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Intensive Care Unit : Acquisition of Infection & AIR CHANGE

Featured Article , AIR 2021 , Issue 1 , Article 1

Jaspreet S. Dhau, President ASIRE

I want to start with a disclaimer; I am neither a physician nor a medical expert. My pain has propelled me to dig into scientific literature about airborne infections and control measures associated with ICUs in India. As part of my role as an R&D director for Molekule, I’ve read many scientific articles on air purification. But as a son of a strong woman who was hospitalized while battling serious illness, I’ve gone to great lengths to familiarize myself on the subject of airborne infections and control measures in ICUs—references to some of these sources are given at the end of this article. I will be happier if someone can shred my inferences from these readings, as it will bring peace to many whose loved ones may be in an ICU. They can find solace knowing that their relative is at a reduced risk of acquiring deadly airborne disease from the hospital

Your life’s most challenging time is when your loved one is on an Intensive Care Unit (ICU) bed, and you are helpless and pondering what to do and the following related emotional battle. You evaluate doctors, hospital staff, and infrastructure and hope they are the best for the situation. At this moment, your belief makes you understand that the hospital is doing everything it could do for the patient. I was in a similar situation in the torrid times of 2020 when the world saw a surge in coronavirus infection (SARS-CoV-2) cases with no sign of the pandemic slowing down. My mother was fighting for her life due to pneumonia and severe sepsis, and septic shock in a reputed hospital in Punjab, India. Since she was on a ventilator and struggling with an airborne infection, and I being familiar with the impact of air quality on patient’s health having respiratory issues,1 I decided to place an air purifier by her bedside. 

To get the right air purifier, I asked the doctor about the number of air changes per hour (ACH) in the ICU. The answer shook me to the core; NONE. Due to my research in air purification and some knowledge about airborne infectious microbes, I could apprehend that her health would deteriorate further. How could she improve in an environment which is a breeding ground for drug-resistant bacteria and highly infectious viruses such as SARS-CoV-2! I did what every son and any reasonable person in my situation would do; I decided to shift my mother to a better-equipped hospital. Shifting was not straightforward due to COVID restrictions with hospitals refusing admission to new patients.

However, I moved her to one of the best and expensive hospitals in the region, assuming higher expenses mean a better-equipped hospital. However, even there, I came for a rude shock, no AIR CHANGE in the ICU. According to my understanding, this is unacceptable anywhere in the world as good indoor air quality is a critical non-pharmacological strategy to prevent hospital-acquired infections.In all these uncertainties, the fiercest warrior in our family lost the battle of her life, which I believe is partly due to ill-equipped (for sure) and probably non-compliant ICUs in hospitals.

Can an ICU in the hospitals be without AIR CHANGE or, in other words, without a standard’ heating, ventilation, and air-conditioning (HVAC)’ system? Are there any regulations and guidelines on ACH for ICUs in India? If there are regulations and policies, what and where are they? So, I started the quest to find answers, and hence this article

Several medical studies have established that infection in the ICU is highest in the hospital, partly due to inadequate facilities.2 Many antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA), Serratia marcescens, and vancomycin-resistant enterococci (VRE) are found to survive and persist in the hospital environment and are responsible for hospital-acquired diseases. I looked into whether these microbes are transmitted through contaminated surfaces (fomite exposure) only or if they could be airborne also. Shiomori et al. (2001) have reported that MRSA may be airborne and may play a role in nasal colonization in the nasal cavity or respiratory tract in MRSA infections.3 The Shiomori research group recommends measures to prevent airborne MRSA spread to control nosocomial MRSA infection in hospitals. The airborne transmission of SARS-CoV-2 through aerosols is also now well established. The SARS-CoV-2-laden droplets released during expiratory activities (talking, coughing, and sneezing) of infected persons become airborne through evaporation. Besides, several medical and surgical procedures may also generate aerosolized infectious particles.4 The fate of these airborne particles depends on the airflow. In inadequate ventilation cases, the airborne particle could remain in the ICU room, leaving patients, staff, and visitors to potentially inhale these infectious particles. It is therefore essential to remove these infectious aerosols through the use of adequate ventilation systems. That’s why guidelines on ventilation in ICUs must be strictly applied all across the world.

