room crowding to maintain indoor air CO₂ concentrations ≤800 parts per million (ppm).

RESULTS

CO₂ levels increased during morning care and especially in rooms housing couples (rooming-in). The median (interquartile range, IQR) time/day with CO₂ concentration > 800 ppm (primary outcome) was 110 min (IQR 47-207) at baseline, 82 min (IQR 12-226.5) during sham periods, 78 min (IQR 20-154) during intervention periods and 140 min (IQR 19.5-612.5) post-intervention. The intervention period only differed significantly from the post-intervention period (P = 0.02), mainly due to an imbalance in rooming-in. Significant but small differences were observed in secondary outcomes of time/day with CO₂ concentrations > 1000 ppm and daily peak CO₂ concentrations during the intervention vs. baseline and vs. the post-intervention period, but not vs. sham. Staff reported cold discomfort for patients as the main barrier towards increasing ventilation.

DISCUSSION

Indoor air CO₂ concentrations in hospital rooms commonly peaked above recommended levels, especially during morning care and rooming-in. There are many possible barriers towards implementing CO₂ monitors to improve ventilation in a real-world hospital setting. A paradigm shift in hospital infection control towards adequate ventilation is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04770597.

The impact of heating, ventilation, and air conditioning design features on the transmission of viruses, including the 2019 novel coronavirus: A systematic review of ventilation and coronavirus

Aerosol transmission has been a pathway for the spread of many viruses. Similarly, emerging evidence has determined aerosol transmission for Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) and the resulting COVID-19 pandemic to be significant. As such, data regarding the effect of Heating, Ventilation, and Air Conditioning (HVAC) features to control and mitigate virus transmission is essential. A systematic review was conducted to identify and comprehensively synthesize research examining the effectiveness of ventilation for mitigating transmission of coronaviruses. A comprehensive search was conducted in Ovid MEDLINE, Compendex, Web of Science Core to January 2021. Study selection, data extraction, and risk of bias assessments were performed by two authors. Evidence tables were developed and results were described narratively. Results from 32 relevant studies showed that: increased ventilation rate was associated with decreased transmission, transmission probability/risk, infection probability/risk, droplet persistence, virus concentration, and increased virus removal and virus particle removal efficiency; increased ventilation rate decreased risk at longer exposure times; some ventilation was better than no ventilation; airflow patterns affected transmission; ventilation feature (e.g., supply/exhaust, fans) placement influenced particle distribution. Few studies provided specific quantitative ventilation parameters suggesting a significant gap in current research. Adapting HVAC ventilation systems to mitigate virus transmission is not a one-solution-fits-all approach. Changing ventilation rate or using mixing ventilation is not always the only way to mitigate and control viruses. Practitioners need to consider occupancy, ventilation feature (supply/exhaust and fans) placement, and exposure time in conjunction with both ventilation rates and airflow patterns. Some recommendations based on quantitative data were made for specific scenarios (e.g., using air change rate of 9 h-1 for a hospital ward). Other recommendations included using or increasing ventilation, introducing fresh air, using maximum supply rates, avoiding poorly ventilated spaces, assessing fan placement and potentially increasing ventilation locations, and employing ventilation testing and air balancing checks. Trial registration: PROSPERO 2020 CRD42020193968.

Occupational Health and Safety Measures in Healthcare Settings during COVID-19: Strategies for Protecting Staff, Patients and Visitors

The COVID-19 (SARS-CoV-2) pandemic has profoundly impacted almost every aspect of healthcare systems worldwide, placing the health and safety of frontline healthcare workers at risk, and it still continues to remain an important public health challenge. Several hospitals have put in place strategies to manage space, staff, and supplies in order to continue to deliver optimum care to patients while at the same time protecting the health and safety of staff and patients. However, the emergence of the second and third waves of the virus with the influx of new cases continue to add an additional level of complexity to the already challenging situation of containing the spread and lowering the rate of transmission, thus pushing healthcare systems to the limit. In this narrative review paper, we describe various strategies including administrative controls, environmental controls, and use of personal protective equipment, implemented by occupational health and safety departments for the protection of healthcare workers, patients, and visitors from SARS-CoV-2 virus infection. The protection and safeguard of the health and safety of healthcare workers and patients through the implementation of effective infection control measures, adequate management of possible outbreaks and minimization of the risk of nosocomial transmission is an important and effective strategy of SARS-CoV-2 pandemic management in any healthcare facility. High quality patient care hinges on ensuring that the care providers are well protected and supported so they can provide the best quality of care to their patients.

