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Equipment for determining the purity of air in the operating room. Design features of ventilation and air conditioning systems for healthcare facilities. Operation of laminar air diffusers

Group 1 according to GOST 52539-2006

List of ongoing operations

– transplantation and transplantation of organs and tissues;
– implantation of foreign bodies (prosthetics of the hip, knee and other joints, hernia repair with a mesh prosthesis, etc.);
– reconstructive and restorative operations on the heart, large vessels, genitourinary system, etc.;
— reconstructive and restorative operations using microsurgical techniques;
– combined operations for tumors of different localization;
— open thoracoabdominal operations;
– neurosurgical operations;
- operations with extensive operating fields and / or long duration, requiring a long stay of tools and materials in the open;
- operations after preoperative chemotherapy and / or radiation therapy for patients with a reduced immune status and multiple organ failure;
- Operations for concomitant trauma, etc.

Laminar ceilings are used to protect the patient and sterile instrument from contamination from the air. The device is built into the ventilation duct of a medical institution directly into the ceiling above the operating table and provides a continuous supply of purified and sterile unidirectional air flow to the operation area. The device must provide air filtration class H14 99% . Laminar field area, not less than 9m2.
Equipment: Laminar ceilings Tion B Lam-1 with body height 400mm, Tion B Lam-1 H290 with body height 290mm (for low ceilings)

In view of the significant air consumption, for the formation of a unidirectional flow, it is advisable to use a ventilation system for operating rooms with partial air recirculation (part of the air is taken by the ventilation system from the street, and part is mixed from the room), provided that it is cleaned and disinfected on filters of at least class H14 with an inactivation of at least 99%
Equipment:

H11 99%
Equipment:

Air Cleanliness Guidelines for Highly Aseptic Operating Rooms

5.5. The cross-sectional area of the vertical unidirectional air flow must be at least 9.0 m2.

6.1.

6.3.

Room group	Type of air flow	Air exchange rate	Filter class
Operating table area		Not installed

6.24. The air supplied to class A cleanliness rooms is cleaned and disinfected by devices that ensure the efficiency of inactivation of microorganisms at the outlet of the unit by at least 99% for class A, as well as the filtration efficiency corresponding to the filters high efficiency(H11-H14). High-purity filters must be replaced at least once every six months, unless otherwise provided by the instruction manual.

For reference:

6.42.

8.9.6.

Group 3 according to GOST 52539-2006

List of ongoing operations

- endoscopic operations;
— endovascular interventions;
- other medical and diagnostic manipulations with small sizes of the surgical field;
- hemodialysis, plasmapheresis, etc.;
- C-section;
– selection of cord blood, bone marrow, adipose tissue, etc. for subsequent isolation of stem cells.

H14 and inactivation of microorganisms on filters not less than 95% . Laminar field area: 3-4m2.
Equipment: Laminar ceiling with a body height of 400mm: Tion B Lam-4 (2600×1800×400mm with a niche for a lamp); for low ceilings with a body height of 290mm: Tion V Lam-4 H290 (3080×1800×290mm with a niche for a lamp).

Due to the significant air consumption, for the formation of a unidirectional flow, it is advisable to use a ventilation system with partial air recirculation (part of the air is taken by the ventilation system from the street, and part is mixed from the room), provided that it is cleaned and disinfected on filters of at least class H14 with an inactivation of at least 95% . This allows you to significantly save energy for heating or cooling the supply air by the ventilation system. This method of air exchange can be provided by installing a laminar ceiling and connecting columns or recirculation modules to it, which provide air from the room.
Equipment: Wall recirculation column -RP for laminar ceilings Tion.

Disinfection and purification of indoor air

To reduce contamination and increase the frequency of air exchange, it is recommended to install autonomous decontaminators of air purifiers (recirculators) with a filtration class of at least H11 and inactivation of microorganisms on filters not less than 95%
Equipment: Decontaminator-air purifier Tion A in mobile and wall-mounted version

Air Cleanliness Guidelines for Small Operating Rooms

According to SanPiN 2.1.3.2630-10 p. 6.24 and new SP 118.13330.2012 - Appendix K, the air must be cleaned and disinfected by devices that provide an air filtration degree of at least class H14 for areas with unidirectional flow and H13 for areas without unidirectional flow, and also inactivation of microorganisms is not less than 95%.

5.4.

In order to ensure the universality of operating rooms belonging to group 3, and the possibility of carrying out any operations, it is recommended at the design stage to consider the issue of their execution in accordance with the requirements for group 1 premises.

The use of a unidirectional air flow is also advisable when carrying out operations related to the introduction of foreign bodies into the human parenteral system (for example, catheters). A sterile catheter or other medical device must be unpacked, located and inserted into the human body in an ISO class 5 area.

5.5. The speed of unidirectional air flow should be between 0.24 and 0.3 m/s. The area with unidirectional air flow must be limited by curtains (shields) around the entire perimeter. Curtains (shields) must be made of transparent materials resistant to disinfectants, as a rule, not less than 0.1 m long. The distance from the lower edge of the curtains (shields) to the floor must be at least 2.1 m.

Due to the significant air flow, it is advisable to use a ventilation and air conditioning system with local air recirculation to form a unidirectional flow. With local recirculation, only room air can be used, or a certain proportion of outside air can be added to it.

The separation of the operating room and other rooms is carried out according to one of the principles: pressure drop or displacing air flow. In the latter case, the cleanliness of adjacent rooms can be largely ensured by the flow of air from the operating room. Airlocks may not be provided.

When applying the differential pressure principle, it is recommended to provide continuous (visual or automatic) pressure monitoring.

Rooms for transporting sterile materials (corridors leading to operating rooms) should have a positive pressure drop, including in relation to the operating room. If sterile materials are transported in airtight containers (bixes), then the air in these rooms (corridors) must be supplied through final filters of at least class F9.

6.1. Outdoor air flow requirements: at least 100 m3/h per person
and not less than 800m3/h per anesthesia machine.

6.3. Air exchange requirements and filter classes

Room group	Room cleanliness class (zones)	Type of air flow	Air exchange rate	Filter class
Operating table area
Area surrounding the operating table

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

6.24. The air supplied to class B cleanliness rooms is cleaned and disinfected by devices that ensure the efficiency of inactivation of microorganisms at the outlet of the unit by at least 95%, as well as the filtration efficiency corresponding to high efficiency filters (H11-H14). (Clarifications of Rospotrebnadzor)

For reference: Prior to the release of these sanitary regulations, conventional (fabric or paper) HEPA filters were routinely used in ventilation systems. Such "passive" filters provide only filtration ("detention") of dust and microorganisms, without providing inactivation (destruction) of microorganisms, while SanPiN 2.1.3.2630-10 require both. Therefore, conventional HEPA filters for filtration and UV disinfection sections for inactivation were often installed to meet the requirements of sanitary regulations. This expensive solution has many disadvantages: from the high energy consumption of UV sections and a large number of UV-resistant microorganisms to the presence of fragile lamps containing mercury in the ventilation duct, which is contrary to the requirements of Rospotrebnadzor.

6.42. It is allowed to recirculate air for one room, provided that a high-efficiency filter (H11-H14) is installed with the addition of outdoor air according to the calculation to ensure standard microclimate parameters and air purity.

8.9.6. The concentrations of harmful chemicals, disinfectants and sterilizing agents, biological factors released into the air during the operation of medical equipment products should not exceed the maximum allowable concentrations of MPC and approximate safe exposure levels established for atmospheric air.

Group 5 according to GOST 52539-2006
Class A according to SanPiN 2.1.3.2630-10

Infectious operating rooms

List of ongoing operations

- for patients with purulent infection,
- for patients with anaerobic infection
- for tuberculosis patients, etc.

To ensure the safety of people in the building and outside it, the air removed from the infectious operating room must be subjected to class filtration. H13 95%
Equipment: Air purifiers for the exhaust ventilation duct:

Laminar ceilings are used to protect the patient and sterile instrument from contamination from the air. The device is built into the supply ventilation channel of the hospital directly into the ceiling above the operating table and provides a continuous supply of purified and sterile unidirectional air flow to the operation area. The device must provide air filtration class H14 and inactivation of microorganisms on filters not less than 95% . Laminar field area: 3-4m2.
Equipment: Laminar ceilings with a body height of 400mm: Tion B Lam-4 (2600×1800×400mm with a niche for a lamp) and for low ceilings with a body height of 290mm: Tion B Lam-4 H290 (3080×1800×290mm with a niche for a lamp).

Disinfection and purification of indoor air

To reduce contamination and increase the frequency of air exchange, it is recommended to install autonomous decontaminators of air purifiers (recirculators) with a filtration class of at least H11 and inactivation of microorganisms on filters not less than 99%
Equipment: Decontaminator-air purifier Tion A in mobile and wall-mounted version

Air Cleanliness Guidelines for Infectious Operating Rooms

The priority is to protect staff and other patients. The air from the infectious operating room should not enter adjacent rooms. According to paragraph 6.18 of SanPiN 2.1.3.2630-10 in infectious diseases departments, exhaust ventilation systems are equipped with air disinfection devices or fine filters that provide a degree of inactivation (destruction) of microorganisms of at least 95%. GOST R 52539-2006 clause 5.9 requires that a separate ventilation system be provided in infectious rooms using H13 class exhaust filters installed at the border of the room and the exhaust duct.

GOST R 52539-2006 "Air purity in medical institutions"

clause 5.4. Basic requirements for clean air in rooms equipped in accordance with GOST R 52539-2006

5.9. In operating rooms where patients with purulent, anaerobic and other infections are operated on, it is advisable to provide zones with a unidirectional air flow according to 5.7.

5.5. The cross-sectional area of the vertical unidirectional air flow must be at least 3-4 m2. The speed of unidirectional air flow should be between 0.24 and 0.3 m/s. The area with unidirectional air flow must be limited by curtains (shields) around the entire perimeter. Curtains (shields) must be made of transparent materials resistant to disinfectants, as a rule, not less than 0.1 m long. The distance from the lower edge of the curtains (shields) to the floor must be at least 2.1 m.

When applying the differential pressure principle, it is recommended to provide continuous (visual or automatic) pressure monitoring.

5.9. In Group 5 rooms, a separate ventilation system should be provided using, if necessary, class H13 exhaust filters installed at the boundary of the room and the exhaust duct. The recommended air exchange rate is at least 12 hours.

In the premises of this group, air recirculation is not allowed.

