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Hygiene requirements for health-care facilities

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Hygiene requirements for health-care facilities RNDr. Sylva R dlov , Ph.D Franti ek Ko ek, M.D., PhD. Third Faculty of Medicine, Charles University, Prague, D1 – PowerPoint PPT presentation

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Title: Hygiene requirements for health-care facilities


1
Hygiene requirements for health-care facilities
  • RNDr. Sylva Rödlová, Ph.D
  • František Kožíšek, M.D., PhD.
  • Third Faculty of Medicine, Charles University,
    Prague, D1
  • 2014

2
Contents/structure
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  1. Hospital hygiene
  2. Building, technical and operational requirements
    for health-care facilities
  3. Infectious and non-infectious hospitalism and its
    prevention(nosocomial infections, hospitalism)

3
Part I
  • Hospital hygiene

4
Factors influencing health of humans
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Internal (heredity).
  • External environmental and occupational
    conditions, life style, health care.
  • Health of population is influenced
  • Health-care ? 20
  • Environment ? 20
  • Life style ? 60 .

5
Health-care facilities (HCF)
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Environment of specific and multiple risks
  • Environment shared by specific group of people
  • Environment of specific exposure routes
  • Environment, where treatment has priority over
    prevention and occasional rapid interventions to
    save human life push away standard use of
    protective aids or rules of work safety

6
Persons x risks
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Biological factors (pathogens, opportunistic
    pathogens)
  • Chemical factors (pollutants)
  • Physical factors (ionizing and non-ionizing
    radiation, noise, lighting and microclimate,
    injuries)
  • Ergonomic factors
  • Psychological and organization factors
  • Patients
  • Medical staff
  • Other staff
  • Visitors

7
What is hospital hygiene ?
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Systematic and continuous use of complex of
    hygienic and epidemiological rules in specific
    conditions of HCF
  • Protection of patients not to leave HCF more
    sick then before
  • The goal is not only to protect patients, but
    also the staff and visitors and also environment
    (before harmful impacts of HCF)

8
Tasks of hospital hygiene
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Preventive tasks? to develop standard working
    procedures to ensure hygienic and epidemiologic
    aspects of HCF? to coordinate programs to lower
    the risks of hospital infections? to consult
    (new) building and reconstructions of HCF from
    hygienic point of view? occupational safety of
    medical staff? etc.

9
Tasks of hospital hygiene
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Intervention and surveillance? to control
    compliance of SOP (standard operating
    procedure)? to supervise disinfection procedures
    and sterilisation centres? to control
    microbiological quality of hospital indoor? to
    monitor cleaning practice? to monitor waste
    management? to monitoring quality of food and
    its proper handling ? etc.

10
Organization of hospital hygiene
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Department of hospital hygiene in HFC
  • State supervision (Department of Epidemiology of
    Regional Public Health Authority)? to control
    compliance with legal requirements (Public
    Health Act)? to approve operational rule?
    preventive surveillance? to investigate
    outbreaks and defined infections in HCF

11
Expert associations
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Society for hospital epidemiology and hygiene of
    the Czech Medical Association
  • Deutsche Gesellschaft für Krankenhaushygiene
    (DGKH) German Society for Hospital Hygiene
  • Swiss Society for Hospital Hygiene (SGSH)
    Schweizerische Gesellschaft für Spitalhygiene
  • Austrian Society for Hygiene, Microbiology and
    Preventive Medicine (ÖGHMP)
  • Etc.

12
Part II
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Building, technical and operational requirements
  • for health-care facilities

13
Legal requirements on construction, technical and
other equipments, indoor environment, operation
etc. in the Czech Republic are set up through
dozens of acts/decrees
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Building Act
  • Spatial Planning Act
  • Fire safety safety rules (act decree)
  • Material and technical equipment of HCF (decree)
  • Occupational Safety Act
  • Public Health Act
  • Act on Pharmaceuticals
  • Radiation Protection Act
  • Waste Management Act
  • Etc.

