Hospital

Hospital hygiene. Hygienic requirements to special hospitals with high epidemiological risk. Prevention of nosocomial infections.

Norfolk and Norwich University Hospital in the East of England. The UK has a publicly funded health care system called the National Health Service

All India Institute of Medical Sciences in Delhi, India

A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays.

Hospitals are usually funded by the public sector, by health organizations (for profit or nonprofit), health insurance companies, or charities, including direct charitable donations. Historically, hospitals were often founded and funded by religious orders or charitable individuals and leaders. Today, hospitals are largely staffed by professional physicians, surgeons, and nurses, whereas in the past, this work was usually performed by the founding religious orders or by volunteers. However, there are various Catholic religious orders, such as the Alexians and the Bon Secours Sisters, which still focus on hospital ministry today.

There are over 17,000 hospitals in the world.

In accord with the original meaning of the word, hospitals were originally "places of hospitality", and this meaning is still preserved in the names of some institutions such as the Royal Hospital Chelsea, established in 1681 as a retirement and nursing home for veteran soldiers.

Etymology

During the Middle Ages hospitals served different functions to modern institutions, being almshouses for the poor, hostels for pilgrims, or hospital schools. The word hospital comes from the Latin hospes, signifying a stranger or foreigner, hence a guest. Another noun derived from this, hospitium came to signify hospitality, that is the relation between guest and shelterer, hospitality, friendliness, hospitable reception. By metonymy the Latin word then came to mean a guest-chamber, guest's lodging, an inn.[2] Hospes is thus the root for the English words host (where the p was dropped for convenience of pronunciation) hospitality, hospice, hostel and hotel.

Etymology

The latter modern word derives from Latin via the ancient French romance word hostel, which developed a silent s, which letter was eventually removed from the word, the loss of which is signified by a circumflex in the modern French word hôtel. The German word 'Spital' shares similar roots.

Grammar of the word differs slightly depending on the dialect. In the U.S., hospital usually requires an article; in Britain and elsewhere, the word normally is used without an article when it is the object of a preposition and when referring to a patient ("in/to the hospital" vs. "in/to hospital"); in Canada, both uses are found.

Types

Lehigh Valley Hospital in Allentown, Pennsylvania

Types

Some patients go to a hospital just for diagnosis, treatment, or therapy and then leave ('outpatients') without staying overnight; while others are 'admitted' and stay overnight or for several days or weeks or months ('inpatients'). Hospitals usually are distinguished from other types of medical facilities by their ability to admit and care for inpatients whilst the others often are

General

The best-known type of hospital is the general hospital, which is set up to deal with many kinds of disease and injury, and normally has an emergency department to deal with immediate and urgent threats to health. Larger cities may have several hospitals of varying sizes and facilities. Some hospitals, especially in the United States, have their own ambulance service.

District

A district hospital typically is the major health care facility in its region, with large numbers of beds for intensive care and long-term care; and specialized facilities for surgery, plastic surgery, childbirth, bioassay laboratories, and so forth.

Specialized

McMaster University Medical Centre, a teaching hospital in Canada

Specialized

Types of specialized hospitals include trauma centers, rehabilitation hospitals, children's hospitals, seniors' (geriatric) hospitals, and hospitals for dealing with specific medical needs such as psychiatric problems (see psychiatric hospital), certain disease categories such as cardiac, oncology, or orthopedic problems, and so forth.

Specialized

A hospital may be a single building or a number of buildings on a campus. Many hospitals with pre-twentieth-century origins began as one building and evolved into campuses. Some hospitals are affiliated with universities for medical research and the training of medical personnel such as physicians and nurses, often called teaching hospitals. Worldwide, most hospitals are run on a nonprofit basis by governments or charities.

Teaching

A teaching hospital combines assistance to patients with teaching to medical students and nurses and often is linked to a medical school, nursing school or university.

Clinics

A medical facility smaller than a hospital is generally called a clinic, and often is run by a government agency for health services or a private partnership of physicians (in nations where private practice is allowed). Clinics generally provide only outpatient services.