An adaptation strategy to urban heat: hospital rooms with radiant cooling accelerate patient recovery

Background

Patients with respiratory diseases are vulnerable to the effects of heat. Therefore, it is important to develop adaptation strategies for heat exposure. One option is to optimise the indoor environment. To this end, we equipped hospital patient rooms with radiant cooling. We performed a prospective randomised clinical trial to investigate potentially beneficial effects of the hospitalisation in rooms with radiant cooling on patients with a respiratory disease exacerbation.

Methods

Recruitment took place in June, July and August 2014 to 2016 in the Charité – Universitätsmedizin Berlin, Germany. We included patients with COPD, asthma, pulmonary hypertension, interstitial lung disease and pneumonia. 62 patients were allocated to either a standard patient room without air conditioning or a room with radiant cooling set to 23°C (73°F). We analysed the patients’ length of stay with a Poisson regression. Physiological parameters, fluid intake and daily step counts were tested with mixed regression models.

Results

Patients hospitalised in a room with radiant cooling were discharged earlier than patients in standard rooms (p=0.003). The study participants in chambers with radiant cooling had a lower body temperature (p=0.002), lower daily fluid intake (p<0.001), higher systolic blood pressure (p<0.001) and an increased daily step count (p<0.001).

Conclusion

The results indicate that a radiant cooling system in hospital patient rooms provides clinical benefits for patients with respiratory disease exacerbations during the warm summer months, which may contribute to an earlier mobilisation. Radiant cooling is commended as a suitable adaptation strategy to reduce the clinical impact of climate warming.

A radiant cooling system in hospital patient rooms provides clinical benefits for patients with respiratory disease exacerbations during summertime. Patients hospitalised in rooms with air convection free radiant cooling are discharged earlier.https://bit.ly/3p9Fkqm

The Role of HVAC Design and Windows on the Indoor Airflow Pattern and ACH

The purpose of heating, ventilation, and air conditioning (HVAC) systems are to create optimum thermal comfort and appropriate indoor air quality (IAQ) for occupants. Air ventilation systems can significantly affect the health risk in indoor environments, especially those by contaminated aerosols. Therefore, the main goal of the study is to analyze the indoor airflow patterns in the heating, ventilation, and air conditioning (HVAC) systems and the impact of outlets/windows. The other goal of this study is to simulate the trajectory of the aerosols from a human sneeze, investigate the impact of opening windows on the number of air changes per hour (ACH) and exhibit the role of dead zones with poor ventilation. The final goal is to show the application of computational fluid dynamics (CFD) simulation in improving the HVAC design, such as outlet locations or airflow rate, in addition to the placement of occupants. In this regard, an extensive literature review has been combined with the CFD method to analyze the indoor airflow patterns, ACH, and the role of windows. The airflow pattern analysis shows the critical impact of inflow/outflow and windows. The results show that the CFD model simulation could exhibit optimal placement and safer locations for the occupants to decrease the health risk. The results of the discrete phase simulation determined that the actual ACH could be different from the theoretical ACH as the short circuit and dead zones affect the ACH.

