Intern
ati
o
n
a
l
Jo
urn
a
l
o
f
P
u
b
lic Hea
l
th Science (IJ
P
HS)
V
o
l.4
,
No
.3
, Sep
t
em
b
e
r
20
15, pp
. 145
~151
I
S
SN
: 225
2-8
8
0
6
1
45
Jo
urn
a
l
h
o
me
pa
ge
: h
ttp
://iaesjo
u
r
na
l.com/
o
n
lin
e/ind
e
x.ph
p
/
IJPHS
Microbi
a
l Ai
r Contamin
ation
in An Intensive Care Unit
Chih-Yi Cha
n
g
1
, Liang Tseng
2
, Lu
ng-Shih
Yang
3
1
Civil
and H
y
dr
a
u
lic
Engin
eer
ing
,
Feng
Chia
Uni
v
ersit
y
,
T
a
iwan
2
Department of Architecture,
Fe
ng Chia
Univers
i
t
y
,
Ta
iwan
3
Department of Land
Ma
n
a
gement, Feng
Chia U
n
iversity
, Taiwan
Article Info
A
B
STRAC
T
Article histo
r
y:
Received
J
u
n 04, 2015
Rev
i
sed
Au
g
20
, 20
15
Accepted Aug 30, 2015
Unit la
yout aff
e
cts
ever
y as
pe
ct
of intens
ive c
a
r
e
s
e
rvices
, inclu
d
ing pati
ent
safet
y
.
A previo
us stud
y
has sho
w
n that p
a
ti
ents
adm
itted
to beds
adja
cen
t to
the sink and to
the door of a large
bay
r
oom
had the highest number of
positive b
l
ood
cultur
e
s and
th
e high
est blood
cultur
e
incid
e
n
ce d
e
nsit
y
,
res
p
ect
ivel
y.
Th
e pres
ent s
t
ud
y
m
eas
ures
m
i
crobial a
i
r cont
am
ination in
a
m
e
dical in
tens
iv
e care uni
t of a m
e
dical c
e
nt
er i
n
centra
l
Ta
iwa
n
. Of the 17
room
s, 8 rooms with distinct p
h
y
sic
a
l env
i
ron
m
ental ch
arac
te
ristics wer
e
selec
t
ed. Sam
p
l
i
ng tests were
conduct
e
d bet
w
een Decem
be
r 2013 and
Februar
y
2014
with a microbial air
sampler (MAS-100NT). TSA was used
for bacter
ia co
llection and DG18 for
fungi collection. Th
e overall av
erag
e
bacterial and f
ungal con
cen
tr
ations were 8
3
CFU/m
3
and
69CFU/m
3
,
respectively
.
Th
e
rang
es
were b
e
tween
8-354 C
F
U/m
3
and 0-1468 CFU/m
3
,
respectively
.
A
significan
t d
i
fferen
ce was
found in th
e bacterial
concen
tration (
p
=.005) b
e
tween differ
e
nt roo
m
locations
. The high
est
concen
tration was found in the rooms located at the front
end of the
circu
l
ation (99
CFU/m
3
), while the lowest was f
ound in the roo
m
s located
at
the r
ear
end
of the
ci
rcul
at
ion (55CF
U
/m
3
). Diff
erenc
e
s
in fung
al
concen
trations
for differ
e
nt r
oom
locations did no
t reach statistical
significance. In
addition
,
diff
erences
in bacteri
a
l
and fungal con
centr
ations
for room
s
with differen
t
s
i
nk lo
cat
ions
did not reach s
t
a
tis
ti
ca
l s
i
gnific
a
nc
e.
Even though
the microbial concentrations
g
e
ner
a
lly
complied with
standards,
the results may
help design
ers and hosp
ital
adm
i
nistrators dev
e
lo
p a hea
lthi
e
r
environment fo
r
patients.
Keyword:
I
ndo
or
air qu
al
ity
Int
e
nsi
v
e ca
re
uni
t
Microbial air c
ontam
ination
Un
it layou
t
Copyright ©
201
5 Institut
e
o
f
Ad
vanced
Engin
eer
ing and S
c
i
e
nce.
All rights re
se
rve
d
.
Co
rresp
ond
i
ng
Autho
r
:
Ch
ih
-Yi C
h
ang,
Ph
.D. Prog
ram
in
Civ
il an
d Hyd
r
au
lic Eng
i
neering
,
Feng
C
h
ia Un
i
v
ersity,
N
o
. 1
0
0
,
W
e
nhw
a
R
d
.,
Seatwen
,
Taichu
ng
, Taiw
an
407
24
,
R.O
.
C
.
Em
a
il: ev
ech
an
g11
7@g
m
ai
l.co
m
1.
INTRODUCTION
Int
e
nsi
v
e
care
uni
t
s
(IC
U)
are
speci
al
i
zed
di
vi
si
o
n
s
of
a
h
o
s
pi
t
a
l
w
h
i
c
h
p
r
ovi
de cl
ose m
oni
t
o
ri
ng
an
d
in
ten
s
iv
e
care for p
a
tien
t
s with
life-th
reat
e
n
i
n
g
c
o
n
d
i
t
i
ons
.
As t
h
e m
o
st
f
u
nda
m
e
ntal physical design
fe
ature,
unit layout affects every aspect of in
tensive care services
, includi
ng
patient
safety
[1]
,
[2]
.