Departments

Resuscitation room bed after a trauma intervention, showing the highly technical equipment of modern hospitals

Departments

Hospitals vary widely in the services they offer and therefore, in the departments they have. They may have acute services such as an emergency department or specialist trauma centre, burn unit, surgery, or urgent care. These may then be backed up by more specialist units such as cardiology or coronary care unit, intensive care unit, neurology, cancer center, and obstetrics and gynecology.

Departments

Some hospitals will have outpatient departments and some will have chronic treatment units such as behavioral health services, dentistry, dermatology, psychiatric ward, rehabilitation services, and physical therapy.

Departments

Common support units include a dispensary or pharmacy, pathology, and radiology, and on the non-medical side, there often are medical records departments, release of information departments, Information Management (IM)(aka IT or IS), Clinical Engineering (aka Biomed), Facilities Management, Plant Ops (aka Maintenance), Dining Services, and Security departments.

Funding

Clinical Hospital Dubrava Modern Medical Center in Zagreb, Croatia.

Funding In the modern era, hospitals are,

broadly, either funded by the government of the country in which they are situated, or survive financially by competing in the private sector (a number of hospitals also are still supported by the historical type of charitable or religious associations).

In the United Kingdom for example, a relatively comprehensive, "free at the point of delivery" health care system exists, funded by the state. Hospital care is thus relatively easily available to all legal residents, although free emergency care is available to anyone, regardless of nationality or status. As hospitals prioritize their limited resources, there is a tendency for 'waiting lists' for non-crucial treatment in countries with such systems, as opposed to letting higher-payers get treated first, so sometimes those who can afford it take out private health care to get treatment more quickly.

Funding

As the quality of health care has increasingly become an issue around the On the other hand, many countries, including the USA, have in the twentieth century followed a largely private-based, for-profit-approach to providing hospital care, with few state-money supported 'charity' hospitals remaining today.[ Where for-profit hospitals in such countries admit uninsured patients in emergency situations (such as during and after Hurricane Katrina in the USA), they incur direct financial losses, ensuring that there is a clear disincentive to admit such patients.world, hospitals have increasingly had to pay serious attention to this matter.

Funding

Independent external assessment of quality is one of the most powerful ways to assess this aspect of health care, and hospital accreditation is one means by which this is achieved. In many parts of the world such accreditation is sourced from other countries, a phenomenon known as international healthcare accreditation, by groups such as Accreditation Canada from Canada, the Joint Commission from the USA, the Trent Accreditation Scheme from Great Britain, and Haute Authorité de santé (HAS) from France.

Buildings Architecture

The National Health Service Norfolk and Norwich University Hospital in the UK, showing the utilitarian architecture of many modern hospitals.

Hospital chapel at Fawcett Memorial Hospital, a for-profit facility operated by HCA.

Buildings Architecture

The Horton General Hospital in Banbury, during 2010. It was built in 1872 and slightly expanded in both 1964 and 1972 and was nearly closed early in 2005.

Buildings Architecture

Modern hospital buildings are designed to minimize the effort of medical personnel and the possibility of contamination while maximizing the efficiency of the whole system. Travel time for personnel within the hospital and the transportation of patients between units is facilitated and minimized. The building also should be built to accommodate heavy departments such as radiology and operating rooms while space for special wiring, plumbing, and waste disposal must be allowed for in the design.

Buildings Architecture

However, the reality is that many hospitals, even those considered 'modern', are the product of continual and often badly managed growth over decades or even centuries, with utilitarian new sections added on as needs and finances dictate. As a result, Dutch architectural historian Cor Wagenaar has called many hospitals:

"... built catastrophes, anonymous institutional complexes run by vast bureaucracies, and totally unfit for the purpose they have been designed for ... They are hardly ever functional, and instead of making patients feel at home, they produce stress and anxiety."

Buildings Architecture

Some newer hospitals now try to re-establish design that takes the patient's psychological needs into account, such as providing more fresh air, better views and more pleasant colour schemes. These ideas hearken back to the late eighteenth century, when the concept of providing fresh air and access to the 'healing powers of nature' were first employed by hospital architects in improving their buildings.

Buildings Architecture

The research of British Medical Association is showing that good hospital design can reduce patient's recovery time. Exposure to daylight is effective in reducing depression. Single sex accommodation help ensure that patients are treated in privacy and with dignity. Exposure to nature and hospital gardens is also important - looking out windows improvies patient's mood, reduces blood pressure and stress level. Eliminating long corridors can reduce nurses' fatigue and stress.

