MMRS 2019-2020

FKUB
Malang
2
HAI
1. Infection Control Programme

2. Infection Control Practices

3. Environmental Management Practices

4. Care of Health Care Workers

5. Infection Control Precautions for Selected Situations

3
 MENTERI KESEHATAN
REPUBLIK INDONESIA

PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA

NOMOR 340/MENKES/PER/III/2010
TENTANG
KLASIFIKASI RUMAH SAKIT

4
5
 A PRACTICAL GUIDE — PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS
WHO/CDS/CSR/EPH/2002.12

Environment
8.1 Buildings
8.2 Air / udara
8.2.1 Airborne contamination and transmission
8.2.2 Ventilation
8.2.3 Operating theatres / OR / OK
8.3 Water
8.4 Food
8.5 Waste
6
 Air / Udara
 Indoor Air Quality / IAQ

 Kwalitas Udara Ruang / KUR

7
Keys word
 Sumber pollutant
 Ventilation rate / ACH
 Negative / Positive pressure
 Indoor / out door air quality

Smbr poll
8
Sumber Pollutants

9
 10
Guidelines for Air Quality, WHO, Geneve, 2000
 BE CAREFUL WHEN USING THESE PRODUCTS !

( California Environmental Protection Agency , no. 3. May, 2001 )

sneezing
11
12
 (B) flash photo of a human sneeze

( Prof Andrew Davidhazy, School of Photographic Arts and Sciences,

Rochester Institute of Technology Rochester, NY, USA, respectively.)
13
(A) Schlieren image (visualization using light refractioncaused
by differences in air density) of a human cough

( Prof Gary S Settles, Department of Mechanical and Nuclear Engineering,

Pennsylvania State University, PA, USA; ) 14
 NUMBER & SIZE of PARTICLES

( Airborne Respiratory Diseases and Mechanical Systems for CONTROL OF MICROBES. HPAC July 1998 )
18
Aerobiology and Its Role in the Transmission of Infectious Diseases
J Pathog. 2013; 2013: 493960
size
20
 ( Airborne Respiratory Diseases and Mechanical Systems for CONTROL OF MICROBES. HPAC July 1998 )
21
size
Common air contaminants and their relative sizes [Hinds 1982].

( Guidance for Protecting Building Environments from Airborne Chemical,Biological, and Radiological Attacks ;
NIOSH April 2003 )
23
 24
SMK3
SMK3
Sistim Managemen Keselamatan
dan
Kesehatan Kerja

25
 SMK3
Elimination
Substitution
Separation / Isolation
Engineering / Environ Control
Administrative Control
PPE

26
EC 27
 RS UA

Kenapa ?
Ruangan perawatan pasien jarak antar titik tengah TT + 2,4 m
Atau jarak TT > 1 meter ( PMK RI 24 TAHUN 2016 )

Kenapa ?
31
( Airborne Respiratory Diseases and Mechanical Systems for CONTROL OF MICROBES. HPAC July 1998 )

32
Aerosol - generating procedure
Diagnostic sputum inducer
Nasopharyngeal aspiration / airway suction
Aerozoliced medication
ET intubation
Chest PT
Bronchoscopy
Positive pressure ventilation
High frequency ventilation
CPR
Postmortem excition of lung tissue
Chariya Sangsajja, MD.
Bamrasnaradura Infectious Disease Institute
Department of Disease Control, MOPH, Thailand May 2009

33
 SMK3
Elimination
Substitution
Separation / Isolation

Engineering / Environ Control

Administrative Control
PPE

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Engineering Control
( Environmental Controls )

- Air Cleaning
- Ventilation

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Air Cleaning
 Ultraviolet / UVGI

 HEPA filter
( High Efficiency Particulate Air )
 OAUGDP

 BioBlower (TM)

36
 Ultraviolet / UVGI
Ultraviolet
Germicidal
Irradiation

UV kuman

37
 Viability of airborne microbes indoors in absence of sunlight.
Based on averages for each microbial group.

( Airborne Respiratory Diseases and Mechanical Systems for CONTROL OF MICROBES. HPAC July 1998 )
38
UV wave
 Ultra Violet