14
Construction technical requirements on HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
15
Construction technical requirements on HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Spatial (city) planning
  • Architectonic aspects of construction
  • Building materials and furnishings
  • Water supply and sanitation
  • Heating, ventilation, air-conditioning,
    microclimatic conditions, noise (coming from
    HCF), lighting etc.
  • (Waste management)

16
Spatial planning
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Environmental factors (terrain, orientation to
    cardinal points, climatic conditions, sources of
    pollution etc.)
  • Geological factors (stability, hydrogeology)
  • Urbanistic factors (access, public transport,
    demography of catchment area)
  • Spatial factors (possibility of expansion)
  • EIA (Environmental Impact Assessment)

17
Architectonic aspects of construction
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • New building x reconstruction of older building
  • Structure and capacity of HCF
  • Hospital pavilions x one big building
    (mono-block)
  • Compatibility with requirements on equipment and
    operation (e.g. separation of clean and unclean
    operations in place or in time)
  • Economical possibilities

18
Building materials and furnishings
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Building materials should not be source of
    pollution
  • Materials and equipments must be easy to clean
    and maintain.
  • Floors, stairs, doors, elevators, windows -
    safety (e.g. doors of WC in patient rooms have to
    be openable from outside etc.)

19
Material and technical equipment of HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Czech Decree No. 92/2012 Coll., on requirements
    on minimum material and technical equipment of
    health-care facilities
  • All kinds of HCF hospitals, outpatients clinics,
    one-day surgery clinics, spa facilities,
    pharmacies, ambulances, residential care

20
General requirements
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • 1. Construction and technical arrangements have
    to allow functional and safe operation of HCF.
  • 2. HCF must
  • constitute operationally closed and functional
    unit,
  • be situated in non-residential premises complying
    to general building requirements,
  • be supplied by drinking water, hot water
    available,
  • be equipped by sewerage
  • have system of ventilation and heating
  • have electricity connection

21
General requirements
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • 3. Rooms for
  • a) manipulation with biological material,
  • b) surgeries, or
  • c) endoscopic interventions or higher risk of
    infections
  • must have washable surface of walls min. up to
    180 cm. All furniture and floors should be easily
    to clean and disinfect.

22
Other requirements on outpatient clinics
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Minimum (floor) space for doctors office (13
    m2), waiting rooms and operating rooms
  • Requirements on basic equipments of doctors
    office (and specialized medical offices for all
    fields), hospital units, etc. etc.

23
Water in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
24
Water in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Obligatory supply of tap drinking water
  • Air- conditioning and hot water quality
    important to prevent infections through
    inhalations and inoculations
  • Rehabilitation pools, spa bath
  • Requirements on ultra-clean water in HCF

25
Water supply in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Two possible modes of operation
  • Operator of HCF customer water from public
    supplies or from another (legal) person
    delivering drinking water for public use (most
    usually) or
  • Using own source of water
  • Different obligations
  • Plumbing (care) as minimum obligation for both
    options

26
Operators of HCF as customer
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Less obligations
  • Own, additional water treatment in HCF
  • ? not necessary in most units,
  • ? ultra-clean water sometimes required in
    special departments (hemodialysis, pharmacy,
    sterile water to wash endoscope and other
    medical tools).
  • ? sterile water for patients with serious
    deficit of immunity

27
Hot water and air-conditioning system
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Habitat for some ubiquitous microorganisms
    (Legionella, NT mycobacteria, Pseudomonas,
    amoebae) opportunistic pathogens
  • Risk of infection inhalation (aerosol) and
    inoculation (e.g. eye washout)
  • Sensitive population immunocompromised persons
  • Most often risks legionellosis (pneumonia) or
    Pontiac fever caused by bacteria Legionella
    pneumophila

28
Rehabilitation spa and pools
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Requirement on water quality, but also on
    treatment and recirculation of water
  • Czech Rep. Decree No. 238/2011 Coll.
  • Risks microbiological and chemical (disinfection
    by products)

29
Protection from adverse effects of noise in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
30
Protection from adverse effects of noise
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Public Health Act and lower regulation
  • Hygienic limits of noise and vibrations (various
    protected areas and buildings day night 600
    2200 and 2200 600)
  • Sound
  • mechanical wave composed of frequencies within
    the range of hearing and of a level sufficiently
    strong to be heard,
  • Noise
  • unwanted sound.

