Journal of Hospital Infection (1991) 19, 63-66 WORKING PARTY REPORT Principles of design of burns units: report of a Working Group of the British Burn Association and Hospital Infection Society* Accepted for publication 5 August 1991 Summary: The overall design of burns units will depend on the required size and available finance. The Working Party has considered the optimal location and specific requirements of a unit, including dressing, operating and isolation rooms, intensive care and ancillary facilities. Various possibilities for ventilation systems in these areas have also been discussed. Keywords: Burns unit; design; isolation; ventilation facilities. Introduction The principles of prevention of infection in burns were described by Colebrook in 1950.’ These principles are still relevant today, although modifications based on increased knowledge of the spread of organisms and new antimicrobial agents have been introduced. Colebrook and his colleagues also described the requirements for a ventilated dressing room.*p3 Spread by contact is now considered to be more important than airborne spread, but it is accepted that patients with extensive burns require protective isolation before the burns become infected, and source isolation if they become infected. Since it is difficult to determine when infection occurs, it is suggested that these patients should be provided with a system of combined source and protective isolation.4 Little information has been published on the design of modern burns units, but the problems of infection control in burns were reviewed in a symposium in 1985.’ Site A major burns unit should, if possible, be part of a Teaching or District General Hospital. A ground floor location is preferred, but not essential. The unit should ideally be part of a trauma centre with intensive care facilities since burns patients may also have multiple injuries; at the least, intensive care facilities should be available in close proximity to the burns unit. Ready access is needed on the hospital site to other specialist skills * Members of the Working Party: G. A. J. Ayliffe K. C. Judkins, J. A. D. Settle, P. J. Wilkinson. (Chairman), J. C. L awrence (Secretary), 0 1991 The Hospital 019556701/91/090063+04003.00/0 63 E. M. Cooke, Infection Society 64 Design of burns units especially renal dialysis, and full laboratory and transfusion facilities. Burns units may be adjacent to other units, such as plastic surgery, provided that there is physical separation, no direct airflow between the burns unit and other areas, and no uncontrolled exchange of staff. Access to physiotherapy, occupational therapy, and dietetics will be required, also psychology services. Requirements of unit Spread by contact is the major route of transmission of infection in the burns unit. Good infection control discipline, particularly handwashing, is more important than complex air conditioning, as is adequate space. The majority of units in the UK contain lo-20 beds. In general, single-bedded rooms and two- to four-bedded bays are needed, but the actual number will be calculated on the anticipated work load. Internal flexibility, e.g. readily removable partitioning, is highly desirable. Wash-handbasins should be provided adjacent to all beds. Three or four of the single rooms should be large (5 x 4m, though 5 x 5 m would be better), and should be equipped to intensive care standards for the management of large burns. These rooms could also be used to isolate infected patients if required. Depending on the size of the unit, a number of other single rooms should be available for the isolation of infected or disturbed patients and these require minimal additional facilities apart from a wash-handbasin and an extractor fan. However, at least half of the single rooms should be, fitted with a toilet and shower. The latter facilities should also be fitted in the twoand four-bedded areas if possible. A major wound dressing facility is essential. This needs to be large, at least 5 x 5 m though 7 x 7 m would be preferable. A dedicated operating theatre is also necessary and this should be .at least the same size as the dressing room. It needs its own ventilation system, double, or preferably, triple lighting and full piped anaesthetic gases, including compressed air at 400 KPa and 700 KPa (the latter for power dermatomes). All these specialized rooms need power sockets, together with provision of piped gases. The ambient temperature of the unit should be maintained at 22-25°C. that infra-red High temperatures, e.g. 3O”C, are not needed, provided heaters are available for specific patients and in theatre/dressing rooms. Ventilation Although the air is not a major route of spread of infection in burns patients, it is generally agreed that a ventilation system is necessary for the operating, dressing and intensive care rooms. A particular problem with burns patients is that both protective and source isolation facilities are required at the same Design of burns units 65 time. A balanced air control system would be optimal but is difficult to attain in practice. Air should not enter these rooms unless filtered, and as the patients may also be