The
r
e are
7 ty
pes
of unit layout: ope
n
or Ni
ght
ingale ty
pe
, c
o
rridor
or continental type
,
dupl
ex
or Nuffield
type
, racetra
ck or
do
u
b
l
e
cor
r
i
d
o
r
t
y
pe, co
urt
y
ard t
y
pe, cr
uci
f
orm
or cl
ust
e
r
t
y
pe, and ra
d
i
al
ty
pe [3]
.
H
o
we
ve
r, t
h
ere
i
s
no
sin
g
l
e
b
e
st so
lu
tio
n fo
r an I
C
U
layou
t [1
],
[4
].
ICUs
are
also a type
of
bi
olog
ical clean unit. Microbi
al contam
in
ati
o
n is t
h
e m
o
st in
flu
e
n
tial
param
e
t
e
r am
o
ng i
n
d
o
o
r
ai
r p
o
l
l
u
t
a
nt
s i
n
he
al
t
h
care envi
r
onm
ent
s
. Ai
r
b
or
ne bact
eri
a
a
nd f
u
ngi
are
p
o
t
e
nt
i
a
l
agents for
i
n
fectious diseas
es,
and
t
h
eir c
once
n
trations
m
u
st
meet certa
in
requ
irem
en
ts fo
r t
h
e safety o
f
p
a
tien
t
s, m
e
d
i
cal staff, an
d
v
i
sito
rs. Prev
ious stu
d
i
es
h
a
v
e
sh
own
th
at air
te
m
p
eratu
r
e, realtiv
e h
u
m
id
it
y [5
],
v
e
n
tilatio
n
syste
m
s [6
],[7
], ou
tdo
o
r p
e
n
e
tratio
n
,
and
o
c
cu
p
a
n
t
d
e
n
s
ity [5],[7
], are th
e
main
facto
r
s affecting
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
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252
-88
06
I
J
PH
S Vo
l. 4
,
N
o
. 3
,
Sep
t
emb
e
r
201
5
:
1
45
–
15
1
14
6
conce
n
trations
of airborne
ba
cteria and
fungi. B
r
acco
et al.
fo
und
t
h
at patien
t
s ad
m
itte
d
t
o
b
e
ds ad
j
a
cen
t t
o
th
e sin
k
and
to th
e d
o
o
r of a l
a
rg
e b
a
y
r
oo
m
h
a
d
th
e h
i
g
h
est n
u
m
b
e
r o
f
po
sitiv
e b
l
o
o
d
cu
ltu
res an
d
th
e h
i
g
h
e
st
blood culture i
n
cide
nce
densi
t
y, resp
ectively
[8].
Eve
n
though
be
d-t
o
-be
d
com
p
arison di
d not
reach
statistica
l
significa
nce, the iss
u
e
of be
d location,
sink location and the c
onc
entrat
ion
of airborne
bacteria a
n
d
fungi is
still wo
rth
investig
atin
g
.
Th
erefo
r
e,
th
e presen
t stud
y
m
easu
r
es ai
rbo
r
n
e
b
acterial and
fu
ng
al con
c
en
tratio
n
s
in
an
I
C
U. The k
e
y o
b
j
ectives o
f
th
e study in
clu
d
e
d
:
1
)
to
m
easu
r
e bacter
ial an
d
fun
g
a
l con
c
en
tr
atio
n
s
against curre
nt
standards; 2) to eval
uat
e
t
h
e
im
pact
of ro
o
m
l
o
cat
i
ons an
d si
n
k
l
o
cat
i
o
ns o
n
bact
eri
a
l
and
fung
al lev
e
ls.
2.
R
E
SEARC
H M
ETHOD
2.
1. Sam
p
l
i
n
g
si
te
The st
udy
took
place in an
adult m
e
dical intens
ive
care
unit at a
1500-be
dded m
e
dic
a
l center i
n
cen
tral Taiwan. Th
e layou
t of th
e un
it is th
e m
o
d
i
fied
op
en
o
r
Nigh
ting
a
le typ
e
, wh
ich
t
h
e u
n
it can
b
e
d
i
v
i
d
e
d
in
to
two
areas, th
e p
a
tien
t
area and
th
e sup
p
o
r
t serv
ices
a
r
e
a
. The
patient
area ha
s a ce
ntral nurse
station a
nd
p
a
tien
t
b
e
d
s
on th
e p
e
rim
e
ter. Th
e sup
port serv
ices area is
located a
d
jace
nt to the
pa
tient area, a
nd t
h
ere is a
cor
r
i
d
or c
o
nne
ct
i
ng t
h
e t
w
o
a
r
eas. F
r
om
t
h
e 17
pat
i
e
nt
ro
o
m
s
i
n
t
h
e u
n
i
t
,
8 sam
p
l
i
ng r
o
o
m
s were sel
ect
ed o
n
t
h
e basi
s
of r
o
om
l
o
cat
i
ons and si
nk l
o
cat
i
o
ns as s
h
o
w
n i
n
Fi
gu
re 1
.
W
i
t
h
re
gar
d
t
o
ro
o
m
l
o
cat
i
ons, R
oom
A,
D, a
n
d
F are located at a
turn
of the
ci
rculation; R
o
om
B and
H a
r
e l
o
cated
at th
e
fron
t end
o
f
th
e circu
l
atio
n;
Room
C and G are located i
n
the middle of the circ
ulati
on. Com
p
ared
to other
select
ed
room
s, the entra
n
ce of
R
oom
E i
s
sli
ght
l
y
off t
h
e m
a
i
n
ci
rcul
at
i
o
n
.