31
Protection from adverse effects of noise
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Health risks of noise specific, non specific
  • Specific hearing impairment
  • Non-specific hypertension, ischemic heart
    disease, annoyance and sleep disturbance (?
    disturbing of healing and recovering process),
    changes in the immune system (?)

32
Protection from adverse effects of noise
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Outdoor protected area hygienic limit basic
    level of acoustic pressure A LAeq,T (50 dB)
    corrections
  • Indoor protected area (buildings) hygienic limit
    basic level of acoustic pressure A LAeq,T (40
    dB) corrections

33
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
Noise limits for indoor protected areas in HCF
Protected indoor area time Correction (in dB)
Hospital room 6.00 22.00 22.00 6.00 0 -15
Operatingl theatre While in use 0
Docors office, consulting room While in use - 5
Waiting rooms, entrance halls, restaurants, café 15
34
Ventilation of HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
35
Ventilation of HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Governmental order 361/2007 Coll. (occupational
    safety)
  • Workplace has to have sufficient ventilation (air
    exchange) either through natural means or with
    forced ventilation
  • Minimum amount of outside air a) 50 m3/hour for
    employees working in category I or IIa

36
Microclimatic (indoor) conditions
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Decree of Ministry of Health 6/2003 Coll.

37
Microclimatic (indoor) conditions of HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Temperature? 24,0 ? 2,0 /warmer season/ ? 22,0
    ? 2,0 /colder season/
  • Air flow? 0,16 0,25 m.s-1 /warmer season/ ?
    0,13 0,20 m.s-1 /colder season/
  • Relative air humidity? lt 64 /warmer season/
    ? 30 /colder season/
  • Relative humidity in room of patients should be
    higher than 55

38
Indoor microbiological quality HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Visible moulds and fungi on walls unacceptable
  • Concentration of bacteria (or moulds) 500 CFU /
    1 m3 air
  • This limit not relevant for rooms requiring
    higher indoor air quality !

39
Clean rooms in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
40
Clean rooms in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Higher air quality required (e.g. in operating
    theatres, intensive care units, ARU, sterile
    tents etc.)
  • Number of particles (solid aerosol 0,5 µm and 5
    µm) limited and rooms are designed in special
    ways and equipped by special technical means
  • Nine categories (classes) according to the
    standard EN ISO 14 644-1 Classification of Air
    Cleanliness

41
Classes of cleanliness (EN ISO)
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
42
Recommended classes for some rooms in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
Room Class
Superaseptic operational theatre 5-6
Background of superaseptic o.t. 7
Aseptic and septic o.t. 7
Background of aseptic and septic o.t. 8
Surgery room 8
ICU burns, transplantations 5-6
CU post operational 8
ARU 7
43
Clean rooms in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Treated air - excess pressure
  • Air-condition in supra-aseptic operating theatre
    (laminar air flow above the operating table
    protects the patient)

44
Lighting
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
45
Lighting in HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Health risks? Visual tiredness ? accident at
    work
  • Governmental order 361/2007 Coll. (occupational
    safety) 45
  • Day light, artificial light, mixed light
  • Lighting (intensity) has to be relevant to work
    (illuminance Em)
  • Lighting should not be cause of dazzle (blind)
    unified dazzle indicator (UGRL)
  • Colour rendering index (CRI Ra) is a
    quantitative measure of the ability of a light
    source to reproduce the colours of various
    objects faithfully in comparison with an ideal or
    natural light source

46
Part III
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Infectious and non-infectious hospitalism and
    its prevention(nosocomial infections,
    hospitalism)

47
Nosocomial infections
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • A nosocomial infection, also known as a
    hospital-acquired infection (HAI), is an
    infection (either exogenous or endogenous origin)
    whose development is favoured by a hospital
    environment. It occurs in causal relationship
    with hospital (HCF) stay or medical intervention.
    It may become visible even after discharge from
    HCF.
  • Term nosocomial comes from Greek nosokomeion,
    which means hospital (nosos illness, komeo
    take care about).