Buildings Architecture

Another ongoing major development is the change from a ward-based system (where patients are accommodated in communal rooms, separated by movable partitions) to one in which they are accommodated in individual rooms. The ward-based system has been described as very efficient, especially for the medical staff, but is considered to be more stressful for patients and detrimental to their privacy. A major constraint on providing all patients with their own rooms is however found in the higher cost of building and operating such a hospital; this causes some hospitals to charge for private rooms.

Nosocomial infection

Classification and external resources

Contaminated surfaces increase cross-transmission

Nosocomial infection

A nosocomial infection (nos-oh-koh-mi-al), also known as a hospital-acquired infection or HAI, is an infection whose development is favoured by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff. Such infections include fungal and bacterial infections and are aggravated by the reduced resistance of individual patients.

Nosocomial infection

In the United States, the Centers for Disease Control and Prevention estimate that roughly 1.7 million hospital-associated infections, from all types of microorganisms, including bacteria, combined, cause or contribute to 99,000 deaths each year. In Europe, where hospital surveys have been conducted, the category of Gram-negative infections are estimated to account for two-thirds of the 25,000 deaths each year. Nosocomial infections can cause severe pneumonia and infections of the urinary tract, bloodstream and other parts of the body. Many types are difficult to attack with antibiotics, and antibiotic resistance is spreading to Gram-negative bacteria that can infect people outside the hospital.

Known nosocomial infections

Ventilator associated pneumonia (VAP)

Staphylococcus aureusMethicillin resistant

Staphylococcus aureus (MRSA)Candida albicansPseudomonas aeruginosaAcinetobacter baumannii

Known nosocomial infections

Stenotrophomonas maltophiliaClostridium difficileTuberculosisUrinary tract infectionHospital-acquired pneumonia (HAP)GastroenteritisVancomycin-resistant Enterococcus

(VRE)Legionnaires' disease

Epidemiology

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Epidemiology

Nosocomial infections are commonly transmitted when hospital officials become complacent and personnel do not practice correct hygiene regularly. Also, increased use of outpatient treatment means that people who are hospitalized are more ill and have more weakened immune systems than may have been true in the past. Moreover, some medical procedures bypass the body's natural protective barriers. Since medical staff move from patient to patient, the staff themselves serve as a means for spreading pathogens. Essentially, the staff act as vectors.

Categories and treatment

Among the categories of bacteria most known to infect patients are the category MRSA, Gram-positive bacteria and Helicobacter, which is Gram-negative. While there are antibiotic drugs that can treat diseases caused by Gram-positive MRSA, there are currently few effective drugs for Acinetobacter. However, Acinetobacter germs are evolving and becoming immune to existing antibiotics. "In many respects it’s far worse than MRSA," said a specialist at Case Western Reserve University.

Categories and treatment

Another growing disease, especially prevalent in New York City hospitals, is the drug-resistant Gram-negative germ, Klebsiella pneumoniae. An estimated more than 20 percent of the Klebsiella infections in Brooklyn hospitals "are now resistant to virtually all modern antibiotics. And those supergerms are now spreading worldwide."

Categories and treatment

The bacteria, classified as Gram-negative because of their reaction to the Gram stain test, can cause severe pneumonia and infections of the urinary tract, bloodstream, and other parts of the body. Their cell structures make them more difficult to attack with antibiotics than Gram-positive organisms like MRSA. In some cases, antibiotic resistance is spreading to Gram-negative bacteria that can infect people outside the hospital. "For Gram-positives we need better drugs; for Gram-negatives we need any drugs," said Dr. Brad Spellberg, an infectious-disease specialist at Harbor-UCLA Medical Center, and the author of Rising Plague, a book about drug-resistant pathogens.

Categories and treatment

One-third of nosocomial infections are considered preventable. The CDC estimates 2 million people in the United States are infected annually by hospital-acquired infections, resulting in 20,000 deaths. The most common nosocomial infections are of the urinary tract, surgical site and various pneumonias.