W
i
t
h
re
gar
d
t
o
si
nk l
o
cat
i
o
ns,
R
oom
A and
E have a c
o
r
n
e
r
si
nk
installed inside
the patient room as
shown in Figure 2; the other 6room
s
share sinks
with an
adjacent room as
sho
w
n i
n
Fi
g
u
r
e
3. The ave
r
a
g
e di
m
e
nsi
ons
of t
h
e sel
ect
ed
ro
om
s are 3.5
m
(L) x3.
7
5
m
(
W) x 3m
(H),
gi
vi
n
g
an
av
er
ag
e
vo
lu
m
e
o
f
3
9
.375m³.
Air
v
e
n
tilatio
n is p
r
ov
id
ed
by a cen
tral air
co
nd
itio
n
i
ng
syste
m
with
HEPA
filter in
st
alled
.
Th
e air
chan
ge
rat
e
i
s
5.
2/
h.
The
r
e i
s
a cei
l
i
ng-m
o
u
n
t
e
d ai
r
o
u
tlet an
d
wall-m
o
u
n
ted
return
air i
n
let in
ev
ery patien
t
ro
om
. Uni
t
m
a
i
n
t
e
nan
ce i
n
c
l
udes a
dai
l
y
hi
g
h
-l
e
v
el
-
d
i
s
i
n
fect
i
o
n p
r
oc
edu
r
e
usi
n
g s
odi
um
hy
poc
h
l
ori
t
e
,
m
ont
hl
y
fl
oo
r
waxi
ng
, a
nd a
st
eri
l
i
zat
i
on p
r
oce
d
ure
wi
t
h
sodi
um
hy
poc
hl
o
r
i
t
e
an
d ul
t
r
avi
o
l
e
t
radi
at
i
o
n
o
n
chan
ges
o
f
occ
upa
nt
.
Fi
gu
re
1.
R
o
o
m
l
a
y
out
an
d s
a
m
p
l
i
ng
ro
om
s i
n
t
h
e
m
e
di
cal IC
U
2.
2. Sam
p
ling proced
ure
Microbial air
sam
p
les from
the 8
selected room
s were collected
between Decem
ber, 2013 and
Febr
u
a
r
y
,
2
014. Du
r
i
n
g
th
e
sam
p
l
i
n
g
p
e
r
i
o
d
,
a r
o
o
m
w
a
s r
a
nd
o
m
ly p
i
ck
ed
an
d m
o
n
ito
r
e
d
f
o
r
two
con
s
ecu
tiv
e
days eve
r
y week (m
ostly Monday and
Tues
day).
At
each sam
p
ling point, air sa
m
p
les were taken at
6
diffe
re
nt tim
e
slots each
day: 9:00,
11:00, 13:00, 15:00, 17:00
a
nd 19
:00.
A m
i
crobial air sam
p
ler –
MAS-
100NT was
us
ed for airborne
bacter
i
a
an
d f
u
n
g
i
col
l
ect
i
o
n
.
The
devi
ce
was o
p
er
at
i
ng
at
10
0 L/
m
i
n for
2.
5
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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PH
S I
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SN
:
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2-8
8
0
6
Mi
crobi
al
Ai
r
C
ont
ami
nat
i
o
n
i
n
an
I
n
t
e
nsi
v
e
C
a
re
U
n
i
t
(
C
hi
h-Yi
C
h
a
n
g
)
14
7
minutes. T
r
ypt
i
c Soy
Aga
r
(TSA)
was
use
d
for
bacter
ia
co
llectin
g
and cu
lturing
.
Dich
loran Glycero
l
-18
(DG18),
wh
ich
is m
o
re effectiv
e in
co
llectin
g
fung
al
co
l
o
n
i
es i
n
a cen
t
r
al-air-con
d
ition
i
ng
ho
sp
ital settin
g
[9]
,
was
use
d
f
o
r f
u
ngi
col
l
e
c
t
i
ng an
d cul
t
u
r
i
ng. B
e
t
w
ee
n measurem
ents, the sa
m
p
ler was cleaned wit
h
75%
et
han
o
l
.
A
f
t
e
r
fi
el
d sam
p
l
i
ng,
TSA a
g
ar
pl
at
es were i
n
c
uba
t
e
d at
3
0
Ԩ
f
o
r
2 day
s
, an
d
D
G
1
8
a
g
ar
pl
at
es were
in
cub
a
ted
at 25
Ԩ
f
o
r
5 day
s
.
Gram
'
s
st
ai
n
was pe
rf
orm
e
d t
o
cl
assi
fy
bact
eri
a
and f
u
n
g
i
duri
n
g col
o
ny
cou
n
t
s
as show
n in
Fig
u
r
e
4
.
Th
e ai
r sam
p
ler
was
factory calib
rated b
e
foreth
e sam
p
lin
g
test. To ensure p
a
tien
t
s cou
l
d g
e
t
prop
er
rest and to avoid disturbing st
aff activities, t
h
e sam
p
le
r wa
s placed at the
end of the
pati
ent be
d as
shown i
n
Fi
gu
re 5
.