Professional and scientific bodies in the US, UK, and Europe have published guidelines on ICUs’ design and layout and emphasized ventilation’s importance. In India too, detailed guidelines on ICU planning and designing have been specified in 2010 and 2020.5,6 The guidelines are clear on the ICU to be fully air-conditioned with control over temperature, humidity, and a minimum of six ACH per room, with two ACH (33%) composed of outside air. Further recommendations are for the re-circulated air passing through filters with 99% filtration efficiency in the particle size range of <5 microns. The guidelines have been there for a while now, yet I wonder why the hospitals are not following them. How are they getting approvals? Aren’t there checks and inspections by regulatory bodies to ensure that hospitals follow guidelines? After all, we’ve been through as a species in the last year, we, the people, deserve these answers

It is not inevitable that following these guidelines will mitigate the issue. Still, it will be an excellent start to reduce airborne infections in the ICUs and improve the health service quality. There is an urgent need to educate the general population about the existing guidelines and cultivate the habit of maintaining cleanliness in a hospital.

With the advent of new technologies, infrastructure, and knowledge, there are several opportunities to upgrade to ICUs’ ventilation guidelines. According to the ISCCM guidelines, 2010 and 2020,5,6 if air conditioning and air change are not possible, then ICU should have windows that can be opened. In 2010 guidelines, I could understand, but in 2020, the exemption is unreasonable since we pride ourselves on electricity reaching every city and village in the country. It appears that the hospitals in India are exploiting this loophole and conveniently violating the guidelines on the air changes, which is unacceptable. In my view, ACH should be mandatory in ICUs, and ventilation through windows could only be an additional option.

Here are some of the other suggestions for improving air quality in ICUs:

1. Higher Filtration Efficiency. Enhance requirements on the filtration efficiency of HVAC filters. The guideline recommends using filters with 99% mechanical efficiency for particles up to 5 μm; however, a significant level of airborne pathogen-laden aerosols is smaller than 5 microns. Therefore, the regulatory body should enhance the requirement on the filtration efficiency of HVAC filters. Integrate filters into the HVAC system that give a filtration efficiency of at least 99.9% for aerosols/particles smaller than 5 microns.

2. HVAC Maintenance. HVAC systems/ventilation ducts need to be regularly deep cleaned to ensure that the system doesn’t become breeding ground and a potential source of infectious microbes’ transmission. This aspect should be incorporated into the inspection guidelines of the hospital.

3. Next Generation Filtration Technologies. Utilize air filters or technologies that could destroy microbes to add an extra layer of protection to the HVAC system. For this, technologies that destroy airborne microbes should be integrated into the HVAC system.

4. Personalized Air Purification Systems (Portable Air Purifiers). The medical community has not widely recognized the use of a personalized air purification system (PAPS) such as portable air purifiers. PAPS provides clean, infection-free air into the patient’s breathing zone by removing microbe-laden droplets and droplet nuclei. A personalized air cleaning system decreases inhaled pollutant concentrations by 2-50x compared with an HVAC system alone.7 Therefore, PAPS systems in the ICU environment close to the patient’s breathing zone will benefit their health, see image at the beginning of the article.

A study by Pantelic et al. has reported using a personalized ventilation system to mitigate the risk of airborne transmissible infection.8 Further, a study by Molekule has shown that HVAC filters reduce microbes but not completely (full disclosure: I currently serve as Molekule’s Senior Director of R & D.). The indoor air purifier prefilter had more pathogenic microbes than the HVAC final filter, indicating infectious microbes remained in the air for a significant amount of time before the HVAC system could remove them.9 This may leave everyone in the hospital environment vulnerable to infection. I would recommend using a portable air purifier in all ICUs, especially in ICUs without adequate ventilation. These systems are inexpensive, low maintenance, and offer additional benefits such as the destruction of infectious microbes and the oxidation of toxic pollutants found in the hospital environment.  

The time has come when we take air quality in ICU seriously and hold hospitals and ourselves accountable.