6.1. Outdoor air flow requirements: at least 100 m3/h per person
and not less than 800m3/h per anesthesia machine.

6.3. Air exchange requirements and filter classes

Room group	Room cleanliness class (zones)	Type of air flow	Air exchange rate	Filter class
Operating table area			Not installed
Area surrounding the operating table

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

6.24. (Clarifications of Rospotrebnadzor)

Group 2 according to GOST 52539-2006
Class A according to SanPiN 2.1.3.2630-10

Resuscitation and intensive care wards with unidirectional flow

Appointment of intensive care and resuscitation wards

Chambers are intended for patients:

- after bone marrow transplantation.
with extensive burns.
- Receiving chemotherapy and radiation therapy in high doses.
- after major surgery.
- with reduced immunity or its complete absence.

Laminar ceilings are used to protect the patient from infection from the air in intensive care and intensive care units. The device is built into the ventilation duct of a medical institution directly into the ceiling above the patient's bed and provides a continuous supply of purified and sterile unidirectional air flow to the bed area. The device must provide air filtration class H14 and inactivation of microorganisms on filters not less than 99% . The area of the laminar field should cover the area of the bed and be at least 1.8m2.
Equipment: Laminar ceilings Tion V Lam-2 (1800x1000x400mm); for low ceilings: Tion B Lam-2 H290 (1800x1000x290mm).
laminar cells

In view of the significant air consumption, in order to form a unidirectional flow over each of the beds of the department, it is advisable to use a ventilation system in intensive care with partial air recirculation (part of the air is taken from the ventilation system from the street, and part is mixed from the room), provided that it is cleaned and disinfected on filters not below class H14 with an inactivation of at least 99% . This allows you to significantly save energy for heating or cooling the supply air by the ventilation system. This method of air exchange can be provided by installing a laminar ceiling and connecting columns or recirculation modules to it, which provide air from the room.
Equipment: Wall recirculation column -RP is suitable for all Tion laminars

Disinfection and purification of indoor air

To reduce contamination and increase the frequency of air exchange, it is recommended to install autonomous decontaminators of air purifiers (recirculators) with a filtration class of at least H11 and inactivation of microorganisms on filters not less than 99%
Equipment: Decontaminator-air purifier Tion A in mobile and wall-mounted version

Air cleanliness standards for resuscitation and intensive care units

According to SanPiN 2.1.3.2630-10 p. 6.24 and new SP 118.13330.2012 - Appendix K, the supply air must be cleaned and disinfected by devices that provide a degree of air filtration of at least class H14 for areas with unidirectional flow and H13 for areas without unidirectional flow, as well as inactivation of microorganisms of at least 99%.

GOST R 52539-2006 "Air purity in medical institutions"

clause 5.4. Basic requirements for clean air in rooms equipped in accordance with GOST R 52539-2006

5.6. In the premises of group 2, the patient's bed should be in the zone of a unidirectional air flow with a flow rate of 0.24 to 0.3 m/s. A more economical solution is vertical flow, but horizontal air flow is also acceptable.
The requirements for ventilation and air conditioning, enclosing structures and areas are similar to the requirements for group 1 premises (5.5).

6.1.

6.3. Air exchange requirements and filter classes

Room group	Room cleanliness class (zones)	Type of air flow	Air exchange rate	Filter class
Patient's bed area			Not installed
The area surrounding the patient's bed

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

6.24. The air supplied to class A rooms is cleaned and disinfected by devices that provide an efficiency of inactivation of microorganisms at the outlet of the unit of 99%, as well as a filtration efficiency corresponding to high efficiency filters (H11-H14). High-purity filters must be replaced at least once every six months, unless otherwise provided by the instruction manual. (Clarifications of Rospotrebnadzor)

Group 3 according to GOST 52539-2006
Class B according to SanPiN 2.1.3.2630-10

Aseptic rooms and rooms without unidirectional flow

List of aseptic chambers and premises

- wards for patients after operations for transplantation of internal organs.
- wards for burn patients.
- wards for patients transferred from intensive care units.
- post-anesthesia wards.
- for debilitated or seriously ill non-surgical patients.
- postpartum, including with the joint stay of the child.
- for nursing newborns (second stage).
- preoperative, anesthetic and other rooms leading to operating rooms;
- aseptic dressing and procedural bronchoscopy; pantries of sterile materials;
– X-ray operating rooms, including sterilization ones at operating rooms;
— CSO: clean and sterile areas;
– dialysis rooms, procedural ICUs, barosals, assistant and filling pharmacies, embryological laboratory

To ensure sterile conditions, air is supplied to aseptic rooms (sterilization departments, dialysis rooms, etc.) and wards (burn, post-anesthesia, postpartum, etc.) through a ventilation system with disinfection and cleaning on filters of at least class H11 95% . Air flow: turbulent.
Equipment: floor-suspended: Tion V (capacity from 300 to 900 m3/h) and Tion V (capacity 2000 and 3000 m3/h); floor: Tion V (capacity from 300 to 25000 m3/h).

To reduce the cost of processing outdoor supply air, it is recommended to use air recirculation (taking part of the air from the room), provided that it is cleaned and disinfected on filters of at least class H14 with an inactivation of at least 95%
Equipment: Wall recirculation column -RP is suitable for all Tion laminars

Disinfection and purification of indoor air

Air cleanliness standards for aseptic rooms and rooms

The air must be treated with devices that filter particles with a class of at least H13 (SP 118.13330.2012 Appendix K), inactivate (destroy) microorganisms with an efficiency of at least 95% (SanPiN 2.1.3.2630-10 p. 6.24), purify the air from harmful substances to the MPC level (No. 384-FZ).

GOST R 52539-2006 "Air purity in medical institutions"

clause 5.4. Basic requirements for air purity in aseptic rooms and rooms with turbulent air flow according to GOST R 52539-2006

In rooms of group 3, air filtration is provided with an air exchange rate that provides a given cleanliness class.

In rooms of group 3 it is allowed to use air recirculation.

Separation of rooms of group 3 and other rooms is carried out according to one of the principles: displacement flow or pressure difference. Continuous monitoring of these parameters and air locks in the premises of group 3 are not provided.

In burn departments for patients with extensive burns, there should be wards (zones) of ISO 5 cleanliness class, equipped with vertical unidirectional airflow to blow the affected areas of the body.

For cases when it is necessary to blow the affected areas of the body from different sides, it is recommended to use autonomous air purification devices to prevent the ingress of contaminants to the affected areas.

6.1. Requirements for outdoor air flow: not less than 100 m3/h per person.

6.3. Air exchange rate - 12-20 times / h, air flow: non-unidirectional

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

6.24. The air supplied to the cleanliness class B rooms is cleaned and disinfected by devices that provide an efficiency of inactivation of microorganisms at the outlet of the unit of 95%, as well as a filtration efficiency corresponding to high efficiency filters (H11-H14). High-purity filters must be replaced at least once every six months, unless otherwise provided by the instruction manual. (Clarifications of Rospotrebnadzor)

Group 5 according to GOST 52539-2006
Class B according to SanPiN 2.1.3.2630-10

Premises of infectious departments and biological laboratories

List of infection rooms

- wards, boxes (including tuberculosis).
dressing rooms, locks and other premises of infectious diseases departments.
- rooms and boxes of microbiological laboratories working with pathogenic microorganisms (aerosol chambers; boxed rooms; microbiological rooms)

To ensure the safety of people in the building and outside it, the air removed from the infectious wards and boxes, as well as the premises of biological laboratories working with pathogenic microorganisms, must be filtered H13 and inactivation (complete destruction) of microorganisms on filters not less than 95%
Equipment: Duct disinfectants-cleaners in the exhaust ventilation duct:
Tion V (capacity from 300 to 900 m3/h) and Tion V (capacity 2000 and 3000 m3/h)

The supply air is supplied through a ventilation system with disinfection and purification on filters not lower than the class H11 with inactivation of microorganisms not less than 95%.
Equipment: Floor-hung duct disinfectants-cleaners: Tion V (capacity from 300 to 900 m3/h) and Tion V (capacity 2000 and 3000 m3/h); floor: Tion V (capacity from 300 to 2400 m3/h) and Tion V (capacity from 2000 to 25000 m3/h)

Disinfection and purification of indoor air

To reduce contamination and increase the frequency of air exchange, it is recommended to install autonomous decontaminators of air purifiers (recirculators) with a filtration class of at least F9 and inactivation of microorganisms on filters not less than 95%
Equipment: Decontaminator-air purifier Tion A in mobile and wall-mounted version

Air cleanliness standards for infection rooms

Removeable from infection rooms, the air must be treated with devices that filter particles with a class not lower than H13(SP 118.13330.2012 Appendix K), inactivate (destroy) microorganisms with an efficiency not lower than 95% (SanPiN 2.1.3.2630-10 p. 6.24), purify the air from harmful substances to the MPC level (No. 384-FZ).

For reference:

Supply the air entering the infectious diseases departments and rooms of biological laboratories, according to SP 118.13330.2012 Appendix K, must be cleaned on class filters from H11 to H13.

GOST R 52539-2006 "Air purity in medical institutions"

clause 5.4. Basic requirements for air purity in infectious rooms according to GOST R 52539-2006

5.9. In Group 5 rooms, a separate ventilation system should be provided using, if necessary, class H13 exhaust filters installed at the boundary of the room and the exhaust duct.

To reduce the supply air consumption and ensure a given air exchange rate, autonomous air purification devices can be used.

The entrance to the room and the exit from it must be organized through an active air lock (lock with forced supply of clean air). Air from the air lock can be fed into the isolator.

The cleanliness class of the lock must not be lower than the cleanliness class of rooms of group 5 (insulators).

Isolators must maintain negative pressure with respect to adjacent rooms, including the air lock. The pressure drop must be at least 15 Pa, and its continuous (visual or automatic) control must be ensured. Visual and audible signaling of simultaneous opening of doors must be provided.

6.4 In rooms of groups 3-5, in order to increase the air exchange rate, reduce the load on the central air conditioner and ensure an air pressure difference (positive or negative), standalone devices air purification with final filters class not lower than F9. To ensure a higher level of cleanliness in the room, the devices can be equipped with final filters of classes H12, H13 and H14.

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

6.18. In infectious, including tuberculosis, departments, exhaust ventilation systems are equipped with air disinfection devices or fine filters.