The i
n
l
e
t
of m
i
crobi
al
ai
r sam
p
l
e
r
was set
at
100
cm
above t
h
e f
l
oo
r, t
h
e l
e
vel
of t
h
e b
r
eat
hi
n
g
zo
n
e
o
f
a lyin
g p
a
tien
t
.
Fi
gu
re 2.
C
o
rn
er
sink
Fi
gu
re 3.
S
h
are
d
sink
Fi
gu
re
4.
G
r
am
'
s
st
ai
n
Fi
gu
re 5.
Sam
p
l
i
ng poi
nt
3.
RESULTS
A
N
D
DI
SC
US
S
I
ON
3.
1. Ai
rb
orne bac
t
eri
al
and
fun
gal
co
ncen
tra
t
i
o
n
s
The hi
g
h
est
va
l
u
e of
bact
eri
a
l
co
nce
n
t
r
at
i
o
ni
nt
he
sam
p
l
i
ng ro
om
s
wasbel
o
w
15
0
0
C
F
U/
m
3
as shown
i
n
Tabl
e
1, t
h
e
m
a
xim
u
m
val
u
e l
e
gi
sl
at
ed
b
y
t
h
e En
vi
ro
n
m
ent
a
l
Prot
ect
i
on
A
d
m
i
ni
st
rati
on
(EP
A
) i
n
T
a
i
w
an.
Th
e to
tal
b
acterial co
ncen
trati
o
n was 83
CFU/m
3
, wh
ich
al
so
m
e
t th
e stan
d
a
rd
set
b
y
th
e Ko
rean
Min
i
st
ry of
Env
i
ron
m
en
t fo
r
h
ealth
care facilities
(8
00
CFU/m
3
) an
d
th
e Ex
cellen
t
C
l
ass o
f
In
doo
r
Air Qu
ality in
Offices
and
Public Places
issue
d
by the
E
nvi
ronm
e
n
tal
Protection De
partm
e
nt in
Hong-Kong (500
CFU/m
3
).
T
h
e
avera
g
e val
u
es
for R
o
om
A-F were bel
o
w
10
0 C
F
U/
m
3
, c
a
tegorizing the
m
as c
l
ean according to the criteria
for ind
o
o
r
air q
u
a
lity d
e
fined
b
y
th
e Sp
an
ish
Asso
ci
atio
n
o
f
Hosp
ital
En
g
i
n
eeri
n
g
(AEIH).
Th
e
av
erage
values f
o
r Roo
m
G and H we
re belo
w 2
0
0
CFU/m
3
,
meeting the c
r
iteria for accepta
ble indoor air qual
ity
in
hos
pi
t
a
l
en
vi
r
o
nm
ent
s
. The
hi
ghe
st
ave
r
age
was f
o
un
d i
n
R
oom
G wi
t
h
conce
n
t
r
at
i
o
n
val
u
e
of
1
1
7
C
F
U/
m
3
,
fol
l
o
we
d by
R
oom
H and R
oom
B
wi
t
h
conce
n
t
r
at
i
o
n v
a
l
u
e of 1
0
4
C
F
U/
m
3
and 9
5
C
F
U/
m
3
, respectively.
Th
e l
o
west
was fo
und
in Room
F with
a concen
tration
v
a
lue of
5
3
CFU/m
3
.
Th
e to
tal b
act
erial co
n
c
en
tratio
n
fo
und
in
th
is stud
y was lower than
th
e resu
lts repo
rted
by
C
huay
b
am
roo
ng
et al.
[6
] (2
49
CFU
/
m
3
), Rocha
et al.
[1
0]
(
1
4
5
CF
U/m
3
), and H
u
an
g
et al
.
[11
]
(
392
CFU/m
3
an
d
35
6 CFU
/
m
3
i
n
IC
U
I a
nd
IC
U
II
, res
p
ect
i
v
el
y
,
d
u
ri
n
g
sam
p
l
i
ng c
onsi
s
t
e
nc
y
st
udy
)
.
T
h
e r
e
sul
t
was also
lo
wer th
an
th
e av
erag
e reported
b
y
Fu
m
a
g
a
lli
et
al.
[
1
2
]
, w
h
o
foun
d
a v
a
l
u
e slig
h
tly h
i
g
h
e
r
th
an
250
CFU/m
3
duri
n
g rest
ri
ct
i
v
e vi
si
t
i
ng pe
ri
o
d
s.
The m
i
nim
u
m
val
u
e
(8 C
F
U/
m
3
) o
f
b
acterial co
n
c
en
tration was
f
oun
d in
R
oom
F an
d
t
h
e
max
i
m
u
m
v
a
lu
e
(
354
CFU
/
m
3
)
w
a
s
f
ound
in Roo
m
B. Th
ese f
i
n
d
i
ng
s
w
e
r
e
co
nsisten
t
with
th
e resu
lts ob
tain
ed
b
y
Li
&
H
o
u
[1
3]
, w
h
i
c
h ran
g
e
d
bet
w
e
e
n 1-
4
2
3
C
F
U/
m
3
in
ICUs.
The
a
v
era
g
es
of bact
eri
a
l
l
e
vel
s
at
9:
0
0
, 1
1
:
0
0, 1
3
:
0
0, 1
5
:
0
0, 1
7
:
0
0
a
n
d 19:
00
t
i
m
e
sl
ot
s
we
re 14
5
CFU/m
3
, 109
C
F
U/
m
3
, 43 C
F
U/
m
3
, 85 C
F
U/
m
3
, 61 C
F
U/
m
3
and 4
6
C
F
U/
m
3
,
r
e
s
p
ec
tiv
e
l
y.