References

  1. A.K. Kaushik, J.S. Dhau, H. Gohel, Y.K. Mishra, B. Kateb, N.Y. Kim, D.Y. Goswami, Electrochemical SARS-CoV-2 sensing at point-of-care and artificial intelligence for intelligent COVID-19 management”, ACS Applied Biomaterials, (2020) 3(11), 7306-7325.
  2. N. H. O’Connell, H. Humphreys, “Intensive care unit design and environmental factors in the acquisition of infection”, Journal of Hospital Infection (2000) 45, 255–262.
  3.  T. Shiomori, H Miyamoto, K Makishima, “Significance of airborne transmission of methicillin-resistant Staphylococcus aureus in an otolaryngology-head and neck surgery unit”, Arch Otolaryngol Head Neck Surg. (2001) 127, 644-8.
  4. B. Ather, T. M. Mirza, P. F. Edemekong, “Airborne Precautions”, https://www.ncbi.nlm.nih.gov/books/NBK531468/
  5. N. Rungta, D. Govil, S.Nainan, M. Munjal J. Divatia, C K Jani, “ICU Planning and Designing in India – Guidelines 2010”, Guidelines Committee ISCCM, (2010).
  6. N. Rungta, K. G. Zirpe, S. B. Dixit, Y. Mehta, D. Chaudhry, D. Govil, R. C. Mishra, J. Sharma, P. Amin, B. K. Rao, G. C. Khilnani, K. Mittal, P. K. Bhattacharya, A. K. Baronia, Y. Javeri, S. N. Myatra, N. Rungta, R. Tyagi, S. Dhanuka, M. Mishra, S. Samavedam, “Indian Society of Critical Care Medicine Experts Committee Consensus Statement on ICU Planning and Designing”, (2020), 24, S43-S60.
  7. A. K. Melikov, R. Cermak, M. Majer, “Personalized ventilation: evaluation of different air terminal devices”, Energy Buildings (2002) 34, 829–836.
  8. J. Pantelic, G. N. Sze-To, K.W. Tham, C. Y. H. Chao, Y. C. M. Khoo, “Personalized ventilation as a control measure for airborne transmissible disease spread”, J R Soc Interface, (2009), S715-26.
  9. https://iaqa.org/wp-content/uploads/2019/01/A-Review-of-HEPA-filters-and-Newer-Air-Purification-Technologies-for-their-Effectiveness-and-Health-Impacts-by-Yogi-Goswami.pdf

The article is dedicated to my mother, Mrs. Ranjit Kaur. Miss you, Mom!

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Ishani sharma

Thankyou for such an informative article sir. Suggestions given by you are the real demand of the present scenario and these should be implemented to get a safer environment.

Harsimar Kaur Khatra

Really informative.

Prachi

This article is the need of the hour. The respiratory diseases are one of the major threat in these times and the air quality and air circulation in ICUs must be checked.

Jaspreet

You are absolutely right, Prachi. Thank you!

Muskan

Thank you for such information

Jaspreet

Thank you for the encouragement

Vrinda

Very informative

Jaspreet

Thank you, Ishani. My objective was to raise an issue and provide a solution. Let’s hope suggestions are implemented all over the world.

Surbhi Bishnoi

I am really shocked to know the conditions of our hospitals. I never imagined that our hospitals are working without proper system and guidelines provided to them. Not everyone is aware about such things, even if not by this article i might remain in the state that our hospitals are doing good. We can’t let this happen to anyone, some strict actions and proper implementation should be done. Hospitals are there to provide us our health back and not to deteriorate it. I really hope this article of yours will open up many minds and would bring some change.

Parneet Chahal

Sincerely, through this article got information about the life risking and miserable conditions of the Hospitals in India which needs to be addressed on timely. It is peak time to fight with airborne infections in hard times of Covid-19. Really enlightening article, sorry for the loss.

Jaspreet

Thank you, Parneet. I am glad the article is able to generate awareness about the air quality in ICUs.

Shaina

The article is an eye opener. Literally shocked reading the conditions.Moreover, it is very informative. Indeed

Jaspreet

Thank you, Shaina

Jaspreet

Thank you for the comment, Surbhi.
The solution to the air quality in hospitals, especially in ICU, is easy to implement. The voice of the people shall make the difference.