6.19. Boxes and boxed chambers are equipped with autonomous ventilation systems with the predominance of air exhaust over inflow and installation of air disinfection devices or fine filters on the exhaust. When installing disinfecting devices directly at the exit from the premises, it is possible to combine the air ducts of several boxes or boxed wards into one exhaust ventilation system.

6.20. In existing buildings, in the absence of supply and exhaust ventilation with mechanical stimulation in the infectious wards, natural ventilation should be equipped with the obligatory equipping of each box and the boxed ward with air disinfection devices that ensure the efficiency of inactivation of microorganisms for at least 95% at the exit.

Air purity standards for biolaboratories

According to the conclusion of the Anti-Plague Center of Rospotrebnadzor, microbiological laboratories conducting work with pathogenic (dangerous) microorganisms, equated to infectious departments, so their mechanically driven exhaust ventilation must be equipped with air disinfection devices and antibacterial filters that provide air filtration with efficiency not lower than H13, as well as continuous inactivation (destruction) microorganisms of 1-4 pathogenicity groups.

For reference: Until recently, conventional (fabric or paper) HEPA filters were commonly used in ventilation systems. Such "passive" filters provide only filtration ("detention") of dust and microorganisms, without providing inactivation (destruction) of microorganisms, while SanPiN 2.1.3.2630-10 require both. Therefore, conventional HEPA filters for filtration and UV disinfection sections for inactivation were often installed to meet the requirements of sanitary regulations. This expensive solution has many disadvantages: from the high energy consumption of UV sections and a large number of UV-resistant microorganisms to the presence of fragile lamps containing mercury in the ventilation duct, which is contrary to the requirements of Rospotrebnadzor.

Safety of work with microorganisms of 3–4 pathogenicity groups
sanitary and epidemiological rules SP 1.2.731-99

4.2.10. Newly constructed and reconstructed laboratories should provide for:

- an autonomous supply and exhaust ventilation device with the installation of fine filters for air ejected from the "infectious" zone (or the equipment of these rooms with biological safety cabinets).

4.2.16. Existing exhaust ventilation from the “infectious” zone of the laboratory should be isolated from other ventilation systems and equipped with fine air filters.

4.2.21. Premises where work with live PBAs is carried out must be equipped with bactericidal lamps in accordance with the Guidelines for the Use of Bactericidal Lamps for the Disinfection of Air and Surfaces in Rooms.

4.5.2. Boxes for placing an aerosol chamber, keeping animals and opening them must be equipped with a mechanical supply and exhaust ventilation with fine air filters, have a backup engine on the hood with automatic switching.

Safety of work with microorganisms of 1-2 groups of pathogenicity (hazards)
sanitary and epidemiological rules SP 1.3.1285-03

2.3.16. The premises of the block for working with infected animals, boxed rooms, microbiological rooms must have autonomous system supply and exhaust ventilation, isolated from other ventilation systems of the building, equipped with fine filters (PTF) at the outlet, tested for protective effectiveness.

2.6.2. All vacuum lines, lines of compressed air and gases in the “contaminated” zone are provided with fine air filters (FTO).

2.7.3. The premises of the "infectious" zone must be equipped with supply and exhaust systems mechanical ventilation with fine filters providing:

Maintaining vacuum in rooms with constant automatic regulation of its parameters and their registration, it is allowed to create and regulate vacuum in other ways in the premises of the "infectious" zone of existing structures;

Creation of directed air flows, the presence of which is controlled by personnel;

Purification of incoming and outgoing air from the premises at the required number of cascades of fine filters;

Maintaining the required sanitary and hygienic conditions in the premises.

2.16.13 The structures of all types of aerosol chambers must be airtight, provide a constant discharge inside the working volume of at least 150 Pa (15 mm of water column) and be equipped with an air purification (decontamination) system.

2.16.14 The air purification system includes fine filters (PTF): one stage at the air inlet and two stages at the outlet. – functional diagnostic rooms, procedural endoscopy (gastroduodenoscopy, colonoscopy, retrograde cholangiopancreatography, etc., except for bronchoscopy).
- halls of physiotherapy exercises
– procedural magnetic resonance imaging
- procedural with the use of chlorpromazine
– procedural for the treatment of neuroleptics

– assembly and washing rooms for artificial kidneys, endoscopy, artificial blood circulation devices, solution-demineralization rooms.
– bathrooms (except for radon rooms), paraffin and ozocerite heating rooms, therapeutic swimming pools
– control rooms, staff rooms, rest rooms for patients after procedures
– procedural and dressing rooms for X-ray diagnostics, fluorography rooms, electric light therapy rooms, massage room
– control rooms of X-ray rooms and radiological departments, photo laboratories
- premises (rooms) for sanitation of patients, showers
- locker rooms in the departments of water and mud treatment
– rooms for radon baths, halls and mud therapy rooms for strip procedures, shower rooms
– premises for storage and regeneration of mud
– rooms for preparing a solution of hydrogen sulfide baths and storing reagents
– rooms for washing and drying sheets, canvases, tarps, mud kitchens
— pantries (except for the storage of reagents), technical rooms (compressor, pump rooms, etc.), equipment repair shops, archives
- sanitary rooms, rooms for sorting and temporary storage of dirty linen, rooms for washing, stretchers and oilcloths, a room for drying clothes and shoes for mobile teams
– pantry acids, reagents and disinfectants
- registries, information lobbies, dressing rooms, rooms for receiving parcels for patients, discharge rooms, waiting rooms, pantry, canteens for patients, a dairy room.
- a room for washing and sterilizing tableware and kitchen utensils at the pantry and canteen departments, hairdressers for serving patients
— storage of radioactive substances, packing and washing in radiological departments
– rooms for X-ray and radiotherapy
– cabinets for electro-, light-, magneto-, thermotherapy, ultrasound treatment
- premises of disinfection chambers: receiving and loading; unloading (clean) compartments
– sectional, museums and preparation rooms at the pathoanatomical departments
- rooms for dressing corpses, issuing corpses, storerooms for funeral accessories, for processing and preparing for burial of infected corpses, rooms for storing bleach
– bathrooms
- enema
– clinical diagnostic laboratories (premises for research)

Ensuring the frequency of air exchange and air purity standards

In wards for adult patients, offices, examination rooms and other rooms without aseptic conditions, filtration of supply air of class F7-F9 is regulated, while the air exchange rate must be ensured, in accordance with Appendix 3 to SanPiN 2.1.3.2630-10. This is achieved by central ventilation with air purification, or, in its absence, by installing a compact supply ventilation with air purification in each separate room.

Tion A in mobile and wall-mounted design

Air purity standards

SP 118.13330.2012 regulates filtration supply air class F7-F9, while the air exchange rate must be ensured, in accordance with Appendix 3 to SanPiN 2.1.3.2630-10.

GOST R 52539-2006 "Air purity in medical institutions"

clause 5.4. Basic requirements for air purity in accordance with GOST R 52539-2006

For patients with suspected active form of tuberculosis or other infectious diseases, rooms should be provided that are separated by doors from the rest of the premises of the admission department. The ventilation of these premises must comply with the requirements for group 5 premises (insulators).

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

List of premises

– premises for the preparation of dosage forms in aseptic conditions
– assistant, defector, harvesting and packaging, seaming and control and marking, sterilization-autoclave, distillation
– control and analytical, washing, unpacking
- storage rooms for the main stock:
a) medicinal substances, finished medicinal products, incl. and thermolabile, and medical supplies; dressings
b) mineral waters, medical glass and returnable transport containers, glasses and other optics, auxiliary materials, clean dishes
- premises for the preparation and packaging of poisonous drugs and drugs, flammable and combustible liquids

For protection from airborne contamination of critical operations such as filling and capping, devices with unidirectional air flow are used. The laminar ceiling or cell is built into the ventilation duct directly into the ceiling above the working area and provides a continuous supply of purified and sterile unidirectional air flow. The device must provide air filtration class H14 and inactivation of microorganisms on filters not less than 99% (requirements for class A according to SanPiN 2.1.3.2630-10). The area of the laminar field of the device is selected depending on the area of the working area of the cleaner production.
Equipment: Laminar cells Tion V Lam-M1 (600x600x400mm), Tion V Lam-M2 (1200x600x400mm)
Laminar ceilings Tion V Lam-2 (1800x1000x400mm); for low ceilings: Tion B Lam-2 H290 (1800x1000x290mm)

Disinfection and purification of supply air

In the premises of the assistant, defector, harvesting and packaging, seaming and control-marking, sterilization-autoclave and distillation supply air is supplied through a ventilation system with disinfection and cleaning on filters of at least class H11 with inactivation of microorganisms not less than 95% (requirements for class B according to SanPiN 2.1.3.2630-10). Since the norms of the air exchange rate are low and do not exceed 4 times, in cases of small rooms up to 50 m2 it is advisable to install compact supply ventilation (without laying air ducts) with air purification instead of central ventilation.

In the premises of pharmacies: control and analytical, washing, unpacking, as well as stock storage warehouses, the requirements for air purity are not regulated, but air exchange standards apply. They are achieved by arranging central system supply and exhaust ventilation, or, if it is impossible or absent, by installing a compact supply ventilation with air purification in each separate room.

Clean air guidelines for pharmacies

Pharmacy ventilation should provide a temperature of at least +18 and no higher than +20 degrees, air flow rate from 0.1 to 0.2 m/s and air humidity from 30% to 60%.
When choosing a ventilation system, it must be taken into account that it is necessary to exclude the entry of dirt, dust and microorganisms from the street into the room. Therefore, of all types of ventilation systems, preference is given to supply ventilation with air purification and disinfection. According to clause 5.16 of SanPiN 2.1.3.2630-10, all parenteral solutions are prepared in a pharmacy in a cabinet with laminar air flow using aseptic technology.

Guidelines MosMU 2.1.3.005-01

7.1. Heating and ventilation systems must be carried out in accordance with the current SNiP (SP 118.13330.2012).
7.2. To exclude the possibility of air masses from entering the corridors and production rooms into the aseptic block between these rooms, it is necessary to install a lock with air overpressure.
7.3. The aseptic unit must be equipped with autonomous supply and exhaust ventilation with a predominance of inflow.
7.4. The movement of air flows must be ensured from the aseptic unit to the premises adjacent to it.
Purified air supply to aseptic rooms can be carried out through the supply holes in the ceiling with a vertical air flow or through the holes in one of the side walls with a horizontal air flow. Allowed use of standalone devices dedusting (or filtering) of air installed indoors, creating horizontal or vertical laminar flows throughout the premises or in separate local areas to protect the most critical areas or operations.