T
h
e hig
h
e
st
avera
g
e
was
f
o
u
n
d
at
9:
0
0
,
whi
c
h
was t
h
e
b
u
si
est
peri
od
f
o
r
cari
n
g
n
u
r
ses wi
t
h
t
a
s
k
s
i
n
cl
ude
d
gi
vi
n
g
be
d-
bat
h
s a
n
d o
r
al
-ri
n
s
i
n
g, c
h
an
g
i
ng s
o
i
l
e
d
di
a
p
ers
,
t
u
rni
ng
o
v
er
pat
i
e
nt
s, a
nd a
d
m
i
ni
st
eri
ng m
e
di
cat
i
o
n
s
. The
seco
nd
hi
ghe
st
ave
r
age
was f
o
u
n
d
at
1
1
:
0
0,
whi
c
h was
t
h
e t
i
m
e
sl
ot
ri
ght
aft
e
r
m
o
rni
n
g
vi
si
t
a
t
i
on. The
l
o
west
av
er
ag
e
w
a
s fo
und
at
13
:00
,
wh
ich w
a
s the qu
iet p
e
r
i
od
. The
bacterial
conce
n
tration raised a
g
ain at
15:
00,
t
h
e t
i
m
e
sl
ot
ri
ght
a
f
t
e
r a
f
t
e
r
n
oo
n
vi
si
t
a
t
i
on.
An
d t
h
e c
once
n
t
r
at
i
o
n l
e
vel
s
went
d
o
w
n
at
1
7
:
0
0 a
n
d
d
o
w
n
agai
n
at 1
9
:
00
. Th
e p
a
ttern
sh
owed clo
s
e relatio
n
s
h
i
p
b
e
t
w
een
bacterial co
n
centratio
n
s
and
d
e
n
s
ities an
d
activ
ities
o
f
t
h
e sam
p
lin
g
site. Th
e resu
lt o
f
t
h
e
Krusk
a
l-Wallis te
st sh
owed
a sign
ifican
t
d
i
fferen
ce in
t
h
e
b
a
cterial
conce
n
t
r
at
i
o
n
bet
w
ee
n t
h
e
di
ffe
rent
t
i
m
e sl
ot
s (p=
.
0
0
0
)
.
Although the
avera
g
es of ba
cteria
l co
n
cen
t
r
atio
n
s
m
e
t
th
e requ
irem
en
ts, th
e co
n
c
en
tratio
n
v
a
lu
es
f
oun
d
o
n
t
h
e f
i
r
s
t d
a
y in
Room B (
3
54
CFU/
m
3
)
,
th
e second
d
a
y in
R
o
o
m
E (
206
CFU
/
m
3
), the first a
nd t
h
e
seco
nd
day
i
n
R
oom
G (
2
4
5
C
F
U/
m
3
and 2
56 C
F
U/
m
3
) at 9:
0
0
, a
n
d t
h
e
fi
rst
day
i
n
R
o
om
G (2
55
C
F
U/
m
3
)
an
d th
e seco
nd d
a
y i
n
R
o
o
m
H
(
214
CFU
/
m
3
) at
11:
00
,
we
re a
b
o
v
e
2
0
0
C
F
U/
m
3
(Figure
6).
According t
o
the
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S Vo
l. 4
,
N
o
. 3
,
Sep
t
emb
e
r
201
5
:
1
45
–
15
1
14
8
l
o
g
b
o
o
k
,
nu
rse
s
’ t
a
sks at
9:
0
0
sl
ot
h
a
ve
be
en m
e
nt
i
oned.
M
o
re
ove
r, al
t
h
ou
g
h
1
1
:
0
0
wa
s t
h
e t
i
m
e
sl
ot ri
g
h
t
after
p
a
tien
t
v
i
sits, th
ere
were no
v
i
sitors
on
th
e
first
d
a
y
o
f
R
o
o
m
G and
th
e second
day o
f
R
o
o
m
H in
the
m
o
rn
in
g v
i
siting
p
e
ri
o
d
.
Howev
e
r, at th
e ti
me of m
easu
r
emen
t, d
o
c
t
o
rs
were p
r
esen
t
treat
in
g
p
a
tien
t
s.
W
i
t
h
t
h
e exce
p
t
i
on of R
oom
B
,
t
h
e hi
ghe
st
val
u
e o
f
f
u
n
g
al
conce
n
t
r
at
i
o
n i
n
t
h
e sam
p
l
i
ng ro
om
s was
un
de
r 1
0
0
0
C
F
U/
m
3
as shown i
n
Tabl
e 1
,
t
h
e m
a
xim
u
m
val
u
e l
e
gi
sl
at
ed by
t
h
e E
P
A. T
h
e t
o
t
a
l
fu
ngal
co
n
c
en
tration
was 69
CFU/
m
3
, wh
ich
m
e
t th
e UK and Sin
g
a
p
o
re st
an
d
a
rd
o
f
i
n
do
or air qu
ality (5
00
CFU/m
3
). The avera
g
e val
u
es
for R
oom
A and R
oom
C
-
H were
bel
o
w 1
0
0
C
F
U/
m
3
, indicating a clean state
of i
n
door air.