Country estimates

The methods used differ from country to country (definitions used, type of nosocomial infections covered, health units surveyed, inclusion or exclusion of imported infections, etc.), so that international comparisons of nosocomial infection rates should be made with the utmost care.

Country estimates

United States: The Centers for Disease Control and Prevention (CDC) estimates that roughly 1.7 million hospital-associated infections, from all types of bacteria combined, cause or contribute to 99,000 deaths each year. Other estimates indicate that 10%, or 2 million, patients a year become infected, with the annual cost ranging from $4.5 billion to $11 billion. In the USA the most frequent type of infection hospitalwide is urinary tract infection (36%), followed by surgical site infection (20%), bloodstream infection (BSI), and pneumonia (both 11%).

Country estimates

France: estimates ranged from 6.7% in 1990 to 7.4% (patients may have several infections). At national level, prevalence among patients in health care facilities was 6.7% in 1996, 5.9% in 2001 and 5.0% in 2006. The rates for nosocomial infections were 7.6% in 1996, 6.4% in 2001 and 5.4% in 2006.

Country estimates

In 2006, the most common infection sites were urinary tract infections (30,3%), pneumopathy (14,7%), infections of surgery site (14,2%). infections of the skin and mucous membrane (10,2%), other respiratory infections (6,8%) and bacterial infections / blood poisoning (6,4%). The rates among adult patients in intensive care were 13,5% in 2004, 14,6% in 2005, 14,1% in 2006 and 14.4% in 2007.

Country estimates

It has also been estimated that nosocomial infections make patients stay in the hospital 4-5 additional days. Around 2004-2005, about 9,000 people died each year with a nosocomial infection, of which about 4,200 would have survived without this infection.

Country estimates

Italy: since 2000, estimates show that about 6.7% infection rate, i.e. between 450,000 and 700,000 patients, which caused between 4,500 and 7,000 deaths. A survey in Lombardy gave a rate of 4.9% of patients in 2000.

United Kingdom: estimates of 10% infection rate,with 8.2% estimated in 2006.

Country estimates

Switzerland: estimates range between 2 and 14%. A national survey gave a rate of 7.2% in 2004.

Finland: estimated at 8.5% of patients in 2005

Transmission

The drug-resistant Gram-negative germs for the most part threaten only hospitalized patients whose immune systems are weak. The germs can survive for a long time on surfaces in the hospital and enter the body through wounds, catheters, and ventilators.

Main routes of transmissionRoute Description

Contact transmission

the most important and frequent mode of transmission of nosocomial infections.

Main routes of transmissionRoute Description

Droplet transmission

occurs when droplets are generated from the source person mainly during coughing, sneezing, and talking, and during the performance of certain procedures such as bronchoscopy. Transmission occurs when droplets containing germs from the infected person are propelled a short distance through the air and deposited on the host's body.

Main routes of transmissionRoute Description

Airborne transmission

occurs by dissemination of either airborne droplet nuclei (small-particle residue {5 µm or smaller in size} of evaporated droplets containing microorganisms that remain suspended in the air for long periods of time) or dust particles containing the infectious agent. Microorganisms carried in this manner can be dispersed widely by air currents and may become inhaled by a susceptible host within the same room or over a longer distance from the source patient, depending on environmental factors; therefore, special air handling and ventilation are required to prevent airborne transmission. Microorganisms transmitted by airborne transmission include Legionella, Mycobacterium tuberculosis and the rubeola and varicella viruses.

Main routes of transmissionRoute Description

Common vehicle transmission

applies to microorganisms transmitted to the host by contaminated items such as food, water, medications, devices, and equipment.

Main routes of transmissionRoute Description

Vector borne transmission

occurs when vectors such as mosquitoes, flies, rats, and other vermin transmit microorganisms.

Transmission

Contact transmission is divided into two subgroups: direct-contact transmission and indirect-contact transmission.

Routes of contact transmissionRouteDescription

Direct-contact transmission

involves a direct body surface-to-body surface contact and physical transfer of microorganisms between a susceptible host and an infected or colonized person, such as occurs when a person turns a patient, gives a patient a bath, or performs other patient-care activities that require direct personal contact. Direct-contact transmission also can occur between two patients, with one serving as the source of the infectious microorganisms and the other as a susceptible host.