Arpita Rawat

Very informative and something that should be taken into immediate consideration especially now when we all suffering through pandemic.

Jaspreet

Thank you, Arpita. There are learnings for all of us and time to act

Shweta

Indeed a very well written article awaring the readers about the present condition of ventilation in ICU in hospitals and at the same time giving some helpful suggestions too.

Jaspreet

I intended to highlight air quality issues in hospitals that are often neglected and provide solutions. Thank you for your comment

Shweta Thakur

Technologies like these are the need for the better future and for us to deal with many such infections and diseases. Thankyou for making us aware of situations that we thought were the best for our family’s as they are not. A very knowledgeable article making us aware of the situation and on indoor air quality.

Rajmeet kaur

Indeed very useful! It’s great

Jasmine sikka

Very informative and well explained.

Mansi

This was very inspiring

Shreya Gupta

This is indeed very informative and something that should be taken into immediate consideration.

Prathna

It was very informative and inspiring too.

Jaspreet

Thank you, All!

Jaspreet

We always take air and air quality for granted, i.e., if the air quality is bad, we think we can do nothing, and if it is good, it is our luck. The good thing is solutions are there. We need to be aware of them.

Jaspreet

We spend most of our time indoors; therefore, awareness of indoor air quality is a must! Thank you for your comment.

Priya thakur

It is very heartbreaking to know about the conditions of our hospitals. I didn’t realised about the conditions of our system before reading this article. We people had in our minds that hospitals are there for our betterment but after reading this article I am shocked. Hospitals should abide all the guidelines issued for them. As you have mentioned use of portable air purifier should be there in the hospital. People are unaware of these conditions. I hope your article will help people to know the exact state of our hospitals.

Pranjal Kaushal

very informative

Gunjan Pattar

This is very inspiring and informative.It bring to us the truth of the health infrastructure in the country.

Jaspreet

Thank you for your comment, Priya. India is one of the most popular destinations for medical tourism. Indian doctors have been known for high-quality training, and hospitals in India boasts of the world’s best medical infrastructure. However, certain aspects of healthcare facilities in India are neglected, and air quality is one. This is easily fixable by increasing awareness about air quality and solutions. The current situation with COVID has reemphasized the need for having a long-term public health strategy that strengthens the general health system.

sehajpreet kaur

An eye-opening article that truly brings out the truth of ICUs and hospitals. The initiative to improve the air quality in ICUs must be undertaken at the earliest.

harmanpreet

Well said⭐️Its informative and inspiring

Arkita Dwivedi

It was very shocking to know about the current condition of hospitals.Your article was truly an eye opening article for me. It brings out the truth of ICU’s and Hospital in light. Thanks for making us aware about such problems which are being face by you people in this pandemic .Suggestions given by you are the real demand of the present scenario.
These should be implemented as soon as possible to get a safer environment.
Thanks 😊

Ria Talwar

Indeed….a very very informative article, thus acting as an eye opener for the society. Such a valuable information. Thank you.

Dhriti

Very informative and suggestions are really useful and must be implemented by the hospital.

Zuhal kargar

Very good informative and true information. In a high technology country this is a heartbreaking news for me.
I wish this article wake up the higher position people and should be taken into immediate consideration especially in the time of a dangerous virus. Thank you for sharing this article.🙏

Jaspreet

Thank you for your comment, Zuhal. Yes, sometimes it is frustrating to know about the deficiencies in the system. But, there is no need to lose heart. India is one of the topmost medical tourism destinations due to our talented doctors and state-of-art medical infrastructure. However, having efficient ventilation systems in our hospitals escaped the attention of administrators and hence this article.

Piyush

This was very inspiring .

Anuska Gupta

This is very much inspiring and eyes opening article. It is showing out a real picture of our system.

Avni

A very knowledgeable article making us aware of the situation and on indoor air quality. Thanku for making us aware . I hope this article would bring some change and saves lives of many people. Suggestions given by you are the real demand of the present scenario and these should be implemented to get a safer environment.