Filling and capping is carried out under laminar air flow.

"Clean" chambers (or clean air laminar tables) should have work surfaces and rails made of smooth, durable material. The laminar flow velocity must be within 0.3 m/s.
7.5. Natural exhaust ventilation without centralized supply of supply air is allowed for detached buildings with a height of no more than 3 floors.
7.6. In each institution, an employee responsible for the operation of ventilation systems must be appointed by order.
7.7. The use of ventilation chambers for other purposes (warehousing, storage of chemical materials, etc.) is not allowed.
7.8. The operating organization must monitor the efficiency of the ventilation systems (air exchange rate, temperature, humidity and cleanliness of the supplied air).

Design temperatures, air exchange rates, air purity

air t not below	Name of divisions	Room class according to SanPiN 2.1.3.2630-10	Air exchange rate, mechanical ventilation		Multiplicity of extraction of nature. air exchange	Filtration air
air t not below	Name of divisions	Room class according to SanPiN 2.1.3.2630-10	inflow	hood	Multiplicity of extraction of nature. air exchange	Filtration air
16°C	Public service halls	—	3	4	3	without requirements
18°С	Registration of orders of attached pharmacies, for receiving and processing orders, prescription	—	2	1	1	without requirements
18°С	Assistant, defector, procurement, packaging, sterilization-autoclave, distillation	B	4	2	1	H11 to H13
18°С	Control and analytical, sterilization solutions, unpacking	B	2	3	1	H11 to H13
18°С	Premises for the preparation of medicines in aseptic conditions	BUT	4	2	not allowed	H14 in unidirectional flow area
Stock storage areas:
18°С	a) medicinal substances, dressings, thermolabile preparations and medical supplies	G	2	3	1	without requirements
18°С	b) medicinal plant materials	G	3	4	3	without requirements
18°С	c) poisonous drugs and drugs	G	—	3	3	without requirements
18°С	d) flammable and combustible liquids	G	—	10	5	without requirements
18°С	e) disinfectants, acids	G	—	5	3	without requirements

operating room microclimate. When ventilating operating rooms, relative humidity should be maintained within 50 - 60%, air mobility 0.15 - 0.2 m / s and a temperature of 19 - 21 ° C in the warm period and 18 - 20 ° C in the cold. The most effective and up-to-date method of ventilation of operating rooms, in terms of combating dust and bacterial air pollution, is to equip operating rooms with laminar air flow, which can be supplied in a horizontal or vertical direction. Vertical flow is preferable, as it allows, at normal air speeds, to achieve 500 - 600-fold exchange per 1 hour.

Operating room heating it is better to organize water, radiation with panels on the ceiling, walls or built into the floor.

Ensuring clean air in the operating unit. In the spread of nosocomial infection, the airborne route is of the greatest importance, and therefore, great attention should be paid to constantly ensuring the cleanliness of the air in the premises of the surgical hospital and the operating unit.

The main component that pollutes the air of the room of the surgical hospital and the operating unit is dust of the smallest dispersion, on which microorganisms are sorbed. Dust sources are mainly ordinary and special clothing for patients and staff, bedding, soil dust ingress with air currents, etc. Therefore, measures aimed at reducing the contamination of the operating room air primarily involve reducing the impact of contamination sources on the air.

Persons with septic wounds and any purulent contamination of the skin are not allowed to work in the operating room.

Before the operation, the staff must take a shower. Although studies have shown that in many cases the shower was ineffective. Therefore, many clinics began to practice
taking a bath with an antiseptic solution.

At the exit from the sanitary inspection room, the staff puts on a sterile shirt, pants and shoe covers. After processing the hands in the preoperative room, put on a sterile gown, gauze bandage and sterile gloves.

The sterile clothing of the surgeon loses its properties after 3-4 hours and is desterilized. Therefore, during complex aseptic operations (such as transplantation), it is advisable to change clothes every 4 hours.

A gauze dressing is an insufficient barrier to pathogenic microflora, and studies have shown that about 25% of postoperative purulent complications are caused by a strain of microflora sown both from a festering wound and from the oral cavity of the operating surgeon. The barrier function of the gauze bandage is improved after treatment with vaseline oil prior to sterilization.

Patients themselves can be a potential source of contamination, so they should be prepared appropriately before surgery.

To reduce the possibility of spreading microflora throughout the premises of the operating unit, it is advisable to use bactericidal light curtains created in the form of radiation from lamps above doors, in open passages, etc. In this case, the lamps are mounted in metal soffit tubes with a narrow slot (0.3 0, 5cm).

Neutralization of air with chemicals is carried out in the absence of people. For this purpose it is allowed to use propylene glycol or lactic acid. Propylene glycol is sprayed with a spray gun at the rate of 1.0 g per 5 m³ of air. Lactic acid used for food purposes is used at the rate of 10 mg per 1 m³ of air. The asepticity of the air in the rooms of the surgical hospital and the operating unit can also be achieved by using materials that have a bactericidal effect. These substances include derivatives of phenol and trichlorophenol, oxydiphenyl, chloramine, formaldehyde, and many others. They are impregnated with bed and underwear, dressing gowns, dressings. In all cases, the bactericidal properties of materials persist from several weeks to a year. Soft tissues with bactericidal additives retain bactericidal action for more than 20 days. It is very effective to apply films or various varnishes and paints to the surface of walls and other objects, in which bactericidal substances are added. For example, oxydiphenyl in a mixture with surfactants is successfully used to give the surface a residual bactericidal effect. It should be borne in mind that bactericidal materials do not have a harmful effect on the human body.

In addition to bacterial great importance there is also air pollution of operating units with narcotic gases: ether, halothane. Studies show that in the process of operating in the operating room air contains 400 - 1200 mg / m³ of ether, up to 200 mg / m³ and more of halothane, up to 0.2% carbon dioxide. Very intense air pollution with chemicals is an active factor contributing to the premature onset and development of surgeons' fatigue, as well as the occurrence of adverse changes in their health status. In order to improve the air environment of operating rooms, in addition to organizing the necessary air exchange, it is necessary to capture and neutralize drug gases that enter the airspace of the operating room from the anesthesia machine and with exhaled diseased air. For this, activated carbon is used. The latter is placed in a glass vessel connected to the valve of the anesthesia machine. The air exhaled by the patient, passing through a layer of coal, is deprived of narcotic residues and comes out purified.

Permissible noise level in the premises of a surgical hospital should not exceed 35 dBA for daytime and 25 dBA for night time, for operating rooms 25 dBA.

Ensuring silence in the premises of the hospital and the operating unit should be provided at the design stages of the hospital: when allocating a site, developing a master plan, designing buildings and constructing them, as well as during the reconstruction of buildings and structures, and ensured during operation. Particular attention is paid to the protection of the operating unit from various noise impacts. In this regard, it should be placed in an isolated extension to the main building with the implementation of anti-noise measures or located on the upper floors of the hospital in a dead end zone. Significant noise is generated by ventilation devices.

All air handling units should be placed in the basement or basement floors, always under the secondary premises, or in extensions to the main building or on the attic floors. It is advisable to place exhaust chambers and devices in the attic (technical floor), placing them above the auxiliary rooms. Noise from transit ducts passing through the premises can be reduced by lining the inner surface of the ducts with sound-absorbing material or by increasing the massiveness of the walls of the ducts (if other conditions permit) and applying soundproofing materials to them.
In order to reduce noise in wards, corridors, halls, pantry and other rooms, sound-absorbing lining should be used, which should also meet sanitary and hygienic requirements for wet cleaning.

Noise generator is also sanitary-technological equipment of hospitals. The wheels of stretchers and wheelchairs for patients should have rubber or pneumatic tires, rubber mats should be laid on tableware carts. Refrigerators should be installed on special rubber shock absorbers, elevator winches on spring or rubber shock absorbers, elevator doors should be sliding, shaft walls should be double (air gap of 56 cm).

Question 9

Purulent dressing should be placed in the purulent department next to the purulent operating room. If the block consists of only two operating rooms, then they are divided into clean and purulent. In this case, the purulent operating room should be strictly isolated from the clean one. The following set of "purulent" rooms can be recommended: operating room, preoperative room, sterilization room, anesthesia room, equipment room, cardiopulmonary bypass room, auxiliary rooms, staff rooms, locks with the necessary equipment.

Number of beds in postoperative wards should be provided according to the norm: two beds per operating room. In the presence of departments of anesthesiology and resuscitation, resuscitation and intensive care, postoperative wards are not provided, and their number is taken into account in the bed capacity of the department of anesthesiology and resuscitation.

In hospitals where the surgical department is located in a separate building, an admission department is arranged in it, the size and structure of which depend on the capacity of the department. It is highly desirable to have an intensive care unit and an outpatient operating room as part of the emergency department.

Organization of the work of the surgical department.

Planned surgical interventions are performed with the permission of the head of the department, complex cases only after a clinical analysis of patients.

On the morning of the operation, the patient is examined by the operating surgeon and the anesthesiologist.

No operation, with the exception of minor interventions (opening panaritium, treatment of superficial wounds), should be carried out without the participation of an assistant doctor. In the absence of a second surgeon, doctors of other specialties are involved in assisting.

The sequence and sequence of operations are established, starting with those requiring the most stringent asepsis rules (on the thyroid gland, for a hernia, etc.). Then operations follow, after which contamination of the operating room and personnel is possible (on the gastrointestinal tract, due to various fistulas).

Major planned surgical interventions it is advisable to do it at the beginning of the week. Interventions associated with the infection of the operating room are scheduled for the end of the week, coinciding with the subsequent general cleaning of the operating room.

The operating sister is obliged to keep a strict record of the instruments, tampons, napkins and other materials taken for the operation, and by the end of the operation, check their presence and report to the surgeon.

Operating and dressing rooms should be subjected to wet cleaning and irradiation with quartz lamps at least twice a day, and general cleaning once a week.

Bacteriological control over the quality of cleaning, the state of microbial contamination of the air (before, during and after the end of the operation) and environmental objects, the sterility of the dressing and suture material, instruments and other items should be carried out at least once a month, and the sterility of the hands of surgeons and skin of the surgical field - selectively once a week.

The architectural and planning solutions of the hospital should exclude the transfer of infections from the ward departments and other rooms to the operating block and other rooms that require special air purity.