infected, air should be discharged directly to the outside and not to other parts of the unit. The following options should be considered for intensive care rooms: (1) Filtered air from a common corridor to individual rooms fitted with an extraction system to maintain them at a negative pressure. (2) Filtered air at positive pressure into individual rooms, extracted in the corridor outside each room. (3) Filtered air at positive pressure into individual rooms and extraction of air from a lobby which separates the room from other parts of the unit. (4) Filtered air at positive pressure into individual rooms, extracted directly to the exterior, balanced if possible. Although option 3 is the most efficient, a separate lobby or anteroom may be undesirable, since patient observation and access to rooms may be restricted and it may take up space unnecessarily. The other options all have possible deficiencies, but in practice should be satisfactory. Option 1 is probably the compromise option of choice if a balanced system (option 4) cannot be provided. A system with an individual lobby and an extraction system is required for the operating theatre and the dressing room, particularly if these are interchangeable, e.g. in small units. The air supply to the operating room can be conventional (i.e. 20-25 changes h-‘, filtering to a particle size of 5 ltrn).(j A similar standard should be applied to dressing rooms since rapid clearance of bacteria from the air is required between patients. A lower air flow (to provide 10 changes h-‘) is sufficient for intensive care rooms. Other single rooms used occasionally for the isolation of infected patients can be provided with an extraction system only (e.g. a window fan). No lobby is necessary. This is adequate for dressing an individual patient in his/her own room. Recommendations are summarized in Table I. Table I. Summary of recommendations on design of burns units 1. Burns units should be part of a Teaching or District General Hospital and preferably adjacent to an Intensive Care Unit. 2. Internal flexibility of room space is desirable and ample storage space is essential. A wash-handbasin should be provided adjacent to each bed. 3. A dedicated dressing room and operating theatre are essential in large burns units. Filtered air should be provided at 20-25 air changes h-‘. A lobby is required separating the dressing room and theatre from the main unit. 4. At least two large single rooms should be equipped to intensive care standards and provided with filtered air at 10 or more air changes h-i. A lobby or air lock with air extraction is desirable but not essential. 5. Air from ventilated rooms should be extracted to the exterior. 6. Other single rooms with an extraction fan or system should be available for patients requiring source isolation. 66 Design Other of burns units requirements Specialized beds, cots for children and equipment appropriate to a specialized graded care unit are required. An on-site biochemistry and haematology laboratory is necessary unless the existing hospital facility can guarantee a rapid response time (i.e. minutes). As a minimum, a facility for blood gas measurement is needed. Burns units require above average storage space, at least equivalent to an extra bed space for every bay. There are no special requirements for food, but a small kitchen may be considered desirable, particularly if provision for baby feeding is required. Waste should be sealed in plastic bags and treated according to hospital policy. Double bagging is not necessary. An adequate storage area for waste bags should be provided, but a separate disposal corridor is unnecessary. Waste chutes should be avoided. A bed-pan washer/disinfector and possibly a washing-up machine should be provided. Both should reach a temperature (e.g. 80°C) suitable for disinfection. A bedpan macerator is an alternative to a washer provided it is well maintained and drainage is satisfactory. Baths can be a source of infection. In general, large baths which are difficult to clean, or with jacuzzi and similar recirculating systems which are difficult to disinfect, should be avoided. Bathroom air should be extracted to the outside. A staff rest area is essential. There should also be good staff changing facilities. No special arrangements are required for visitors. Other facilities, e.g. offices, stores and seminar rooms, will also be required, but will not be considered in this document. References Colebrook L. A New Approach to the Treatment of Burns and Scalds. London: Fine Technical Publications 1950. Bourdillon RB, Colebrook L. Air hygiene in dressing rooms for burns or major wounds. Lancet 1946; 1: 561-565, 601-605. Colebrook L, Duncan JM, Ross WPD. The control of infection in burns. Lancet 1948; 1: 893-899. Lowbury EJL, Ayliffe GAJ, Geddes AM, Williams JD, Eds. Control of Hospital Infection: A Practical Handbook London: Chapman and Hall 1981 (revised edition in press). GAJ, Lawrence JC, Eds. Symposium on Infection Control in Burns. r Hasp Infect 5. Ayliffe 1985; 6 (Suppl. B): 3-66. Engineering of Operating Departments: A Design Guide. Inter-authority 6. Ventilation Working Group No. 10. London: DHSS 1983.