48
Epidemiology of nosocomial infections
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • USA about 2 millions patients per year cause of
    death 88,000 persons/year (1995), costs about 4.5
    11 billions USD.
  • France prevalence 6.87 in 2001 a 7.5 in 2006
    (up to 30 at ICU) about 9000 death per year.
  • Italy prevalence about 6.7 (2000), i.e. 450 to
    700 thousands patients per year 4,500 to 7,000
    death.

49
Epidemiology of nosocomial infections
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Czech Republic data on national level not yet
    available ongoing pilot project
  • Brno (St. Anna hospital)
  • ARU (2007-2011) 2925 patients - 570 HAI (19.5)
    total prolongation of hospitalization 410 days/
    2011)
  • Of 570 HAI 31 exogenous, 31 endogenous 38
    not identified
  • 2011 main cause of HAI Klebsiella pneumonie
    (31), Pseudomonas aeruginosa (16).

50
Epidemiology of HAI
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Source of infection (patient, staff, visitors)
  • Transmission route (direct contact, inoculation,
    inhalation, implantation, ingestion)
  • Sensitive human ( patient weakened by primary
    illness)
  • Risk of HAI increase directly with
  • number of invasive interventions,
  • duration of hospitalisation (colonization with
    multirezistant nosocomial strains),
  • spectrum of medication.

51
Spectrum of HAI agents
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Spectrum of agents is changing 1950s mostly
    Staphylococcus aureus 1970s gram-negative
    bacteria (e.g. Pseudomonas aeruginosa) since
    1980s mostly gram-positive bacteria with multiple
    resistance vancomycin resistant enterococci
    (VRE) and methicillin-resistant Staphylococcus
    aureus (MRSA).
  • Microorganisms of low virulence x
    immunocompromised patients.

52
Epidemiological measures
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Hygienic regimen of patients (personal hygiene,
    hospital bedding and dress, placement and
    movement of patients etc.)
  • Regime of care (protective means, washing and
    disinfection of hands, individual single-use
    aids, disinfection and sterilization)
  • Regime of visits (mostly airborne diseases)
  • Czech Decree No. 306/2012 Coll., specifying
    conditions for prevention of origin and
    transmission of infectious diseases and hygienic
    requirements on management of HCF and social care

53
Hygienic measures
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Regime of hospital catering (nutritional and
    hygienic aspects)
  • Cleaning rules (aesthetic and hygienic aspects
    effort for microbiologically safe environment)
  • Disinfection and sterilization
  • Waste management (according to type of hazardous
    wastes)

54
Disinfection and sterilization
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
55
Disinfection and sterilization
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Requirements given by decree 306/2012
  • Levels of disinfection mechanistic cleaning ?
    disinfection ? high level disinfection, double
    disinfection ? sterilization
  • Standard operational procedures
  • Physical methods of disinfections (boiling,
    boiling under pressure, disinfection in special
    machines Tgt 90C, UV irradiation, etc.)
  • Chemical methods of disinfections (agents
    registered according to Biocide Act), mostly
    substances based on chlorine, phenol, iodine,
    quaternary ammonium salts, etc.

56
Disinfection
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • High level disinfection (killing all growing
    stages of microorganisms, but not cysts of
    protozoa or helmints)? chemical sterilization
    in solutions (old term), e.g. solution of 2
    glutaraldehyde for 2-3 hours, Persteril (Acidum
    peraceticum) 0,5 for 10 minutes etc.
  • Tools disinfected with this method are intended
    for immediate use or not more than 8 hours
    storage (covered by sterile drape in closed
    boxes).
  • Process has to be recorded date, name of
    patients, disinfection solution, concentration,
    exposure (time), signature.