Modeling hospital energy and economic costs for COVID-19 infection control interventions

The study objective assessed the energy demand and economic cost of two hospital-based COVID-19 infection control interventions: negative pressure (NP) treatment rooms and xenon pulsed ultraviolet (XP-UV) equipment. After projecting COVID-19 hospitalizations, a Hospital Energy Model and Infection De-escalation Models quantified increases in energy demand and reductions in infections. The NP intervention was applied to 11, 22, and 44 rooms for small, medium, and large hospitals, while the XP-UV equipment was used eight, nine, and ten hours a day. For small, medium, and large hospitals, the annum kWh for NP rooms were 116,700 kWh, 332,530 kWh, 795,675 kWh, which correspond to annum energy costs of $11,845 ($1,077/room), $33,752 ($1,534/room), and $80,761 ($1,836/room). For XP-UV, the annum-kilowatt-hours (and costs) were 438 ($45), 493 ($50), and 548 ($56) for small, medium, and large hospitals. While energy efficiencies may be expected for the large hospital, the hospital contained more energy-intensive use rooms (ICUs) which resulted in higher operational and energy costs. XP-UV had a greater reduction in secondary COVID-19 infections in large and medium hospitals. NP rooms had a greater reduction in secondary SARS-CoV-2 transmission in small hospitals. Early implementation of interventions can result in realized cost savings through reduced hospital-acquired infections.

Ventilation and air-conditioning systems in dental clinics and COVID-19: How much do we know?

Background

This study evaluated the association between knowledge and management of ventilation and air-conditioning systems (VAC) to avoid the spread of the SARS-CoV-2 virus in health facilities by dentists and demographic variables.

Material and Methods

A cross-sectional digital media survey was administered to dentists as part of global research. The core questionnaire was used including four additional questions on VAC (Q1: knowledge, Q2: work settings, Q3: temperature, and Q4: maintenance). A descriptive analysis was conducted for sociodemographic and VAC variables, and bivariate analysis was carried out using different tests.

Results

5370 dentists answered the survey (median age of 45 years; 72.22% women). About half of the respondents said that they knew about the guidelines issued for the management of air conditioners (AC) during the pandemic, and 16.77% have made modifications to their VAC systems during this period. The most frequent AC temperature range used in the dentists’ offices during the pandemic was 18°C to 20°C. As age increased, self-reported knowledge about VAC guidelines expanded. Remote and rural regions were perceived to have less knowledge of the guidelines.

Conclusions

Although perceptions of knowledge about VAC systems during the COVID-19 pandemic was high, the temperature in dental offices was colder than that recommended. Greater disclosure of VAC management practices and adherence to VAC management guidelines are required.

Key words:Air conditioning, dentistry, coronavirus.

Ventilation-Associated Particulate Matter Is a Potential Reservoir of Multidrug-Resistant Organisms in Health Facilities

Most healthcare-associated infections (HCAIs) develop due to the colonisation of patients and healthcare workers by multidrug-resistant organisms (MDRO). Here, we investigated whether the particulate matter from the ventilation systems (Vent-PM) of health facilities can harbour MDRO and other microbes, thereby acting as a potential reservoir of HCAIs. Dust samples collected in the ventilation grilles and adjacent air ducts underwent a detailed analysis of physicochemical properties and biodiversity. All Vent-PM samples included ultrafine PM capable of reaching the alveoli. Strikingly, >70% of Vent-PM samples were contaminated, mostly by viruses (>15%) or multidrug-resistant and biofilm-producing bacterial strains (60% and 48% of all bacteria-contaminated specimens, respectively). Total viable count at 1 m from the ventilation grilles was significantly increased after opening doors and windows, indicating an association between air flow and bacterial contamination. Both chemical and microbial compositions of Vent-PM considerably differed across surgical vs. non-surgical and intensive vs. elective care units and between health facilities located in coal and chemical districts. Reduced diversity among MDRO and increased prevalence ratio in multidrug-resistant to the total Enterococcus spp. in Vent-PM testified to the evolving antibiotic resistance. In conclusion, we suggest Vent-PM as a previously underestimated reservoir of HCAI-causing pathogens in the hospital environment.