Diya

Very informative and very well written article.

khushi

this is very useful information for us.. its really make us aware about these conditions …the portable air purifier should be use in hospital as it os necessary ….this advice should be come in action specially in this pendemic time. …this is amazing!!!!!

Deepali Sharma

The issues discussed in this article are so serious but they are so unknown. I am sure 90% of the Indians were not even aware about this .I am sorry for your loss sir. Thankyou for digging into this topic and writing about it in a very understandable language.

Jaspreet

Thank you, Deepali. I agree with you on the seriousness of the poor quality of indoor air in ICUs. Ensuring good indoor air quality improves the health of the patients and is a huge cost saving for the patients and the hospital administration.

Kriti Kaur Bhatia

Very effective and mind boggling article.

Prakriti Chaudhary

Informative article👍

Jaspreet

Thank you, Kriti.

Ananya Madan

It’s really informative and the hospitals as well as the government should take part in implementing these things

Jaspreet

Agree with you, Ananya!

Khushi Goyal

Wonderful and very knowledgeable article. Got to about eye-opening scenarios prevailing in the country n effective medical infrastructure has become a need seeing the present pandemic situation.

jesica garg

this article was an eye opener to the ways hospitals (ICUs in particular) are cheating the very patients they serve.
Thankyou for this article, sir. hope the article raises enough awareness for the system to change for all of our betterment.

Jaspreet

Thank you for the comment Jesica! I won’t be calling it cheating, but the governments and hospital administrations have failed to realize the importance of good indoor air quality in managing patients’ health. In fact, we have also neglected the impact of air quality on our health. We have all taken for the fact that nothing could be done on the air we breathe.

jesica garg

that is so true. thanks again for the article!

Lavish

Very informative article.

Jaspreet

Thank you, Lavish

Kirandeep Kaur

It was a very informative article in the time when we all are suffering from this pandemic. Very good efforts of you sir

Jaspreet

Thank you, Kirandeep

Jasmine

Must dessiminate everywhere !

Jaspreet

Thank you, Jasmine. Please forward and share it with your family and friends. We provide free access to the AIR magazine articles to ensure that the general public can be made aware of air quality issues and bring to them state-of-the-art technologies that improve the quality of the air we breathe.

Harsimran Kaur

This was Very informative.Thankyou for such an informative article sir.Very informative and something that should be taken into immediate consideration especially now when we all suffering through pandemic.

Urmila Chakraborty

Clean air is an essential requirement for human survival. It was very shocking to know about such poor air quality in such sensitive areas like ICUs. This article is indeed very helpful in highlighting such a grave issue in an informative manner.

Akshi kanta

Its hard to believe that The conditions of our hospitals is damn miserable. Its the place , which requires the best techniques and betterment. Because the life of many people is guaranteed here. So, should be properly ventilated and cleaned.

Surbhi

Sir this article was very informative and we hope for the upgradation of the system in hospitals.

Ananya

This information is very educative. The conserned authorities shouldn’t play with life of their patients like this. They must ensure proper air quality and other necessary services to their patients. Not only authorities, we are also responsible to check if our loved ones are given good care at these places and in these situations. We need to give importance to the value system and make hospitals a secure and reliable place. The situation mentioned in the article is eye opening not only to hospitals and staff but also to all of us.

harmanpreet

So well said⭐️And it is so informative and inspiring

Rhythm Kalia

It’s heartbreaking to know about the condition of our hospitals and it’s very informative and helpful.

Loveleen

Very inspiring article

Mannat

In this study, the air around patients hospitalized with COVID-19 was frequently contaminated with SARS-CoV-2 RNA but rarely with viable viruses. The available data suggest that COVID-19 requires particular conditions to be transmitted through the air (such as AGPs), leaning toward the effectiveness of surgical face masks in most circumstances. High viral loads found in toilets and/or bathrooms, staff areas, and public hallways argue for a careful consideration of these areas for the prevention of COVID-19 transmission. However, the presence of viable viruses should be primarily considered, given that it is a required link for the potential of cross-transmission. This was very inspiring to all of us..Thank you..🙏

RITIKA

This is very imaginative, inspiring and wonderful article

Vidhi

It was a very informative article which open our eye regarding the careless system of ICU’s and hospitals.