UV-C light ranges in wavelength from 200–280 nanometers (nm) but operates most
effectively as a germicidal light at a frequency of 253.7 nm.
UVC-Germ Blaster's UV-C light penetrates the cell walls of the
microorganism, damaging its genetic structure by separating the bonds
in the DNA strand.
The damaged bonds in the DNA prohibit future reproduction and ultimately
destroys the microorganism. 39
UV damage to DNA
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41
 ( TUBERCULOSIS INFECTION CONTROL : A PRACTICAL MANUAL FOR PREVENTING TB )

hepa 42
 Air Cleaning
 Ultraviolet C

 HEPA filter
( High Efficiency Particulate Air )
 OAUGDP
 BioBlower

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Four primary filter collection mechanisms

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ventilasi
45
 FILTER

Primary panel filter

Secondary filter

HEPA or tertiaary filter

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47
Engineering Control
( Environmental Controls )

- Air Cleaning
- Ventilation

48
Ventilation
- Natural ventilation
( ada yg hybrid )

- Mechanical ventilation
Local exhaust ventilation
General ventilation
49
 Natural Ventilation

A room with an open window and a fan will have less

TB / airborne-transmission risk than an enclosed
room with no fan.
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- Natural ventilation
( ada yg hybrid )
Air Mixing and Removal
A propeller fan helps mix air in a room.
This dilutes any infectious particles by spreading them throughout the room.

If this dilution effect is combined with a way to replace room air with fresh air,
such as an open window or door, the result will be fewer particles overall in
the room.
52
Ventilation
Natural ventilation

Mechanical ventilation
Local exhaust ventilation
General ventilation

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Local Exhaust Ventilation

- enclosing devices
- exterior devices

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Enclosing devices for local exhaust ventilation include :
1. booths for sputum induction or administration of aerosol-ized
medications
2. tents or hoods for enclosing and isolating a patient, and
3. BSCs
exterior
devices

las 56
 Exhaust fan
Ada perubahan fasa
dari padat , cair
dan gas

hobby 57
GV
( All About Power Tools, 2002, ISBN: 0-89721-478-1 ) 58
Ventilation
- Natural ventilation
- Mechanical ventilation
Local exhaust ventilation

General ventilation

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General ventilation
- Dilution & Removal
- air pattern flow
- air direction
- directional airflow
- negative pressure
- positive pressure

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AIR FLOW
PATTERNS

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pressure
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63
Monitoring Ventilation Systems

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 General ventilation
- Cooling tower
- AHU
- single pass
- recirculation

Cooling t
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 Diagram cooling tower

AHU

ahu
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 dilution
OA

RA

Schema ahu
 Recirculation & single pass
( HCWH )

Silencer Flow rate controller Fan Filter

Exhaust Air Grille

Weather louvre Control damper

+
Humidifier
Terminal filter

Cooling coil Ward/bangsal

Secondary Filter
with droplet
separator
Heating
coil Re-circulated air

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69
70
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2 room
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74
 Isolation Room
- Protective Environment Room / PE’r
( al : Kamar operasi )

- Airborne Infectious Isolation Room / AII’r

- Critical care room

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Protective Environment Room / PE’r

 Kamar Operasi
 Kamar luka bakar
 Kamar utk immunosuppressive
 Tindakan invasive

OR
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 Kamar Operasi

Operating Room
( protective environment )

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 8.2.2 Ventilation
Fresh filtered air, appropriately circulated, will dilute and remove airborne bacterial contamination.
It also eliminates smells. Desirable ventilation rates, expressed in air changes per hour, vary with the
purpose of a particular area (5). High-risk hospital areas (operating rooms, nurseries, intensive care
units, oncology, and burn units) should have air with minimal bacterial contamination.
• Adequate ventilation systems require proper design and maintenance to minimize microbial contamination.
All outdoor air inlets must be located as high as possible above ground level; inlets must be remote from
ventilation discharge outlets, incinerators, or boiler stacks.
• Within rooms, the location of air inlets and exhaust outlets influences the movement of air.

High wall or ceiling inlets and low wall outlets allow clean air to move
downward through the area toward the contaminated floor where it is
removed through the low exhaust.