To exclude the possibility of air masses from entering the ward departments, the stair-lift unit and other rooms into the operating unit, a device between these rooms and the operating unit of a lock with air overpressure is necessary.

The movement of air flows should be provided from operating rooms to adjacent rooms (preoperative rooms, anesthetic rooms, etc.), and from these rooms to the corridor. Exhaust ventilation is required in the corridors.

The amount of air removed from the lower zone of the operating rooms should be 60%, from the upper zone - 40%. Fresh air is supplied through the upper zone. In this case, the inflow should prevail over the exhaust by at least 20%.

It is necessary to provide for isolation (isolated) ventilation systems for clean and purulent operating rooms, for maternity units, resuscitation departments, dressing departments, ward sections, X-ray and other special rooms.

In each institution, an order must appoint a person responsible for the operation of ventilation and air conditioning systems; air ducts must be carried out according to the approved schedule, but at least 2 times a year. Elimination of current malfunctions, defects should be carried out without delay. Filters should be inspected, cleaned and replaced at least once a month.

The operating organization must monitor the temperature, humidity and chemical contamination of the air, check the performance of the ventilation system and the frequency of air exchange. In the main functional rooms, operating rooms, postoperative rooms, delivery rooms, intensive care wards, PTO, rooms for storing potent and toxic substances, pharmacy warehouses, rooms for the preparation of medicines, laboratories, the department of therapeutic dentistry, amalgam preparation, special rooms of radiological departments and other rooms and offices, using chemical and other substances and compounds that can have a harmful effect on people's health - 1 time in 3 months; infectious diseases and other hospitals (departments), bacteriological, viral laboratories, X-ray rooms - 1 time in 6 months; in other rooms - 1 time in 12 months. The results of the control must be formalized by an act stored in the institution.

4.3. Sanitary assessment of the ventilation regime.

Sanitary assessment of ventilation efficiency is based on:

sanitary inspection of the ventilation system, assessment and mode of its operation;

calculation of the actual volume of ventilation and the frequency of air exchange according to instrumental measurements;

objective study of the air environment and microclimate of ventilated premises.

Appreciating the mode natural ventilation(infiltration of outside air through various cracks and leaks in windows, doors, and partly through the pores of building materials into rooms), as well as their ventilation through open windows, vents and other openings arranged to enhance natural air exchange, consider the installation of aeration devices (transoms, vents, aeration channels) and ventilation mode. In the presence of artificial ventilation (mechanical ventilation, which does not depend on the outside temperature and wind pressure and provides, under certain conditions, heating, cooling and cleaning of the outside air), the time of its operation during the day, the conditions for maintaining the air intake and air cleaning chambers are specified. Next, it is necessary to determine the ventilation efficiency, finding it from the actual volume and frequency of air exchange. It is necessary to distinguish between the necessary and actual values of the volume and frequency of air exchange.

The required volume of ventilation is the amount of fresh air that should be supplied to the room per 1 person per hour so that the CO 2 content does not exceed the permissible level (0.07% or 0.1%).

The required ventilation rate is understood as a number showing how many times within 1 hour the room air must be replaced by outside air so that the CO 2 content does not exceed the permissible level.

Table 11

Air exchange rate in hospital rooms (SNiP-P-69-78)

Premises	Air exchange rate per hour

Chambers for adults	80 m 3 per bed	80 m 3 per bed
Chambers for prenatal, dressing, manipulation, preoperative, procedural
Maternity, operating, postoperative wards, intensive care wards	By calculation, but not less than ten times the exchange
Postpartum wards	80 m 3 per bed
Wards for children	80 meters 3 per bed
Wards for premature, infants and newborns	According to the calculation, but not less than 80 m 3 per bed

To determine the rate of air exchange in a room with natural ventilation, it is necessary to take into account the cubic capacity of the room, the number of people in it and the nature of the work carried out in it. Using the above data, the natural air exchange rate can be calculated using the following three methods:

1. In residential and public buildings, where changes in air quality occur depending on the number of people present and the household processes associated with them, the calculation of the necessary air exchange is usually carried out on the basis of carbon dioxide emitted by one person. The calculation of the volume of ventilation for carbon dioxide is carried out according to the formula:

L \u003d K x n / (P - Ps) (m 3 / h)

L - the desired volume of ventilation, m 3; K - the volume of carbon dioxide emitted by 1 person per hour (22.6 l); n is the number of people in the room; P - the maximum allowable content of carbon dioxide in indoor air in ppm (1% 0 or 1.0 l / m3 of cubic air); Ps - carbon dioxide content in atmospheric air (0.4 ppm or 0.4 l / m 3)

Per 1 person, the volume of required ventilation air per 1 person is 37.7 m 3 per hour. Based on the rate of ventilation air, the dimensions of the air cube are established, which in ordinary residential premises should be at least 25 m 3 per adult. The necessary ventilation is achieved with 1.5 air changes per hour (37.7:25=1.5).

2. The indirect method is based on a preliminary chemical determination of the content of carbon dioxide in the room air and accounting for the people in it.

The calculation of the air exchange rate is carried out according to the formula:

K = k x n /(P - Ps) x V)

where: K - desired air exchange rate; k is the number of liters of CO 2 exhaled by a person or other sources per hour; n is the number of people or other sources of CO 2 in the room; P - detected concentration of CO 2 in ppm; Ps is the average concentration of CO 2 in the atmosphere in ppm; V- cubic capacity of the room in m 3

For example: n \u003d 10 people, P \u003d 1.5% 0, V \u003d 250 m 3

K \u003d 22.6 x 10 / (1.5 - 0.4) x 250) \u003d 0.8 times

Usually, no more than one air exchange occurs per hour due to filtration, and therefore, if there is more air exchange, it can be concluded that a more thorough fit is necessary. window frames etc., to eliminate the adverse effect of currents of penetrating air during the cold season.

3. Air exchange rate: in the presence of natural draft ventilation (windows, transoms), it can be taken into account by taking into account the volume of air entering or removed from the room through the windows (transoms) per unit of time. To do this, measure the area of the lumen of the window (transom) and the speed of air movement in the opening of the window. The speed of air movement in the window opening is measured with a vane anemometer and calculated by the formula:

K = a x b x c / V

where: a - the area of \u200b\u200bthe window (transom), m 2; b- speed of air movement in the opening of the window (transom), m/sec; s - ventilation time, sec; V is the volume of the room, m 3.

When dividing the resulting volume of air entering or removed through the window (transom), the calculation of the air exchange rate in the room is determined per hour.

Calculation example: In a ward with a cubic capacity of 60 m 3, where there are 3 people, ventilation occurs due to the window, which is opened for 10 minutes every hour. The speed of air movement in the window opening is 1 m/sec, the window area is 0.15 m 2 . Assess the air exchange in the ward.

Solution: 0.15 m 3 enters the ward in 1 second, 90 m 3 in 10 minutes. The air exchange rate is equal to:

K \u003d 0.15 x 1 m / s x 600 s / 60 \u003d 1.5

The required volume of incoming air for three people in this room per hour should be:

22.6x0.3 / (1-0.4) = 113 m 3

and the air exchange rate is equal to: 113:60=1.8

Therefore, the actual air exchange rate is 1.5 times per 1 hour with the required ventilation volume 1.6 times per 1 hour, which requires an increase in the ventilation time of this ward.

TOPIC QUESTIONS:

Changing the purity of air in closed rooms of hospitals.

Definition of the concept of "metabolites" (anthropotoxins).

Indicators of air purity (organoleptic, physical, chemical).

Bacteriological indicators of air pollution (for various hospital premises).

Physiological and hygienic significance of carbon dioxide.

Express method for determining CO 2 .

Methods for determining bacterial air pollution in various premises of medical institutions (sedimentary, filtration).

Sedimentation-aspiration method.

The device and rules for working with the Krotov device.

Indicators of indoor air purity.

Hygienic requirements for ventilation of various structural units of hospitals.

The concept of air conditioning.

Sanitary assessment of the effectiveness of various ventilation modes.

Definition of the concepts "required volume of ventilation" and "required ventilation rate".

The frequency of air exchange in hospital rooms.

Determination of the rate of air exchange during natural ventilation and its hygienic assessment.

INDEPENDENT WORK OF STUDENTS.

I. Master the methodology for determining the content of carbon dioxide in the classroom by the express method (description is given above).

PROTOCOL

determining the content of CO 2 in the air of the room

Date and time of the study

Brief description of the room and ventilation features

The number of people involved and the nature of their activities

Definition Air volume, ml CO 2 content (%)

Conclusion:

In the hygienic assessment of air purity, the following is taken into account: very clean air - carbon dioxide concentration up to 0.05%; air of good purity - up to 0.07%; satisfactory purity - up to 0.1%.

II. To master the sedimentation-aspiration method for studying bacilli. The device of Krotov's apparatus and the principle of counting are described above.

PROTOCOL

determination of the number of microorganisms in the indoor air

Date and time of the study

Name of the surveyed premises

A brief description of:

a) the sanitary condition of the premises

b) cleaning systems

c) ventilation mode

d) human activities

Conclusion: hygienic assessment of bacterial indoor air pollution

Proposals to reduce bacterial indoor air pollution

For a sanitary assessment of air purity, the obtained indicators are compared with the data in Table 12 below.

Table 12

Indoor air purity indicators based on 1 m 3 of air

A.P. Inkov, Ph.D. tech. Sciences, ECOTERM LLC

Ventilation systems, heating and air conditioning (VOK) should provide optimal conditions microclimate and air environment of the premises of a hospital, maternity hospital or other hospital. When designing, building (reconstructing) and operating FOC systems, one should use the main provisions of the existing special normative documents, as well as a number of other documents approved by the Russian Ministry of Health. At the same time, EQA systems for medical institutions (HCIs), in accordance with Russian standards, have a number of features compared to others. public buildings and structures. Some of them are listed below.

1. The use of vertical collectors for both supply and exhaust systems is not allowed in the buildings of healthcare facilities.
2. Air removal from operating rooms, anesthesia, resuscitation, birth and X-ray rooms is carried out from two zones (upper and lower).
3. Relative humidity and temperature of operating units is maintained constantly and around the clock.
4. In hospital wards, relative air humidity is standardized only for the winter period.
5. Air recirculation is not allowed in the buildings of healthcare facilities in VOK systems.
6. The temperature of the heat carrier for water heating systems must correspond to the purpose of the building.
7. Sound pressure level from ventilation systems in wards and operating rooms of hospitals should not exceed 35 dBA.
In view of the foregoing, it is clear that only specialized design organizations with a library of regulatory documents and certain experience can carry out a high-quality design of the FQA system. practical work.

