Sanpin 2.1 3.2630 14 sanitary and epidemiological requirements. New Sanpin for medical institutions

Resolution of the Chief State Sanitary Doctor of the Russian Federation dated May 18, 2010 N 58
"On approval of SanPiN 2.1.3.2630-10 "Sanitary and epidemiological requirements for organizations engaged in medical activities"

With changes and additions from:

3. From the moment the sanitary and epidemiological rules and regulations SanPiN 2.1.3.2630-10 “Sanitary and epidemiological requirements for organizations engaged in medical activities” are put into effect, SanPiN 2.1.3.1375-03 “Hygienic requirements for placement, arrangement, equipment and operation of hospitals, maternity hospitals and other medical hospitals", approved by the resolution of the Chief State Sanitary Doctor Russian Federation dated 06.06.2003 N 124 (registered with the Ministry of Justice of Russia on 06.18.2003, registration N 4709); SanPiN 2.1.3.2195-07, amendment No. 1 to SanPiN 2.1.3.1375-03, approved by Decree of the Chief State Sanitary Doctor of the Russian Federation dated April 25, 2007 No. 19 (registered with the Ministry of Justice of Russia on June 5, 2007, registration No. 9597); SP 3.1.2485-09 "Prevention of nosocomial infections in surgical hospitals (departments) of medical organizations", addition No. 1 to SanPiN 2.1.3.1375-03, approved by Resolution of the Chief State Sanitary Doctor of the Russian Federation dated February 13, 2009 No. 9 (registered with the Ministry of Justice Russia 03/20/2009, registration N 13548); SanPiN 2.1.3.2524-09 "Sanitary and hygienic requirements for dental medical organizations", amendment No. 2 to SanPiN 2.1.3.1375-03, approved by Resolution of the Chief State Sanitary Doctor of the Russian Federation dated 07.07.2009 N 48 (registered with the Ministry of Justice of Russia on 08.20.2009 , registration N 14581); SanPiN 3.5.2528-09 "Organization of disinfection and sterilization measures in medical and preventive organizations", addendum No. 2 to SanPiN 2.1.3.1375-03, approved by Resolution of the Chief State Sanitary Doctor of the Russian Federation dated 08/06/2009 No. 51 (registered with the Ministry of Justice of Russia on 08/26/2009) .2009, registration N 14624); SanPiN 2.1.3.2576-10 amendment No. 3 to SanPiN 2.1.3.1375-03, approved by Resolution of the Chief State Sanitary Doctor of the Russian Federation dated 04.03.2010 No. 18 (registered with the Ministry of Justice of Russia on 04.27.2010, registration No. 17017).

G.G. Onishchenko

Registration N 18094

Sanitary and epidemiological requirements for entrepreneurs and organizations engaged in medical activities have been determined (SanPiN 2.1.3.2630-10).

They replace SanPiN 2.1.3.1375-03 “Hygienic requirements for the placement, design, equipment and operation of hospitals, maternity hospitals and other medical hospitals” (including additions and changes).

It has been established where treatment and prevention organizations (HPOs) should be located. Thus, psychiatric and infectious diseases hospitals are located at a distance of at least 100 m from residential buildings (previously - at least 500 m). In residential buildings, medical facilities for providing assistance to persons with alcohol or drug addiction, microbiological laboratories, and magnetic resonance imaging departments cannot be located.

Requirements for buildings, structures and premises have been established, interior decoration, water supply and sewerage, heating, ventilation, lighting, inventory and equipment.

It is recommended to ventilate the rooms at least 4 times a day for 15 minutes. They should also have cabinets to store patients' belongings. Window glass should be washed at least 2 times a year. Previously - at least once a month from the inside and once every 3 months from the outside (spring, summer, autumn).

For cleaning, it is allowed to hire professional cleaning companies working around the clock. The exception is class A premises.

The rules of personal hygiene, as well as the organization of nutrition for patients, have been determined.

It has been established how preventive, anti-epidemic, disinfection and sterilization measures are carried out. Requirements for working conditions of medical staff, etc. have been established.

One of the main requirements imposed by the state on medical institutions is compliance with Sanitary Rules and Norms, or SanPiN. This document was developed for state control risks of contracting various infectious diseases directly in medical organizations. Compliance with these standards is a mandatory factor in the work of the clinic. We understand the features of medical SanPiN that you need to pay attention to.

Contents of medical SanPiN 2.1 3.2630-10

A document regulating all basic requirements for medical institutions - SanPiN 2.1 3.2630-10 “Sanitary and epidemiological requirements for organizations engaged in medical activities.” Here are instructions on how and where it is possible to locate a clinic, how heating, water supply, sewerage and ventilation systems are formed, and parameters for the compliance of artificial and natural light clinics, its microclimate and air environment, and much more.

In addition to general instructions, the medical SanPiN describes in detail the sanitary and epidemiological requirements for the organization of specific departments of the clinic. These units include all obstetrics and gynecology offices, perinatal centers, intensive care units and intensive care, as well as emergency departments.

It is convenient to manage a clinic in accordance with SanPiN requirements in the Clinic Online program. Maintaining documentation, tracking the consumption of disinfectants, regulating the work of all departments and doctors.

Try Clinic Online

In addition, this SanPiN contains requirements for how to disinfect and sterilize medical premises, as well as rules for organizing preventive measures aimed at reducing the risk of the spread of infectious diseases.