COVID-19 Outbreak and Hospital Air Quality: A Systematic Review of Evidence on Air Filtration and Recirculation

The outbreak of SARS-CoV-2 has made us all think critically about hospital indoor air quality and the approaches to remove, dilute, and disinfect pathogenic organisms from the hospital environment. While specific aspects of the coronavirus infectivity, spread, and routes of transmission are still under rigorous investigation, it seems that a recollection of knowledge from the literature can provide useful lessons to cope with this new situation. As a result, a systematic literature review was conducted on the safety of air filtration and air recirculation in healthcare premises. This review targeted a wide range of evidence from codes and regulations, to peer-reviewed publications, and best practice standards. The literature search resulted in 394 publications, of which 109 documents were included in the final review. Overall, even though solid evidence to support current practice is very scarce, proper filtration remains one important approach to maintain the cleanliness of indoor air in hospitals. Given the rather large physical footprint of the filtration system, a range of short-term and long-term solutions from the literature are collected. Nonetheless, there is a need for a rigorous and feasible line of research in the area of air filtration and recirculation in healthcare facilities. Such efforts can enhance the performance of healthcare facilities under normal conditions or during a pandemic. Past innovations can be adopted for the new outbreak at low-to-minimal cost.

Does the Laminar Airflow System Affect the Development of Perioperative Hypothermia? A Randomized Clinical Trial

OBJECTIVES

We aimed to compare tympanic membrane temperature changes and the incidence of inadvertent perioperative hypothermia (IPH) in patients undergoing laparoscopic cholecystectomy under general anesthesia in laminar airflow systems (LAS-OR) and conventional turbulent airflow systems (CAS-OR).

BACKGROUND

Different heating, ventilation, and air-conditioning (HVAC) systems are used in the operating room (OR), such as LAS and CAS. Laminar airflow is directed directly to the patient in LAS-OR. Does laminar airflow in ORs cause faster heat loss by convection?

METHODS

This is a prospective, randomized study. We divided 200 patients with simple randomization (1:1), as group LAS and group CAS, and took the patients into the LAS-OR or CAS-OR for the operation. Clinical trial number: IRCT20180324039145N3. The tympanic membrane temperatures of patients were measured (°C) before anesthesia induction (T ₀) and then every 15 min during surgery (T_n). Changes (Δ_n) between T ₀ and T_n were measured.

RESULTS

In the first 30 min, there was a temperature decrease of approximately 0.8 °C (1.44 °F) in both groups. Temperature decreases at 45 min were higher in group LAS than in group CAS but not statistically significant, Δ₄₅, respectively, 0.89 (95% confidence interval [CI] [0.77, 1.02]) versus 0.77 (95% CI [0.69, 0.84]; p = .09). IPH occurred in a total of 60.9% (112 of 184) of patients in the entire surgical evaluation period in group LAS and group CAS (58.9% vs. 62.8%, p = . 59).

CONCLUSIONS

IPH is seen frequently in both HVAC systems. Clinically, the advantage of HVAC systems relative to each other has not been demonstrated during laparoscopic cholecystectomy.

Challenges faced in establishing a dedicated 250 bed COVID-19 intensive care unit in a temporary structure

An Intensive Care Unit (ICU) is an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency. While this availability of trained manpower and specialized equipment makes it possible to care for critically ill patients, it also presents singular challenges in the form of man and material management, design concerns, budgetary concerns, and protocolization of treatment. Consequently, the establishment of an ICU requires rigorous design and planning, a process that can take months to years. However, the Coronavirus disease-19 (COVID-19) epidemic has required the significant capacity building to accommodate the increased number of critically ill patients. At the peak of the pandemic, many countries were forced to resort to the building of temporary structures to house critically ill patients, to help tide over the crisis. This narrative review describes the challenges and lessons learned while establishing a 250 bedded ICU in a temporary structure and achieving functionality within a period of a fortnight.