Below we consider in more detail the most difficult issue with the design , postoperative wards, resuscitation rooms, intensive care wards, delivery boxes, anesthetic and other rooms, classified according to the standards to the cleanliness category "OC". In these rooms, ventilation and air conditioning are mandatory, and at the same time, the frequency of air exchange is determined by calculation from the conditions of heat release assimilation, but not less than ten times the exchange
(see Table 1 for norms).

Table number 1. Estimated temperatures, air exchange rates, cleanliness categories in medical institutions

It should be noted right away that the classification of premises according to the degree of air purity adopted in the work is outdated and requires processing in accordance with the current regulatory documents.
The new standard was adopted and introduced in Russia on May 18, 2000 and harmonized with the international standard ISO 14644-1-99. This article will use the terms and definitions of this standard, which limits the purity grades to ISO class 1 (highest grade) to ISO grade 9 (lowest grade).
It is known that prolonged stay of patients in conventional surgical and therapeutic hospitals is dangerous for them. After some time in the hospital, they become carriers of the so-called hospital strains and carriers of pathogens of various infections. This also applies to medical staff. Infection prevention and treatment methods such as antibiotics, immune and hormonal preparations, wet cleaning of premises with antiseptic solutions, ultraviolet irradiation, etc. do not give the desired effect.
A clean room compared to these methods has a fundamental difference. It is not aimed at fighting and destroying already existing microorganisms in the room. It does not allow them there, and microorganisms emanating from patients or medical personnel are immediately removed from the room by air flow. The goal of clean operating rooms is to reduce the growth of microbial contamination, primarily in the area of the operating room and instrument tables.
According to the modern classification, operating rooms can be classified as clean rooms (CP) of ISO class 5 and above. The class of a clean room is characterized by a classification number that determines the maximum allowable concentration of aerosol particles of a certain size in one cubic meter of air. A particle is understood as a solid, liquid or multi-phase object with a size of 0.05 to 100 microns. When classifying CP, non-living particles with a size of 0.1 to 5 microns are considered. A cleanroom may contain one or more clean zones (a clean zone may be open or enclosed) and be located both inside and outside the cleanroom.
According to the standard, a cleanroom is a room in which the concentration of airborne particles is controlled and which is constructed and used in such a way as to minimize the intake, emission and retention of particles inside the room, and in which other parameters are controlled, as necessary, such as temperature, humidity and pressure.

In accordance with the standard, three time phases of the creation and existence of a cleanroom should be distinguished:
1. As-built: a state in which the cleanroom system is complete, all service systems are connected, but there is no production equipment, materials and personnel.
2. Equipped (at-rest): the state in which the cleanroom system is equipped and debugged in accordance with the agreement between the customer and the contractor, but there is no staff.
3. Operational: the state in which the cleanroom system is operating in the intended manner, with a specified number of personnel working in accordance with the documentation.
This above division is of fundamental importance in the design, construction, certification and operation of clean rooms. Particulate air purity in a cleanroom or clean area should be determined from one (or more) of the three cleanroom conditions. When designing and building medical institutions, we will be most interested in the last, operational state of the state of emergency.
The air around us contains a large number of both living and non-living particles, differing in nature and size. In the standard, when determining the air purity class in a clean room, the concentration of non-living aerosol particles ranging in size from 0.1 to 5.0 microns is taken into account. When assessing the class of air purity in operating rooms, an important criterion is the number of living microorganisms in it, so this issue needs to be considered in more detail.
The paper analyzes the main sources of air micropollution. Foreign statistical data are given, showing that there is approximately one microorganism per 1,000 suspended aerosol particles. It is said that in view of the multiplicity of factors affecting microbial contamination, these data are of an approximate, probabilistic nature. But nevertheless they give an idea of the relationship between the number of non-living particles and the number of microorganisms in the air.

Airborne particle purity classes for cleanrooms and clean areas

To assess the required class of air purity in operating rooms, depending on the volume concentration of microorganisms in it, you can use the data of the summary table. 2 standards.

Class 5 clean rooms in Table. 2 are divided into two subclasses:
- Subclass A - with the maximum allowable number of microorganisms not more than 1 (achieved in a unidirectional air flow).
- Subclass B - with the maximum allowable number of microorganisms not more than 5.
Higher class cleanrooms (classes 4 to 1) should be free of microorganisms at all.
In order to proceed to review practical issues, which are of most interest to designers of HVAC systems, we will once again consider some of the requirements imposed by regulatory documents on ventilation and air conditioning systems. In passing, we note that in addition to the requirements for VC systems, designers must also know and comply with the entire list of other mandatory requirements for CP: requirements for planning decisions, requirements for the design and materials of CP, requirements for CP equipment, requirements for engineering systems, requirements for medical personnel and technological clothing, etc. Due to the limited scope of this article, these issues are not considered here.

Below is a list of only some of the basic requirements for ventilation and air conditioning systems of the emergency.
1. The air supply system in the emergency room from 1 to 6 classes, as a rule, should provide the organization of air exchange with a vertical unidirectional flow. For class 6, non-unidirectional airflow is possible. The standard provides a definition: unidirectional air flow - air flow with, as a rule, parallel jets (streamlines) passing in the same direction with the same speed in cross section. The terms "laminar" and "turbulent" flow are not recommended for characterizing air flows in the CP.
2. Coverings of air ducts and their structures located in clean rooms, as well as coverings of filter chambers and their structures must allow periodic treatment with disinfectant solutions. This requirement is mandatory for controlled microbial contamination emergencies.
3. must have automatic temperature and humidity control, interlock, remote control, alarm.
4. In a CV with unidirectional vertical flow, the number of openings that discharge air flows from the CV is selected in accordance with the need to ensure the verticality of the air flows.

In addition to the above requirements for ventilation and air conditioning systems operating rooms should also be added:
- The requirement to use multi-stage filtration of the air supplied from the outside (at least 3 stages) and the use of high-efficiency final filters with a class of at least H12.
- The requirement to provide the necessary speed of a unidirectional flow of 0.2-0.45 m/s at the outlet of .
- The requirement for a positive differential pressure in the operating room and surrounding areas in the range of 5-20 Pa.

New construction and renovation of hospital operating theaters to meet all the requirements of class 5 and higher cleanrooms is very costly. The cost of only the enclosing structures of one operating room with a "laminar" flow is from several tens of thousands of US dollars and more, plus the cost of a central air conditioner system. If abroad standards for air purity in various hospital premises have been developed and are in force (in Germany and Holland, the number of operating clean operating rooms taken together is more than 800), then in our country the issue of setting requirements for equipping the operating room with all systems is often decided at the level of the chief physician of the hospital and his deputies, who are sometimes simply unfamiliar with regulatory requirements to clean rooms, and their choice is determined primarily by financial capabilities, especially in budgetary organizations.
Having considered the complex general requirements to the ventilation and air conditioning systems of the emergency, we can conclude that the correct organization of air flows (unidirectional, non-unidirectional) is one of the most important conditions for ensuring the required air purity and patient safety. The air flow must carry away all particles emitted by people, equipment and materials from the clean area.

On fig. 1 shows the most common air supply schemes in the operating room and their comparative analysis in terms of bacterial contamination is performed. Scheme 1d provides unidirectional vertical airflow, the other schemes - non-unidirectional airflow.
The quality of the unidirectional air flow is greatly influenced by the design of the distributor through which the air flows directly into the clean room. This distributor is located directly between the HEPA filters and the frequency converter. It can be made in the form of a lattice or in the form of a single or double mesh made of metal or synthetic material. The size of the hole and the distance between the holes through which air passes is important. The greater this distance, the worse quality flow (Fig. 2).

If in rooms with unidirectional air flow the air diffuser occupies the entire area of the ceiling above the operating area, then in rooms of a lower cleanliness class with non-unidirectional air flow, supply diffusers occupy only a part of the ceiling, sometimes quite a small one. Exhaust grilles can also be located in different ways (schemes 1a, 1b, 1c, 1e). In this case, only methods of numerical mathematical modeling make it possible to take into account all the variety of influencing factors on the picture of air flows and evaluate how the position of filters, equipment, heat sources (lamps, etc.) affects air flows and the class of cleanliness in various areas of the operating room.
Different kinds versions of ceiling diffusers with a filter for clean rooms manufactured by GEA are shown in fig. 3.

These diffusers are equipped with hermetic valves to isolate the air filter from the rest of the air conditioning system. This allows you to replace the air filter without turning off the air conditioner. The tightness of the air filter installation in the diffuser cell can be monitored using a tightness sensor. Sensors are also built in to measure the differential pressure across the filter.
Main results comparative analysis various ways of supplying clean air to operating rooms according to the work are presented in fig. 4.

The figure shows the measurement results for different flows and two limit curves that must not be exceeded for operating rooms type A (especially high requirements according to DIN 1946, part 4, edition 1998) or type B (high requirements).
Using the indicator of microbial contamination with a known volumetric air flow, it is possible to calculate microbial contamination (CFU/m3)*: K=n.Q.ms/V,
where:
K - colony-forming units per 1 m 3 of air;
Q is the initial intensity of microbial sources;
ms - indicator of microbial contamination;
V - volumetric air flow;
n is the number of personnel in the operating room.
The following conclusions are made in the work. Separate diffusers or perforated ceilings supply clean air and mix it with polluted air (dilute method). Indicators of microbial contamination are at best around 0.5. With a unidirectional “laminar” air flow, a microbial contamination index of 0.1 or less is achieved.
As mentioned above, with radial outlet diffusers on the ceiling in the room, a mixed flow is created. This output at a volume flow rate of 2,400 m3/h meets the class B standard requirements, and a flow rate of 2,400 m3/h can be taken as the minimum allowable clean air flow rate supplied to the operating area (this flow rate is taken as the reference volume flow rate in the standard DIN 4799, designed to evaluate and compare different types of ceilings).
To date, ceiling-type mesh air distribution devices for creating a unidirectional air flow for operating rooms are produced by a number of companies, for example, , ADMECO AG, ROX LUFTTECHIK GmbH, etc.

On fig. 5 shows a typical structural diagram of such an air distribution device (laminar ceiling).