Routes of contact transmissionRouteDescription

Indirect-contact transmission

involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments, needles, or dressings, or contaminated gloves that are not changed between patients. In addition, the improper use of saline flush syringes, vials, and bags has been implicated in disease transmission in the US, even when healthcare workers had access to gloves, disposable needles, intravenous devices, and flushes.

Risk factorsFactors predisposing a patient to infection can broadly be divided into three areas:

People in hospitals are usually already in a poor state of health, impairing their defense against bacteria – advanced age or premature birth along with immunodeficiency (due to drugs, illness, or irradiation) present a general risk, while other diseases can present specific risks - for instance, chronic obstructive pulmonary disease can increase chances of respiratory tract infection.

Risk factorsFactors predisposing a patient to infection can broadly be divided into three areas:

Invasive devices, for instance intubation tubes, catheters, surgical drains, and tracheostomy tubes all bypass the body’s natural lines of defence against pathogens and provide an easy route for infection. Patients already colonised on admission are instantly put at greater risk when they undergo an invasive procedure.

Risk factorsFactors predisposing a patient to infection can broadly be divided into three areas:

A patient’s treatment itself can leave them vulnerable to infection – immunosuppression and antacid treatment undermine the body’s defences, while antimicrobial therapy (removing competitive flora and only leaving resistant organisms) and recurrent blood transfusions have also been identified as risk factors.

Prevention

Hospitals have sanitation protocols regarding uniforms, equipment sterilization, washing, and other preventative measures. Thorough hand washing and/or use of alcohol rubs by all medical personnel before and after each patient contact is one of the most effective ways to combat nosocomial infections. More careful use of antimicrobial agents, such as antibiotics, is also considered vital.

Prevention

Despite sanitation protocol, patients cannot be entirely isolated from infectious agents. Furthermore, patients are often prescribed antibiotics and other antimicrobial drugs to help treat illness; this may increase the selection pressure for the emergence of resistant strains.

Sterilization

Sterilization goes further than just sanitizing. Sterilizing kills all microorganisms on equipment and surfaces through exposure to chemicals, ionizing radiation, dry heat, or steam under pressure.

Isolation

Isolation precautions are designed to prevent transmission of microorganisms by common routes in hospitals. Because agent and host factors are more difficult to control, interruption of transfer of microorganisms is directed primarily at transmission.

Handwashing and gloving

Handwashing frequently is called the single most important measure to reduce the risks of transmitting skin microorganisms from one person to another or from one site to another on the same patient. Washing hands as promptly and thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of infection control and isolation precautions.

Handwashing and gloving

Although handwashing may seem like a simple process, it is often performed incorrectly. Healthcare settings must continuously remind practitioners and visitors on the proper procedure in washing their hands to comply with responsible handwashing. Simple programs such as Henry the Hand, and the use of handwashing signals can assist healthcare facilities in the prevention of nosocomial infections.

Handwashing and gloving

In addition to handwashing, gloves play an important role in reducing the risks of transmission of microorganisms. Gloves are worn for three important reasons in hospitals. First, gloves are worn to provide a protective barrier and to prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. In the USA, the Occupational Safety and Health Administration has mandated wearing gloves to reduce the risk of bloodborne pathogen infection.

Handwashing and gloving

Second, gloves are worn to reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to patients during invasive or other patient-care procedures that involve touching a patient's mucous membranes and nonintact skin.

Handwashing and gloving

Third, gloves are worn to reduce the likelihood that hands of personnel contaminated with microorganisms from a patient or a fomite can transmit these microorganisms to another patient. In this situation, gloves must be changed between patient contacts, and hands should be washed after gloves are removed.

Handwashing and gloving

Wearing gloves does not replace the need for handwashing, because gloves may have small, non-apparent defects or may be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between patient contacts is an infection control hazard.

Mitigation

The most effective technique of controlling nosocomial infection is to strategically implement QA/QC measures to the health care sectors and evidence-based management can be a feasible approach. For those VAP/HAP diseases (ventilator-associated pneumonia, hospital-acquired pneumonia), controlling and monitoring hospital indoor air quality needs to be on agenda in management whereas for nosocomial rotavirus infection, a hand hygiene protocol has to be enforced. Other areas that the management needs to be covered include ambulance transport.

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