Muskan Narula

Thank you so much for such an informative article.
This is very inspiring.
Thank you for making us aware about this all .

Sam

This really needed to be concerned specially in this pandemic conditions. This really a great topic.

Hiya

A very well written article
An eye opener that brings out the truth of hospital. Suggestion given by you are eye opener about the current scenario.

Anshika

Very informative and somenthing that should be taken into immediate consideration as we all are suffering through pandemic ….

Muskan Batra

A really really appreciate.for opening the eyes towards the patient in the ICU. By the
irresponsiblity of us sometimes ,someone lost their life.hopefully, by this the people should understand.

Raimon Tiwana

Very well written and informative.

Siya Chauhan

This time is very critical time we need to implement social distancing in hospital and everywhere now more than ever knowing that people here will be more susceptible to die from covid-19.

Anika

Thank you for such an informative article sir! I hope, these measures are put into effect at the earliest.

Akshika jain

Its very inspiring and informative.

Tranam

It is very valuable article. The suggestions are really good👍🏻. Such things have become really important nowadays .

Ridham

This was a very crucial information that we all need to know. Thank you for this information.

DEEPTI

Coronavirus outbreak has challenged the economic, medical and public health infrastructure of India and to some extent of other countries especially, its neighbors. Time alone will tell how the virus will impact in our life. More so, future outbreaks of viruses and pathogens of zoonotic origins are likely to continue. Therefore apart from curbing this outbreak, efforts should be made to devise comprehensive measures to prevent future outbreaks of zoonotic origins.

Shruti Gupta

This is an eye opening article. It brings out the whole conditions of our iCUs and hospitals. This article aware us about so many things which we always take care but we didn’t realise tha we are ignoring all this. Thank you for making us aware of the situation which we were thinking is good for us and our family but it’s not. I hope this article help many of us to know the exact situation and how to improve all these.

Lubhanshi

This article opened the eyes of many because most of the people Don’t even know that what is the Quality of air in icu’s…. for me, this article was very informative and provided me a lot of true information .

Antriksh

This initiative must be taken as these are inexpensive and purifies the air . Thankyou for providing us the true picture of ICU facilities .

Drishti

Quite informative specifically for me as i lost my family member in these crisis and now learning about the conditions in the hospital this made me more aware

Simar

Thank you sir ,you have given this information of you own through this article from which we could come to know about this fact, its very informative.
Thanks a lot!

Amisha

This was quite depressing to know about the present condition of our country’s hospital ICU’s as when a person is hospitalised his /her life is being put at stake , so he /she deserves the best treatment . But , at the end of the day , our medical science is enhancing its reach day by day , so I believe that one day or the other , we’ll surely come up from these airborne diseases /infections in ICU’s . This article was truly eye opening ……….

Shaily Singh

Hope this will improve the conditions we are going through. Mentioned suggestions should be taken asap. Its the need of the situation.

Aditi

Really Informative article. I really liked the details involved in every part of it. It not only gives an insight to the situation in hospitals but also makes you aware of many causes hence, which definitelty alerts us and will help us take preventive measures and changes in future.
I really appreciate your efforts Sir.

Jaspreet

Thank you for liking the article, Aditi!

Hanshika

This is very informative article making us aware of the situation and on indoor air quality.

Jaspreet

Thank you, Hanshika

Naina Goyal

This article was truly worth reading,as these suggestions really need to be applied.But on the same side,I feel very sad for our hospitals as proper guidelines are not being followed among most of them. Also this situation is not being focused by the government too. I hope this article will bring the necessary change in our society.

Jaspreet

Thank you for the encouragement, Naina! I hope voices like ours are heard and, at the same time, efficient air purification technologies are integrated into the system.

Shikha

After reading this, my view is that this is Very informative and something that should be taken into immediate consideration especially now when we all suffering through pandemic.

Jaspreet

Thank you, Shikha. Voices such as your matters!

Preeti Panchal

Thank you for making us aware of situations that we thought were the best for us. It was really an informative and knowledgeable

Jaspreet

Thank you, Preeti