The a
v
era
g
e
value of Room
B was below 200 C
F
U/m
3
, which
represe
n
ted an accepta
ble state
f
o
r
ind
oor
air
.
Th
e
h
i
gh
est aver
ag
e
w
a
s
f
ound
in
R
o
o
m
B w
ith
co
n
c
en
tr
atio
n
v
a
lu
e
o
f
16
2
C
F
U
/
m
3
, follo
wed
by
R
oom
E and R
o
om
D
wi
t
h
co
ncent
r
a
t
i
ons o
f
7
7
C
F
U/
m
3
and 7
4
C
F
U/m
3
, resp
ectiv
ely. Th
e lo
west
avera
g
e
was
found i
n
Room
F with
a c
o
ncent
r
ation
val
u
e of
16 CFU/m
3
. It was
worth
no
tin
g th
at th
e
stand
a
rd
devi
at
i
o
ns o
f
R
oom
B
,
D, E and
G we
re
hi
g
h
er t
h
a
n
t
h
e ave
r
age
va
l
u
es, w
h
i
c
h e
xhi
bi
t
e
d co
nsi
d
era
b
l
e
v
a
riation
s
o
f
fun
g
a
l lev
e
ls in th
ese
four roo
m
s.
Table 1.
Bacterial
and fungal conce
n
trations
(CFU/m
3
)
Roo
m
Bacter
ial concentr
ation
Fungal
concentr
aion
N Mean
(SD
)
Min
Max
N
Mean
(SD
)
Min
Max
A 12
69(
33.
99)
36
136
12
65(
56.
69)
8
188
B 12
95(
87.
80)
32
354
12
162(
41
3.
11)
4
1468
C 12
70(
31.
52)
26
142
12
52(
37.
49)
8
114
D 12
57(
50.
64)
16
196
12
74(
76.
28)
10
238
E
12
89(
66.
84)
16
206
12
77(
90.
71)
0
252
F 12
53(
32.
51)
8
124
12
16(
8.
67)
4
32
G 11
117(
97.
4
0
)
14
256
12
49(
88.
73)
0
310
H 12
104(
57.
7
8
)
26
214
12
52(
48.
03)
8
188
Th
e to
tal fung
al co
n
c
en
trat
io
n
fo
und
in th
is st
udy
w
a
s hi
gh
er t
h
a
n
t
h
e res
u
l
t
s
rep
o
rt
e
d
by
C
huay
b
am
roo
ng
et al
.
[
6
] (67
CFU
/
m
3
), Rocha
et al.
[
10]
(9 C
F
U/
m
3
), and
Hua
n
g
et al.
[1
1]
(1
2 CF
U
/
m
3
and
59 C
F
U/
m
3
i
n
IC
U I a
nd
IC
U II
, res
p
ect
i
v
el
y
,
duri
ng sa
m
p
li
ng co
nsi
s
t
e
ncy
st
udy
). H
o
we
ve
r, t
h
e re
sul
t
was
lo
wer th
an
t
h
e av
erag
e repo
rt
ed
b
y
Fu
m
a
g
a
lli
et al.
[12
]
, w
h
o
fo
und
a valu
e
b
e
t
w
een
25
0
and
30
0
CFU
/
m
3
d
u
ring
restrictiv
e v
i
siting
p
e
rio
d
s
. Th
e m
i
n
i
m
u
m v
a
lu
e (0 CFU/m
3
) of f
u
n
g
al
co
nce
n
t
r
at
i
on wa
s f
o
u
nd i
n
R
oom
E an
d R
oom
G.
The
m
a
xi
m
u
m
val
u
e
(1
4
6
8
C
F
U/
m
3
)
was
fo
u
n
d
i
n
R
oom
B
,
an
d s
u
ch
a
hi
g
h
l
e
ve
l
wa
s
una
bl
e t
o
e
x
pl
ai
n at
t
h
i
s
p
o
i
n
t
.
T
h
ese l
e
vel
s
were
hi
gh
er th
an
th
e resu
lts
reported
b
y
Li
&Ho
u
[13
]
wh
ich
were
in t
h
e ra
nge
of bet
w
een
0 a
n
d 319 CFU/m
3
in ICU e
n
v
i
ro
nm
ents.
The a
v
era
g
es
o
f
f
u
n
g
al
co
nce
n
t
r
at
i
o
ns at
9:
0
0
,
11:
00
, 1
3
:
0
0
,
1
5
:
0
0,
17:
00
and
1
9
:
0
0 t
i
m
e
sl
ot
s wer
e
62 C
F
U/
m
3
, 7
0
CFU/m
3
(wi
t
h t
h
e val
u
e of
14
6
8
C
F
U/
m
3
subt
racted),
56
CFU/m
3
, 72
C
F
U/
m
3
, 31 C
F
U/
m
3
and 31
C
F
U/
m
3
, respect
i
v
el
y
.
The hi
g
h
est
val
u
es we
re f
o
u
n
d
at
11:
00
and
15:
0
0
, t
h
e
t
i
m
e
sl
ot
s ri
ght
aft
e
r
m
o
r
n
in
g and af
ter
noo
n
v
i
siti
n
g
. Th
e low
e
st v
a
l
u
es
w
e
r
e
fo
und
at
17
:00
an
d
1
9
:
0
0
. The fu
ng
al
p
a
ttern
w
a
s
d
i
fferen
t
to
b
a
cterial p
a
ttern
. Th
e resu
lt o
f
th
e Kru
s
k
a
l-Wallis test sh
o
w
ed
no
si
gn
ifican
t d
i
fferen
ce in
th
e
fungal conce
n
tration bet
w
een th
e
di
ffe
re
nt
t
i
m
e sl
ot
s (
p
>0
.