In practice, the most common size of such devices (ceilings) is from 1.8x2.4 m 2 to 3.2x3.2 m 2, and the latter size is the most common abroad. For example, for1.8x2.4 m 2 the required air flow will be 3100 m 3 / h (at a speed of air outlet from the device of 0.2 m/s). From the practice of designing several operating theaters at the Moscow Central Institute of Traumatology and Orthopedics (CITO) by our design department, we can conclude that such a flow rate corresponds to a 25-fold air exchange in a room with an area of 30-40 m 2 and always exceeds the calculated flow rate necessary for the assimilation of heat excesses characteristic for typical recruitment and equipment for these premises.
Our data are in good agreement with the data of the work, which shows the amount of heat release of 1.5-2.0 kW, typical for operating rooms, as well as the calculated value of clean air supply of 2000-2500 m 3 / h (17-20 times per hour). In this case, the temperature of the supply air should differ from the temperature of the operating area by no more than 5 degrees.
The larger the size laminar ceiling in the above range, the higher the degree of patient safety, however, at the same time, capital and operating costs increase significantly. Abroad, a reasonable compromise is widely used - the introduction of an air recirculation system in the operating room through highly efficient HEPA filters built into the "laminar" ceiling. This allows you to increase the size of the "laminar" ceiling up to 3.2x3.2 m 2 while maintaining low capital and operating costs for the central air conditioner.
For example, operating rooms are being designed, where, when outdoor air is supplied with an air conditioner of 1200-2000 m 3 /h, the circulation flow in the operating room is up to 8000 m 3 /h, while energy supply costs are significantly reduced. Enlargementup to 3.2x3.2 m 2 allows you to include in the sterile area not only the patient, but also the instrument table and the working staff, especially if you also use special enclosing plastic aprons (Fig. 6).

Another advantage of the system for using air circulation in the operating room (which is allowed in accordance with part 4 of DIN 1946) is the possibility at night, when the operating room equipment is not in use, to turn off the air conditioner completely or partially for outside air, using only the equipment (fan ) internal system circulation of clean air, while consuming approximately 400 watts of power.
Speaking about energy saving in EQA systems for operating rooms in hospitals, it should be noted the work of prof. O. Ya. Kokorina. In this work, it is also proposed to use a circulating mixing and cleaning supply unit, but this scheme is analyzed only for the option of supplying a non-uniform flow of clean air in the operating room according to the scheme shown in Fig. 1a.
Given the energy attractiveness of the proposed scheme, designers may encounter problems during its implementation with the need to place a mixing and cleaning unit with a capacity of 2,400 m3 / h in rooms near the operating room, as well as problems with the distribution of air ducts for the supply and exhaust systems, since a monoblock air supply unit is used - exhaust unit.

* The term CFU means "colony forming units" (CFU - Colony Forming Units) and is a more accurate description of microbial contamination. Clean room technology allows to ensure the level of microbial contamination of less than 10 CFU/m 3 . There is evidence that reducing microbial air pollution in the area of the operating table by 10 times reduces the risk of infection by 2%.
Example:
Q=30,000 microbes per person per hour (assumption). For 8 people in the operating room with µs=0.1 and a volume flow of 2400 m 3 /h K=8x30000x0.1/2400=10 CFU/m3.
Published in ABOK magazine

What is going on with us, no one knows. The picture in our hospitals is certainly much worse. Judging by the level of current industry regulations, our healthcare has not yet come to an understanding of the problem. And the problem is clear. It was put in the magazine "Technology of Purity", No. 1/96, 10 years ago. In 1998, ASINCOM developed the Standards for Air Cleanliness in Hospitals based on foreign experience.

In the same year they were sent to the Central Research Institute of Epidemiology. In 2002, this document was submitted to the State Sanitary and Epidemiological Supervision. There was no response in both cases. But in 2003, SanPiN 2.1.3.1375-03 "Hygienic requirements for the placement, arrangement, equipment and operation of hospitals, maternity hospitals and other medical hospitals" was approved - a backward document, the requirements of which sometimes contradict the laws of physics (see below).

The main objection to the introduction of Western standards is "there is no money." It is not true. There is money. But they don't go where they need to go. A decade of experience in certifying hospital premises by the Clean Rooms Certification Center and the Clean Room Testing Laboratory has shown that the actual cost of operating rooms and intensive care units exceeds, sometimes several times, the costs of facilities built according to European standards and equipped with Western equipment. At the same time, the objects do not correspond to the modern level. One of the reasons is the lack of a proper regulatory framework.

Existing standards and norms

Clean room technology has been used in Western hospitals for a long time. As early as 1961 in the UK, Professor Sir John Charnley equipped the first "greenhouse" operating room with an air flow velocity of 0.3 m/s descending from the ceiling. This was a radical means of reducing the risk of infection in patients undergoing hip transplantation.

Prior to this, 9% of patients had infection during surgery, and repeated transplantation was required. It was a true tragedy for the sick. In the 70-80s. cleanliness technology based on ventilation and air conditioning systems and the use of high-performance filters has become an integral element in hospitals in Europe and America. At the same time, the first standards for air purity in hospitals appeared in Germany, France and Switzerland. Currently, the second generation of standards based on the current level of knowledge is being released.

Switzerland

In 1987, the Swiss Institute for Health and Medical Institutions (SKI - Schweizerisches Institut fur Gesundheits und Krankenhauswesen) adopted the "Guidelines for the construction, operation and maintenance of air preparation systems in hospitals" - SKI, Band 35, "Richtlinien fur Bau, Betrieb und Uberwachung von raumlufttechnischen Anlagen in Spitalern. The management distinguishes three groups of premises - tab. one.

In 2003, the Swiss Society of Heating and Air Conditioning Engineers adopted the guideline SWKI 99-3 "Heating, ventilation and air conditioning systems in hospitals (design, construction and operation)". Its essential difference is refusal to ration air purity by microbial pollution (CFU) to evaluate the operation of the ventilation and air conditioning system. The evaluation criterion is the concentration of particles in the air (not microorganisms).

The manual establishes clear requirements for the preparation of air for operating rooms and provides an original method for assessing the effectiveness of cleanliness measures using an aerosol generator. A detailed analysis of the manual is given in the article by A. Brunner in the journal "Technology of Purity", No. 1/2006.

Germany

In 1989, Germany adopted the DIN 1946 part 4, “Cleanroom technology. Clean air systems in hospitals” – DIN 1946, Teil 4. Raumlufttechik. Raumlufttechishe Anlagen in Krankenhausern, Dezember, 1989 (revised 1999). A draft DIN standard has now been prepared, containing purity values for both micro-organisms (sedimentation method) and particles.

The standard regulates in detail the requirements for hygiene and cleanliness methods. Classes of premises Ia (highly aseptic operating rooms), Ib (other operating rooms) and II have been established. For classes Ia and Ib, the requirements for the maximum allowable air pollution by microorganisms (sedimentation method) are given - see table. 2. The requirements for filters for various stages of air purification are established: F5 (F7) + F9 + H13.

The Society of German Engineers VDI has prepared a draft standard VDI 2167, part "Equipment of hospital buildings - heating, ventilation and air conditioning". The draft is identical to the Swiss manual SWKI 99-3 and contains only editorial changes due to some differences between "Swiss" German and "German" German.

France

The air purity standard AFNOR NFX 90-351, 1987 in hospitals was adopted in France in 1987 and revised in 2003. The standard sets limits for the concentration of particles and microorganisms in the air. The particle concentration is determined by two sizes: ≥ 0.5 µm and ≥ 5.0 µm. Cleanliness is an important factor only in the equipped state of cleanrooms.

For more details on the requirements of the French standard, see the article by Fabrice Dorchies “France: the standard for clean air in hospitals” (Journal “Cleanliness Technology”, No. 1/2006). The listed standards detail the requirements for operating rooms, set the number of filtration stages, filter types, laminar zone sizes, etc.

Hospital cleanroom design is based on the ISO 14644 series of standards (previously based on Fed. Std. 209D).

Russia

In 2003, SanPiN 2.1.3.1375-03 "Hygienic requirements for the location, arrangement, equipment and operation of hospitals, maternity hospitals and other medical hospitals" was adopted. Some of the requirements of this document are puzzling. For example, Appendix 7 establishes sanitary and microbiological indicators for rooms of different cleanliness classes - see table. five.

In Russia cleanroom cleanliness classes were established by GOST R 50766-95, then GOST R ISO 14644-1-2001. Part 1. Classification of air purity. It is logical to expect that industry documents must comply with the national standard, not to mention the fact that the definitions of “conditionally clean”, “conditionally dirty” for cleanliness classes, “dirty ceiling” for ceilings look strange.

SanPiN 2.1.3.1375-03 establishes for "especially clean" rooms (operating rooms, aseptic boxes for hematological, burn patients) the indicator of the total number of microorganisms in the air, CFU / m 3, before starting work (equipped state) "no more than 200". And the French standard NFX 90-351 is no more than 5. These patients should be under unidirectional (laminar) air flow.

In the presence of 200 CFU/m 3 the patient in a state of immunodeficiency (aseptic box of the hematology department) will inevitably die. According to LLC "Cryocenter" (A.N. Gromyko), microbial air pollution in maternity hospitals in Moscow ranges from 104 to 105 CFU / m 3, and the last figure refers to the maternity hospital where homeless people are brought. The air of the Moscow metro contains approximately 700 CFU/m 3 . This is better than in the "conditionally clean" rooms of hospitals according to SanPiN. In clause 6.20 of the above SanPiN it is said “In sterile rooms, air is supplied by laminar or slightly turbulent jets (air velocity less than 0.15 m / s)”. This contradicts the laws of physics: at a speed of less than 0.2 m / s, the air flow cannot be laminar (unidirectional), and at less than 0.15 m / s it becomes not “weakly”, but highly turbulent (non-unidirectional).

The figures of SanPiN are not harmless, it is according to them that objects are monitored and projects are examined by sanitary and epidemiological surveillance authorities. You can release advanced standards as much as you like, but as long as SanPiN 2.1.3.1375-03 exists, things will not budge. It's about not just mistakes. We are talking about the public danger of such documents. What is the reason for their appearance?

Lack of knowledge of European norms and fundamentals of physics?
knowledge, but
- intentionally worsening conditions in our hospitals?
- lobbying someone's interests (for example, manufacturers of inefficient air purification products)?

How does this relate to protecting public health and consumer rights? For us, consumers of healthcare services, such a picture is absolutely unacceptable. Severe and previously incurable diseases are leukemia and other blood diseases. Now there is a solution, and there is only one solution: bone marrow transplantation, then suppression of the body's immunity for the period of adaptation (1-2 months).