A PRACTICAL GUIDE — PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS

WHO/CDS/CSR/EPH/2002.12
78
8.2.3 Operating theatres
Modern operating rooms which meet current air standards are virtually free of particles larger than
0.5 μm (including bacteria) when no people are in the room. Activity of operating room personnel is
the main source of airborne bacteria, which originate primarily from the skin of individuals in the
room. The number of airborne bacteria depends on eight factors (Table 1).

Conventional operating rooms are ventilated with 20 to 25 air

changes per hour of high-efficiency filtered air / HEPA
delivered in a vertical flow.

or 79
High wall or ceiling inlets and low wall outlets

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82
83
Layout of a typical air curtain system Air motion Control (ASHRAE Journal March 2009)

84
CFD / computational fluid dynamics analysis of a typical air curtain

Air motion Control (ASHRAE Journal March 2009)

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Global Guidelines for the Prevention of Surgical Site Infection.
© World Health Organization 2016

In many countries, the use of HEPA filters

(at least 99.97% efficient in removing particles
≥0.3 µm in diameter) in the operating room
ventilation system is mandatory by law.
 Factors influencing airborne contamination
in operating theatres

1. Type of surgery
2. Quality of air provided
3. Rate of air exchange / ACH
4. Number of persons present in operating theatre
5. Movement of operating room personnel
6. Level of compliance with infection control practices
7. Quality of staff clothing
8. Quality of cleaning process

PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE — WHO/CDS/CSR/EPH/2002.12

ilo / ssi 87
88
Basic Guide to Particle Counters and Particle Counting
( Copyright © 2006 Particle Measuring Systems, Inc.)
89
Demonstration of how a walking person may entrain air into their wake
(Tang et al., 2006)
( Natural Ventilation for Infection Control in Health-Care settings )
90
 Demonstration of how opening a door may transport air from inside an isolation room to the
outside, during the door-opening motion itself (Tang et al., 2005)
91
plane
ACH
92
 ACH
Air Change per Hour

93
 ( ACH )

( Q : V ) X 60
Q = air flow rate ( cu ft/min )
----------------------------------- X 60 min
V = room volume (cu ft )

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 CONTOH
Ruangan dengan volume 100m³ sekurang-kurangnya
1 (satu) fan dengan diameter 50 cm dengan debit
udara 0,5 m³/detik, dan frekuensi pergantian udara
per-jam adalah 2 (dua) sampai dengan 12 kali.

Volume ruang : 100 m³

12 ACH : 100 X 12 = 1200 m³/jam = 0.33 m³/detik

100 cubic foot/minute = 169.90108 cubic meter/hour

100 cubic foot/minute = 169.90108 cubic meter/hour
HEPA Filter Selection Table
CFM
Singkatan dari Cubic Feet per Minute
Menggambarkan efisiensi kipas menyangkut
aliran udara yang dikeluarkan kipas , satu
kubiknya dalam satu menit
Environmental Controls

 Control source of infection

 Dilute and remove contaminated air
 Control airflow ( clean air to less-clean air )
 PMK RI NOMOR 7 TAHUN 2019
KESEHATAN LINGKUNGAN RUMAH SAKIT

Tabel 7 : Standar Baku Mutu Ventilasi Udara menurut Jenis

Ruangan
 100 percent outside air: effect of ach on reduction of
initial level of room microbial contamination.

( Airborne Respiratory Diseases and Mechanical Systems for CONTROL OF MICROBES. HPAC July 1998 )
101
2 138 207
4 69 104
6 46 69
12 23 35
15 18 28
20 14 21
50 6 8
400 <1 1
Tabel 8 : Standar Baku Mutu Suhu, Kelembaban, dan
Tekanan Udara menurut Jenis Ruang
 ( Basic concept of ventilation flow rate http://www.who.int/csr/bioriskreduction/en/ )

Pollutant generation rate

Indoor conc = Outdoor conc + ----------------------------------
Ventilation flow rate

This is a useful relationship. We can easily find that :

• the higher the outdoor concentration, the higher the indoor concentration

• the higher the ventilation rate, the lower the indoor concentration

• the higher the generation rate, the higher the indoor concentration.