57
Sterilization
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Final stage, incl. drying and proper packaging
    and storage
  • Approved physical and chemical sterilization
    procedures (technical standards, e.g. EN 550)
  • Physical saturated steam under pressure, hot
    water under pressure (e.g. for surgery tools for
    immediate use), dry heat, radiation, etc.
  • Chemical formaldehyde, ethylene oxide, etc.
  • Defined expiration time of packaging materials

58
Hygienic requirements on operation of HCF
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Public Health Act (258/2000 Coll. as amended)
  • Czech Decree No. 306/2012 Coll., specifying
    conditions for prevention of origin and
    transmission of infectious diseases and hygienic
    requirements on management of HCF and social
    carePrevention and surveillance of infectious
    diseases Hygienic requirements on management of
    HCF and social care

59
Decree No. 306/2012
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Receiving and principles of care about patients
    in HCF and institutions of social care
  • Sterilization, higher level disinfection,
    disinfection
  • Handling with bedding and dress
  • Cleaning
  • Principles of waste management

60
State supervision / enforcement
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Requirements on material and technical equipment
    of health-care facilities Regional Authority
    Dept. of Health Care
  • Microclimatic conditions, noise, lighting,
    occupational issues, disinfection and
    sterilization, routine operation of HCF
    (cleaning) Regional Public Health Authority
    Dept. of Epidemiology and Dept. of Occupational
    Safety

61
Non-infectious hospitalism
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • any deviation from usual course of disease,
    developing in relation to hospital stay there is
    no infectious cause, but rather in area of mental
    hygiene, social relations, ethic of medical staff
    and other stressors

62
Definition of HOSPITALISM
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • 1
  • a the factors and influences that adversely
    affect the health of hospitalized persons
  • b the effect of such factors on mental or
    physical health
  • 2
  • the deleterious physical and mental effects on
    infants and children resulting from their living
    in institutions without the benefit of a home
    environment and parents

63
Syndrome of hospitalism
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Group of symptoms, which develop because of long
    stay in hospital or similar HCF and separation
    from family it concerns mainly children
  • Symptom apathy, sadness, loss of appetite, lack
    of interest disproportionate reaction of patient
    to his/her environment not interested in
    contacts, sulkiness tearful animosity
  • All these moods may have negative impact on
    health status of patient

64
Important stressors
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Disease (inconvenience, feeling of loss, lower
    self-confidence)
  • Break in current social contacts, isolation
  • Unknown surroundings (isolation, sensorial
    deprivation, impersonal sterile atmosphere,
    unpleasant lighting, noise or bad odour, loss of
    privacy)
  • Change in daily (biological) rhythm
  • Building new social contacts (confidence/distrust)

65
Important stressors
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Anonymity of patient number, diagnosis, but
    loss of name
  • Inadequate information for patients
  • Stay among other seriously ill people. May be the
    first personal experience with death concern
    about own health (death)

66
Hospitalism recognized disease
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Hospitalism appears under adjustment disorders at
    F43.2, in the World Health Organization's
    classification of diseases (ICD-10).
  • F43.2 Adjustment disorders state of subjective
    distress and emotional disturbance, usually
    interfering with social functioning and
    performance, arising in the period of adaptation
    to a significant life change or a stressful life
    event.

67
Prevention of hospitalism
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Physical and psychical activity reading, radio,
    exercise toys for children, colours
  • Reduce negativism
  • Keep patients in good mood
  • Allow visits from family, friends if possible
  • Reduce pains (if there is)

68
Professional behaviour in contact with patient
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • To communicate (talk) with patient, not to treat
    (nurse) him/her with silence
  • To motivate patient, encourage him/her
  • To adjust hospital surroundings to be patient
    friendly
  • Not to exchange special medical information in
    front of patient
  • Show interest about patient
  • Satisfy spiritual needs of patient

69
Professional behaviour in contact with patient
Hospital hygiene Health-care facilities
Infectious and non-infectious hospitalism
  • Ensure adequate information to patients
  • Establish closer contact with family
  • Respect dignity and character of patient
  • Provide feeling of safety to patients
  • Unlimited visiting hours
  • Doctor can become a patient too!

70
Thank you
sylva.rodlova_at_lf3.cuni.cz
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