So that a person who is in a state of immunodeficiency does not die, he is placed in sterile air conditions (under laminar flow). This practice has been known around the world for decades. She also came to Russia. In 2005, two intensive care units for bone marrow transplantation were equipped in the Nizhny Novgorod Regional Children's Clinical Hospital. Chambers are made at the level of modern world practice.

This is the only way to save the doomed children. The patient's bed is located in the zone of unidirectional air flow (ISO class 5). But in the FGUZ "Center for Hygiene and Epidemiology of the Nizhny Novgorod Region" they staged an illiterate and ambitious paperwork, delaying the commissioning of the facility for six months. Do these employees understand that they may have unsaved children's lives on their conscience? The answer must be given to mothers by looking into their eyes.

Development of the national standard of Russia

An analysis of the experience of foreign colleagues made it possible to highlight several key issues, some of which caused a heated discussion when discussing the standard.

Room groups

Foreign standards mainly consider operational ones. Some standards deal with isolators and other spaces. There is no comprehensive systematization of premises for all purposes with a focus on the classification of cleanliness according to ISO. In the adopted standard, five groups of rooms are introduced depending on the risk of infection of the patient. Separately (group 5) isolated insulators and purulent operating rooms. Classification of premises is made taking into account risk factors.

Criteria for assessing air purity

What to take as a basis for assessing air purity:

particles?
microorganisms?
this and that?

The development of norms in Western countries according to this criterion has its own logic. In the early stages, the purity of the air in hospitals was assessed only by the concentration of microorganisms. Then came the use of particle counting. Back in 1987, the French standard NFX 90-351 introduced air purity control for both particles and microorganisms. Particle counting with a laser particle counter makes it possible to quickly and in real time determine the concentration of particles, while it takes several days for the incubation of microorganisms on a nutrient medium.

Next question: And what, in fact, is checked during the certification of clean rooms and ventilation systems? The quality of their work and correctness are checked design decisions. These factors are unambiguously evaluated by the concentration of particles, on which the number of microorganisms depends. Of course, microbial contamination depends on the cleanliness of walls, equipment, personnel, etc. But these factors relate to current work, to operation, and not to the assessment of engineering systems.

In this regard, Switzerland (SWKI 99-3) and Germany (VDI 2167) take a logical step forward: particulate air control installed. Recording of microorganisms remains a function of the epidemiological service of the hospital and is aimed at the current control of cleanliness. This idea was included in the draft Russian standard. On the this stage it had to be abandoned due to the categorically negative position of the representatives of the sanitary and epidemiological supervision.

The maximum allowable standards for particles and microorganisms for various groups of premises are taken according to analogues with Western standards and based on own experience. Particle classification corresponds to GOST ISO 14644-1.

Cleanroom states

GOST ISO 14644-1 distinguishes between three states of cleanrooms. In the constructed state, the fulfillment of a number of technical requirements is checked. The concentration of contaminants, as a rule, is not standardized. In the equipped state, the room is fully equipped with equipment, but there is no staff and there is no technological process(for hospitals - there is no medical staff and the patient).

In the operating state, all the processes provided for by the purpose of the premises are carried out in the premises. Rules for the production of medicines - GMP (GOST R 52249-2004) provide for the control of contamination by particles both in the equipped state and in the operated state, and by microorganisms - only in the operated state. There is logic in this.

Emissions of contaminants from equipment and personnel during the production of medicines can be standardized and compliance with the standards can be ensured by technical and organizational measures. In a medical institution there is a non-standardized element - the patient. It is impossible for him and the medical staff to dress in an ISO class 5 coverall and completely cover the entire surface of the body. Due to the fact that the sources of pollution in the operating state of the hospital premises cannot be controlled, it makes no sense to establish standards and certify the premises in the operated state, at least in terms of particles. This was understood by the developers of all foreign standards. We also include in GOST the control of premises only in the equipped state.

Particle sizes

Cleanrooms were originally controlled for contamination with particles equal to or greater than 0.5 µm (≥ 0.5 µm). Then, based on specific applications, requirements began to appear for the concentration of particles ≥ 0.1 µm and ≥ 0.3 µm (microelectronics), ≥ 0.3 0.5 µm (production of drugs in addition to particles ≥ 0.5 µm ), etc. The analysis showed that in hospitals it makes no sense to follow the “0.5 and 5.0 µm” template, but it is enough to control particles ≥ 0.5 µm.

Unidirectional flow rate

It has already been noted above that SanPiN 2.1.3.3175-03, by setting the maximum permissible values for the speed of a unidirectional (laminar) flow of 0.15 m/s, violated the laws of physics. On the other hand, it is impossible to introduce the GMP norm of 0.45 m/s ±20% in medicine. This leads to discomfort, superficial dehydration of the wound, can injure it, etc. Therefore, for areas with unidirectional flow (operating rooms, intensive care wards), the speed is set from 0.24 to 0.3 m/s. This is the limit of the permissible, from which it is impossible to leave. Below is shown the distribution of the modulus of air flow velocity in the area of the operating table for a real operating room in one of the hospitals, obtained by the method computer simulation. It can be seen that at a low speed of the outgoing flow, it quickly turbulates and does not perform a useful function.

Dimensions of the zone with unidirectional airflow

A laminar zone with a "deaf" plane inside is useless. In the operating room of the Central Institute of Traumatology and Orthopedics (CITO), the author was operated on for an injury six years ago. It is known that a unidirectional air flow narrows at an angle of about 15% and what was in CITO does not make sense. The correct scheme (Klimed): It is no coincidence that Western standards provide for the size of a ceiling diffuser that creates a unidirectional flow of 3x3 m, without “deaf” surfaces inside. Exceptions are allowed for less critical operations.

Solutions for ventilation and air conditioning

These solutions comply with Western standards, are economical and efficient. Made some changes and simplifications without losing the meaning. For example, H14 filters (instead of H13) are used as final filters in operating rooms and intensive care units, which have the same cost, but are much more efficient.

Autonomous Air Cleaning Devices

Autonomous air cleaners are effective tool ensuring clean air (except for rooms of groups 1 and 2). They are low cost, allow flexible decisions and can be used on a massive scale, especially in established hospitals. There are a wide variety of air cleaners on the market. Not all of them are effective, some of them are harmful (they emit ozone). The main danger is the wrong choice of air cleaner. The Cleanroom Testing Laboratory conducts an experimental evaluation of air cleaners according to their intended use. Relying on reliable results is an important condition for fulfilling the requirements of GOST.

Test Methods

The manual SWKI 99-3 and the draft standard VDI 2167 give a method for testing operating rooms using dummies and aerosol generators (article by A. Brunner). The use of this technique in Russia is hardly justified. In a small country, one specialized laboratory can serve all hospitals. For Russia, this is unrealistic. From our point of view, it is not necessary. With the help of dummies, typical solutions are worked out, which are laid down in the standard, and then serve as the basis for design. These standard solutions are being worked out in the conditions of the institute, which is done in Lucerne, Switzerland. In mass practice, standard solutions are applied directly. At the finished facility, tests are carried out for compliance with standards and the project. GOST R 52539-2006 gives a systematic test program for clean rooms in hospitals for all the necessary parameters.

Legionnaires' disease is a companion of old engineering systems

In 1976, an American Legion convention was held in a Philadelphia hotel. Of the 4,000 participants, 200 fell ill and 30 died. The cause was a microorganism species named Legionella pneumophila in connection with the mentioned event and numbering more than 40 varieties. The disease itself was named Legionnaires' disease. Symptoms of the disease appear 2-10 days after infection in the form of headache, pain in the limbs and throat, accompanied by fever.

The course of the disease is similar to ordinary pneumonia, and therefore it is often misdiagnosed as pneumonia. In Germany, with a population of about 80 million, about 10,000 people are officially estimated to suffer from Legionnaires' disease every year, but most cases remain unsolved. The risk category includes people with weakened immune system, the elderly, young children, those with chronic diseases and smokers.

The infection is transmitted by airborne droplets. The causative agent enters the room air from old ventilation and air conditioning systems, supply systems hot water, showers, etc. Legionella multiplies especially rapidly in still water at temperatures between 20 and 45 °C. At 50°C, pasteurization occurs, and at 70°C, disinfection occurs. Dangerous sources are old large buildings (including hospitals and maternity hospitals) with ventilation systems and hot water supply. About measures to combat the disease - read on page 36 (Ed. note)

* Aspergillus, a common fungus that is usually harmless to humans, is a particular danger. But they pose a risk to the health of immunodeficient patients (for example, drug-induced immunosuppression after organ and tissue transplantation or patients with agranulocytosis). For such patients, inhalation of even small doses of Aspergillus spores can cause severe infectious diseases. In the first place here is a lung infection (pneumonia). Hospitals often experience infections associated with construction or renovation work. These cases are caused by the isolation of Aspergillus spores from building materials during construction work, which requires the adoption of special protective measures (SWKI 99-3).

* Based on the article by M. Hartmann "Keep Legionella bugs at bay", Cleanroom Technology, March, 2006.

Equipment for determining the purity of air in the operating room. Design features of ventilation and air conditioning systems for healthcare facilities. Operation of laminar air diffusers

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

Infectious operating rooms

GOST R 52539-2006 "Air purity in medical institutions"

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

Resuscitation and intensive care wards with unidirectional flow

GOST R 52539-2006 "Air purity in medical institutions"

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

Aseptic rooms and rooms without unidirectional flow

GOST R 52539-2006 "Air purity in medical institutions"

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

Premises of infectious departments and biological laboratories

GOST R 52539-2006 "Air purity in medical institutions"

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

Safety of work with microorganisms of 3–4 pathogenicity groups sanitary and epidemiological rules SP 1.2.731-99

Safety of work with microorganisms of 1-2 groups of pathogenicity (hazards) sanitary and epidemiological rules SP 1.3.1285-03

GOST R 52539-2006 "Air purity in medical institutions"

SANPIN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

Guidelines MosMU 2.1.3.005-01

On fig. 5 shows a typical structural diagram of such an air distribution device (laminar ceiling).

Safety of work with microorganisms of 3–4 pathogenicity groups
sanitary and epidemiological rules SP 1.2.731-99

Safety of work with microorganisms of 1-2 groups of pathogenicity (hazards)
sanitary and epidemiological rules SP 1.3.1285-03