IR 106
 Isolation Room
Protective Environment Room / PE’r

Airborne Infectious Isolation Room / AII’r

107
Chariya Sangsajja, MD.
Bamrasnaradura Infectious Disease Institute
Department of Disease Control, MOPH, Thailand
May 2009

108
 SARS
Avian Influenza
TB (MDR)
dan
Other Airborne infection
( Covid-19 )
109
 Evidence of Airborne Transmission
of
the Severe Acute Respiratory Syndrome Virus
Ignatius T.S. Yu, M.B., B.S., M.P.H., Yuguo Li, Ph.D., Tze Wai Wong, M.B., B.S.,
Wilson Tam, M.Phil., Andy T. Chan, Ph.D., Joseph H.W. Lee, Ph.D.,
Dennis Y.C. Leung, Ph.D., and Tommy Ho, B.Sc.

Airborne Transmission of Communicable Infection —

The Elusive Pathway
Chad J. Roy, M.S.P.H., Ph.D., and Donald K. Milton, M.D., Dr.P.H.

n engl j med 350;17 www.nejm.org april 22, 2004

110
111
112
113
114
Airborne Infectious Isolation Room
( AII’r )
 Negative pressure
 Single pass
 Recirculation

115
Single pass 116
117
118
119
120
121
122
 Exhaust Air Grille Silencer Flow rate controller Fan Filter

Weather louvre Control damper

+ Heater

Humidifier
Prefilter Terminal filter

Cooling coil Secondary Filter Ward/bangsal

with droplet
separator
Heating
coil
X Re-circulated air X
123
CR 124
Chariya Sangsajja, MD.
Bamrasnaradura Infectious Disease Institute
Department of Disease Control, MOPH, Thailand
May 2009

125
Chariya Sangsajja, MD.
Bamrasnaradura Infectious Disease Institute
Department of Disease Control, MOPH, Thailand
May 2009

126
127
128
 Ruang pelayanan penyakit menular melalui udara
Airborne transmission diseases

P M K RINOMOR 24 TAHUN 2014

Hal 18

Harus mempunyai pertukaran udara yang baik (minimal 12 ACH)

dimana pembuangan udaranya dapat menggunakan ventilasi
mekanik, yang harus diarahkan ke luar ke tempat yang tidak
membahayakan pasien, pengunjung maupun petugas rumah
sakit.

129
Airborne Transmission of Communicable Infection —
The Elusive Pathway
Chad J. Roy, M.S.P.H., Ph.D., and Donald K. Milton, M.D., Dr.P.H.

n engl j med 350;17 www.nejm.org april 22, 2004

131
( n engl j med 350;17 www.nejm.org april 22, 2004 , Ignatius T.S. Yu, M.B., B.S., M.P.H.,)
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135
136
Sewage
water drain

137
139
Air Sampling
- Passive
- Active

140
141
142
143
FS 209

144
 ISO 14644

145
bio indstr
 UV

TB 146
Fin 3 148
 Take Action to Improve
Air Quality
in
Every Room

Fin 1 149
 The right to healthy air
is everyone’s right
( Healthy Building 2000 conference, in Espoo, Finland, on 6–10 August. 2005 )

150
Fin
Pahlawan Kita
Pertanyaan ?

152
Semoga bermanfaat
aliimam04@yahoo.com
081 334 663 808

153
 INDONESIA akan sulit mencapai eliminasi tuberkolosis yang ditargetkan pada 2030 apabila
strategi yang dilakukan hanya penemuan kasus dan mengobatinya hingga sembuh. Diperlukan
kerja sama lintas sektor dan komitmen bersama untuk mengakhiri tuberkolosis di Indonesia yang
angkanya saat ini diperkirakan 842.000 kasus setiap tahunnya.
MI Rabu 14 November 2018

Sementara itu, Dr dr Erlina Burhan SpP(K) dari Departemen

Pulmonologi dan Ilmu Kedokteran Respirasi FKUI-RS
Persahabatan mengatakan dalam mengeliminasi, intervensi yang
dilakukan pemerintah masih berfokus pada penemuan kasus TB
dan mengobatinya. Ia meyakini tanpa adanya pendekatan lain
yakni aspek pencegahan, eliminasi TB pada 2030 akan sulit
dicapai.
Fin 2 160
162
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