Lagrangian modeling of inactivation of airborne microorganisms by in-duct ultraviolet lamps

There has been increasing interest in modeling the UV inactivation on airborne microorganisms via the Lagrangian approach as a result of its outstanding features in calculating UV dose with particle trajectory. In this study, we applied the Lagrangian method to model the disinfection performance of in-duct UV lamps on three bacteria: Pseudomonas alcaligenes, Salmonella enterica and Escherichia coli, respectively. For modeling, the airborne bacteria's inactivation was determined by critical survival fraction probability (CSFP) and maximal bearable UV dose (MBUD) methods, respectively. The results indicated that Lagrangian modeling utilizing the MBUD method needs to appropriately evaluate the maximal UV dose (D _mb ), which is bearable for airborne microorganisms. The disinfection efficacy obtained by using the CSFP method agreed well with experimental measurements. Within the Lagrangian framework, the recommended empirical value for critical survival fraction (F _sc ) was 0.4 for modeling the disinfection efficacy of in-duct UV lamps. Besides, the disinfection efficacies of in-duct UV lamps with full luminous length on P. alcaligenes and E. coli were 100% with Re within the range of 4.11 × 10⁴ to 8.22 × 10⁴. Moreover, the present numerical model was also applied for further validation with inactivation measurements of in-duct UV lamps performed by the U.S. Environmental Protection Agency (EPA). Based on the results, the UV disinfection efficacies obtained by the present modeling method had a closed agreement with EPA experimental results. It deserved to pay more investigations on the optimal value of F _sc in further for accurately applying Lagrangian modeling on air UV disinfection.

Negative pressure rooms and COVID-19

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes 2019 novel coronavirus disease (COVID-19), has rapidly developed into a global pandemic and public health emergency. The transmission and virulence of this new pathogen have raised concern for how best to protect healthcare professionals while effectively providing care to the infected patient requiring surgery. Although negative pressure rooms are ideal for aerosol-generating procedures, such as intubation and extubation, most operating theatres are generally maintained at a positive pressure when compared with the surrounding areas. This article compares negative and positive pressure rooms and the advantages of a negative pressure environment in optimising clinical care and minimising the exposure of patients and health care professionals to SARS-CoV-2.

Impact of HVAC-Systems on the Dispersion of Infectious Aerosols in a Cardiac Intensive Care Unit

At the end of 2019, a variation of a coronavirus, named SARS-CoV-2, has been identified as being responsible for a respiratory illness disease (COVID-19). Since ventilation is an important factor that influences airborne transmission, we proposed to study the impact of heating, ventilation and air-conditioning (HVAC) with a variable air volume (VAV) primary air system, on the dispersion of infectious aerosols, in a cardiac intensive care unit, using a transient simulation with computational fluid dynamics (CFD), based on the finite element method (FEM). We analyzed three scenarios that followed the dispersion of pathogen carrying expiratory droplets particles from coughing, from patients possibly infected with COVID-19, depending on the location of the patients in the intensive care unit. Our study provides the mechanism for spread of infectious aerosols, and possibly of COVID-19 infection, by air conditioning systems and also highlights important recommendations for disease control and optimization of ventilation in intensive care units, by increasing the use of outdoor air and the rate of air change, decreasing the recirculation of air and using high-efficiency particulate air (HEPA) filters. The CFD-FEM simulation approach that was applied in our study could also be extended to other targets, such as public transport, theaters, philharmonics and amphitheaters from educational units.

Health effects of heating, ventilation and air conditioning on hospital patients: a scoping review

Background

In the face of climate change, the protection of vulnerable patients from extreme climatic conditions is of growing interest to the healthcare sector and governments. Inpatients are especially susceptible to heat due to acute illness and/or chronic diseases. Their condition can be aggravated by adverse environmental factors. Installing air conditioning can be seen as an element of public health adaptation because it was shown to improve mortality rates of hospital patients experiencing hot temperatures. Still, the mediating factors and resulting health effects are largely unknown.

Method

The PRISMA-ScR guideline was followed for this scoping review. Available evidence on the health effects of Heating, Ventilation, Air Conditioning (HVAC) and fans was searched in Medline, Embase and the Cochrane Library. The focus of the search strategy was on inpatients of the hospital. Grey literature was screened on 14 relevant websites. English and German publications were eligible without restrictions on publication date. Results were charted according to the categories population, intervention, control and outcome together with a qualitative description.