0
5
)
.
A
lth
oug
h
t
h
e
av
er
ag
es
o
f
f
u
n
g
a
l co
n
c
en
tr
atio
n
s
m
e
t r
e
q
u
ir
em
en
ts, th
e co
n
c
en
tr
ation
valu
es fo
und
d
u
r
i
ng
t
h
e seco
nd
d
a
y i
n
Roo
m
D
(2
38
C
F
U
/
m
3
) at
9:
00
,
t
h
e sec
o
n
d
day
i
n
R
oom
B
(
1
46
8 C
F
U/
m
3
) and
the
first
day
in
Ro
om
E (2
5
2
CF
U/m
3
) at
11:
0
0
,
t
h
e
fi
r
s
t
day
i
n
R
oom
E (
2
0
4
C
F
U/
m
3
) at
13:
00
, t
h
e
fi
rst
day
i
n
R
oom
G (3
10
C
F
U/
m
3
) at
15:
00,
were a
b
ov
e 20
0 C
F
U/
m
3
as sh
own
in
Fig
u
re 7
.
Th
e activ
ities at
th
e 9
:
00
sl
ot
ha
ve bee
n
descri
bed a
b
o
v
e.
In c
o
nt
rast
t
o
t
h
e re
su
lts
for b
acterial
measu
r
i
n
g, th
ere were
v
i
sito
rs
o
n
t
h
e
seco
nd
day
i
n
R
oom
B
a
nd t
h
e fi
rst
day
i
n
R
oom
E duri
n
g t
h
e m
o
rni
n
g
vi
si
t
i
ng pe
ri
o
d
,
and t
h
e fi
rst
day
i
n
Ro
o
m
G
d
u
ring
th
e afterno
on v
i
sitin
g p
e
riod.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Mi
crobi
al
Ai
r
C
ont
ami
nat
i
o
n
i
n
an
I
n
t
e
nsi
v
e
C
a
re
U
n
i
t
(
C
hi
h-Yi
C
h
a
n
g
)
14
9
Fi
gu
re
6.
B
act
eri
a
l
co
ncent
r
at
i
ons
at
di
ffe
rent
t
i
m
e
sl
ot
s (C
F
U
/
m
3
)
Fi
gu
re
7.
F
u
n
g
a
l
conce
n
t
r
at
i
o
ns at
di
f
f
ere
n
t
t
i
m
e
sl
ot
s (C
FU
/m
3
)
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S Vo
l. 4
,
N
o
. 3
,
Sep
t
emb
e
r
201
5
:
1
45
–
15
1
15
0
3.
2.
Pa
ti
ent
ro
om l
o
ca
ti
on
s
a
nd si
nk
l
o
c
a
ti
ons
Using
a Kru
s
k
a
l-Wallis tes
t
, sig
n
i
fican
t
d
i
fferen
ces were fou
n
d
i
n
th
e b
acterial an
d
fun
g
a
l
conce
n
t
r
at
i
o
ns
of t
h
e 8 sam
p
l
i
ng
ro
om
s (p=.
02
1a
nd
p=.
0
0
1
,
respe
c
t
i
v
el
y
)
. The sam
p
l
i
ng
ro
om
s were t
h
en
di
vi
de
d i
n
t
o
5 cat
ego
r
i
e
s i
n
cl
udi
ng
fr
ont
en
d o
f
t
h
e ci
rcul
at
i
on (R
o
o
m
s
B
and H
)
, m
i
d
d
l
e
of t
h
e ci
rc
ul
at
i
o
n
(R
o
o
m
s
C
and G)
, rea
r
en
d
o
f
t
h
e ci
rc
ul
at
i
o
n (R
oom
s D a
nd
F)
, o
ff t
h
e c
i
rcul
at
i
on
(R
o
o
m
E), an
d faci
ng t
h
e
entra
n
ce (R
oom
A).
Th
e
resu
lts of
th
e Kru
s
kal-Wallis test sh
owed
a si
gn
ificant d
i
fferen
ce i
n
th
e b
acterial
co
n
c
en
trati
on
bet
w
ee
n t
h
e di
ffe
rent
l
o
cat
i
o
ns o
f
t
h
e sam
p
l
i
ng r
oom
s (p=
.
0
0
5
)
. T
h
e hi
g
h
est
co
ncent
r
at
i
on wa
s f
o
u
n
d
i
n
t
h
e
l
o
cat
i
on
of t
h
e
fr
ont
e
nd
of t
h
e ci
rcul
at
i
on
(9
9 C
F
U/
m
3
), fol
l
owe
d
by
m
i
ddl
e of t
h
e ci
rc
ul
at
i
on (
9
3 C
F
U/
m
3
),
of
f t
h
e ci
rc
ul
at
i
on (
8
9 C
F
U/
m
3
), and
facing the e
n
tra
n
ce
(69 CFU/m
3
). The lowest wa
s found i
n
the
rear e
nd
of t
h
e circ
ulation (55 CFU/m
3
).
Ho
we
ver,
d
i
ffere
nces i
n
f
u
ngal
c
o
ncent
r
a
t
i
ons
fo
r
di
ffe
r
e
nt
r
oom
l
o
cat
i
ons
did
not reac
h st
atistical significance.
W
i
t
h
re
gar
d
t
o
si
nk l
o
cat
i
ons
,
t
h
e sam
p
l
i
ng r
oom
s were t
h
e
n
di
vi
de
d i
n
t
o
2 cat
eg
ori
e
s:
p
a
t
i
e
nt
ro
om
s
w
ith
co
rn
er
sink
in
stalled
(
R
oo
m
s
A
an
d E)
an
d p
a
tien
t
r
oom
s w
ith
sh
ar
ed
sink
s
(
R
oo
ms B, C,
D
,
F,
G
and
H).
Th
e
resu
lt o
f
Kru
s
k
a
l
-
Wallis test sh
o
w
ed
n
o
si
g
n
ifican
t d
i
fferen
ce fo
r
bo
th
b
acterial and
fung
al
conce
n
t
r
at
i
o
n,
pos
si
bl
y
d
u
e t
o
t
h
e
fact
t
h
at
t
h
e pat
i
e
nt
ro
om
s we
re
ope
n i
n
desi
g
n
.
4.
CO
NCL
USI
O
N
Th
e h
i
g
h
e
st bacterial co
n
c
en
tration
s
in
the sa
m
p
lin
g
roo
m
s
met th
e s
t
an
d
a
rd
set b
y
th
e EPA i
n
Taiwan. T
h
e
overall a
v
era
g
e
bacter
ial
co
n
c
en
tration
was 8
3
CFU/m
3
, an
d b
acterial co
n
c
en
tration
s
ran
g
ed
bet
w
ee
n 8
a
n
d 35
4
C
F
U/
m
3
. Alth
oug
h th
e av
erag
e
b
acterial lev
e
ls
re
prese
n
ted a clea
n
(10-100 CFU/m
3
)
and
acceptable (100-200 CFU/m
3
) state of i
n
door air
quality i
n
hospita
l envi
ronm
ents accordi
ng t
o
the criteria
d
e
f
i
n
e
d
b
y
th
e Sp
an
ish
A
s
sociatio
n
o
f
H
o
sp
ital En
g
i
n
e
er
i
n
g
(
A
EIH
)
, ther
e w
e
r
e
6
m
e
asu
r
em
en
ts o
v
er
200
CFU/m
3
duri
n
g t
h
e
9:
00
an
d
11:
00
t
i
m
e
sl
ot
s.
W
i
t
h
th
e ex
cep
tio
n
o
f
Roo
m
B, th
e h
i
g
h
e
st
v
a
lu
e of
f
ungal co
n
cen
t
r
ation
s
in
th
e sam
p
lin
g
ro
o
m
s
met EPA standards. The overall avera
g
e
f
u
n
g
al
c
once
n
t
r
at
i
on was 69
C
F
U/
m
3
, and
fungal conce
n
trations
r
a
ng
ed
b
e
t
w
een
0 and
1
468 CFU
/
m
3
. Although t
h
e a
v
e
r
age
fungal leve
ls re
pre
s
ent
e
d a clean (10-100
CFU/m
3
) and acceptable
(100-200 CFU/m
3
)
state
o
f
ind
o
o
r
air
qu
ality
in
ho
sp
ital
en
v
i
ronmen
ts,
th
ere were 5
measurem
ents ove
r
200 CFU/
m
3
duri
n
g
t
h
e
9:
0
0
,
1
1
:
0
0,
1
3
:
00 a
n
d
15:
00
t
i
m
e
sl
ot
s.
W
i
t
h
re
ga
rd t
o
r
o
om
l
o
cat
ions
, a si
gni
fi
cant
di
f
f
ere
n
ce
was found i
n
the bacte
r
ial conce
n
trati
on
(p=
.
005). T
h
e
highest concentration wa
s
found in the room
s
located at th
e fr
o
n
t
end
o
f
t
h
e ci
rcul
at
i
o
n (9
9
CFU/m
3
), wh
ile th
e lo
west was fou
n
d
in
the roo
m
s
lo
cated
at the rear e
nd
of th
e circ
ulation (55 CFU/m
3
).
Diffe
re
nces in fungal c
once
n
trations
bet
w
een room
locations di
d not
r
each statistical significance
.
W
ith
r
e
g
a
r
d
to
sink
lo
catio
n
s
, b
acter
ial
and
f
ungal
con
cen
tr
ati
o
n
s
f
o
r
ro
o
m
s
w
ith
d
i
ff
er
en
t sin
k
lo
cation
s
d
i
d
no
t
reach statistical significance
. Even
though the
m
i
crobi
al concent
r
ations
were ge
nerally co
m
p
lie
d with
st
anda
rd
s, t
h
e
resul
t
s
m
a
y
hel
p
de
si
g
n
ers
a
n
d
h
o
s
p
i
t
a
l
ad
m
i
ni
st
rat
o
rs
de
vel
o
p a
heal
t
h
i
e
r e
nvi
r
o
nm
ent
s
fo
r
pat
i
e
nt
s.
REFERE
NC
ES
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h
id, M
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ecad
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i
c
a
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tien
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r
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ial bloodstrea
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n
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h
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n
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.
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