Results

The review process yielded eleven publications of which seven were issued after 2003. Seven were clinical trials, three cross-sectional studies and one was a case report. The publications described the installation of HVAC on general wards and in intensive care units. Main topics were heat stress protection and support of thermoregulation, but also the rewarming of hypothermic patients. HVAC use resulted in a recovery effect shown by improved vital signs, reduced cardiac stress, accelerated recuperation and greater physical activity. This protective effect was demonstrated by a shorter hospital stay for patients with respiratory disease and a reduction of mortality for heat illness patients.

Conclusion

This scoping review summarises the fragmented evidence on health effects of HVAC and fan utilisation for inpatients. Installing HVAC has the potential to improve patients’ outcomes and to make hospital treatment more efficient during heat waves. The application of HVAC could be a promising adaptation measure to mitigate the adverse effects of climate change on health and healthcare systems.

Airborne route and bad use of ventilation systems as non-negligible factors in SARS-CoV-2 transmission

The world is facing a pandemic of unseen proportions caused by a corona virus named SARS-CoV-2 with unprecedent worldwide measures being taken to tackle its contagion. Person-to-person transmission is accepted but WHO only considers aerosol transmission when procedures or support treatments that produce aerosol are performed. Transmission mechanisms are not fully understood and there is evidence for an airborne route to be considered, as the virus remains viable in aerosols for at least 3 h and that mask usage was the best intervention to prevent infection. Heating, Ventilation and Air Conditioning Systems (HVAC) are used as a primary infection disease control measure. However, if not correctly used, they may contribute to the transmission/spreading of airborne diseases as proposed in the past for SARS. The authors believe that airborne transmission is possible and that HVAC systems when not adequately used may contribute to the transmission of the virus, as suggested by descriptions from Japan, Germany, and the Diamond Princess Cruise Ship. Previous SARS outbreaks reported at Amoy Gardens, Emergency Rooms and Hotels, also suggested an airborne transmission. Further studies are warranted to confirm our hypotheses but the assumption of such way of transmission would cause a major shift in measures recommended to prevent infection such as the disseminated use of masks and structural changes to hospital and other facilities with HVAC systems.

Construction time, cost and testing data of a prefabricated isolation medical unit for COVID-19

Coronavirus Disease 2019 (COVID-19) has been identified as a global pandemic by the World Health Organization (WHO). The breakout of COVID-19 in various countries and regions brings a great threat to people's life and adds an unprecedented high pressure on healthcare systems. Due to the high infectivity of COVID-19, high standard negative pressure isolation units are required to accommodate the patients with COVID-19 and protect health workers. A novel prefabricated negative pressure isolation medical unit was designed and constructed in Shenzhen, China to help to accommodate the patients with COVID-19. This article provides detailed construction cost, time and testing data for this isolation medical unit. Considering the construction happened during the lockdown in Shenzhen (and in China), the construction cost and time can provide precious and rare information as well as guidelines to construct or expand appropriate medical facilities to accommodate the patients with COVID-19.

Impact of a New Portable Air Purification Technology Device in the Pediatric Hospital Setting - A Pre-post Assessment Study

Introduction

We assessed whether portable photo-electrochemical oxidation (PECO) air purification in the pediatric hospital room setting could improve health outcomes for patients admitted with respiratory distress. 

Methods

We performed a prospective study evaluating the use of a portable air purifier with PECO technology. The historical control group comprised matched patients. Twenty-seven PECO-equipped portable air filtration devices were placed in the rooms. Clinical endpoints included length of stay in the hospital, length of stay in the intensive care unit (ICU), rates of intubation, non-invasive ventilation, and nebulizer use.

Results

The mean length of ICU stay was 0.7 days in the pre-intervention period and decreased to 0.4 days post-intervention. The mean length of overall hospitalization reduced by 0.3 days. The rate of non-invasive ventilation use was 77% in the pre-intervention period and decreased to 23% in the post-intervention period. The rate of nebulizer use was 59% in the pre-intervention period and 41% in the post-intervention period. The rate of intubation was 57.1% in the pre-intervention period and 43% in the post-intervention period. 

Conclusion 

Portable PECO air purification may reduce hospital length of stay, rates of intubation, and need for non-invasive intervention and nebulizers for pediatric patients admitted with respiratory distress.