Hazard class in medicine: tuberculosis clinics and dispensaries

03/28/2016 changes to the new SanPiN came into force for medical institutions, relating to the organization of the work of specialized tuberculosis clinics and anti-tuberculosis dispensaries, other specialized anti-tuberculosis institutions and their structural divisions, and the separate buildings and structures included in them (clause 10.8.4, SanPiN 2.1 3.2630-10). More specifically, the additions address the issue of repurposing these enterprises. Now, in accordance with the updates, everything depends on the degree of risk of tuberculosis infection on the territory of the clinic and its premises.

SanPiN has developed three hazard classes in medicine:

• an object of hazard class A is considered non-hazardous in medicine. This class will include objects that have never been used and at the moment are not involved in any way in the diagnosis, treatment, or placement of patients diagnosed with tuberculosis. These could be catering units, workshops, garages, pharmacies, some administrative buildings and more.
• Hazard class B in medicine is already characterized as an object with potential danger. These are medical institutions, the premises of which, according to the medical SanPiN, have ever been used for the examination, treatment and placement of patients with extrapulmonary forms of tuberculosis.
• Objects classified according to medical SanPiN as class B are considered dangerous. This includes all organizations that receive patients with pulmonary forms of tuberculosis, conduct their examination, treat them, and also serve as hospitals for such patients. Also, these are all clinical diagnostic and microbiological laboratories, pathology departments, wastewater treatment plants and other medical facilities.

There are often buildings that contain several rooms of different hazard classes. In this case, there is a requirement to assign the entire building to the highest available risk class.

Hazard class in medicine: procedure for repurposing a clinic

The reorientation of medical institutions, taking into account the hazard class in medicine, is carried out by health authorities in each constituent entity of the Russian Federation, together with the supervisory authorities of the state sanitary and epidemiological service. In their work, they must be guided by certain rules, which in turn require the mandatory determination of the hazard class of the object.

• An object of hazard class A in medicine must undergo disinfection/sterilization before repurposing. It must be carried out by the organization with which the relevant agreement has been concluded.
• for an object with hazard class B in medicine, in order to undergo repurposing, in addition to disinfection/sterilization of premises, it is necessary major renovation. A major overhaul means a complete renovation of the ventilation system, replacement of wooden components of rooms and structures (doors, floors, frames, facing panels, etc.), as well as removal of old paint, plaster and tiles.
• The longest preparation for repurposing will be for objects of hazard class B. At the first stage, such premises undergo disinfection, after which they undergo conservation for at least three years. Then, a major renovation is carried out in the premises, with the same requirements as for renovations at class B facilities. In the end, everything ends with the disinfection of all premises.

After preparing the premises for the repurposing procedure, it is necessary to check the effectiveness of the disinfection using laboratory methods.

IMPORTANT!
If a class B or C object is located in a building with wooden structures, then its repurposing is excluded. Such objects are demolished, all wooden components and structures are burned.

In addition to disinfecting the premises of the organization for the prevention and treatment of tuberculosis, all soil adjacent to the building must be reclaimed.

New SanPiN for medical institutions

The latest changes to SanPiN also affected some items. What you should pay attention to:

1. According to the resolution, the term “medical and preventive institution” / “therapeutic and preventive organization” is now replaced by the term “medical organization” in the corresponding case throughout the text of the document.

2. the word “hospitals”, which appears in the first sentence of clause 2.2 of Chapter 1, should, according to the new SanPiN for medical institutions, be replaced with the phrase “medical organizations providing medical care in a hospital setting, providing round-the-clock medical observation and treatment (hereinafter referred to as hospitals )".

3. special attention Medical SanPiN focuses on the rules for carrying out measures for disinfection/sterilization of medical premises. Following these rules will help the organization reduce the risk of the spread of infectious diseases in a clinical setting where there is constant contact between healthy and sick visitors.

4. The clinic administration needs to instruct cleaners and nurses on cleaning technology in a medical institution, not only upon hiring, but also at certain intervals.

5. Based on the requirements of the new SanPiN for medical institutions regulatory act, sanitary personnel must carefully monitor the cleanliness of premises, equipment and inventory, carry out wet cleaning (washing equipment and all surfaces of the room) twice a day, using special disinfectants, means personal protection.

IMPORTANT!
Products and working solutions are used not only for the sterilization and disinfection of medical instruments, during the disinfection of medical premises, treatment rooms, surfaces of devices and equipment, they also process all cleaning equipment and medical waste of class B and C.

6. Disinfectants should be stored in a specially equipped place located outside the treatment rooms. All detergents and disinfectants are in original packaging with a label; ready-made working solutions – in separate containers(they are tightly closed with a lid, identified by a label indicating the name of the solution, its purpose, composition, concentration, period of use).

7. Cleaning equipment is also stored in accordance with SanPiN. All mops, rags, containers contain markings. In addition, color coding can be used to designate equipment, where each color will correspond to a specific type of cleaning and the room where it needs to be carried out. The encoding diagram must be placed in the inventory storage area. To store cleaning equipment, the clinic administration must allocate a separate room where all items will stand separately, in accordance with their purpose: for treating walls and floors, bathrooms, corridors, offices.

8. The new SanPiN for medical institutions also stipulates that washing machines should be placed in the area where cleaning carts are assembled, and windows should be washed twice a year.

Rules for general cleaning of clinics according to medical SanPiN

In accordance with the new requirements, general cleaning of the clinic premises must be carried out at least once a month, according to a pre-approved cleaning schedule. The concept of “general cleaning” includes wet cleaning of all surfaces, washing floors, disinfecting equipment, equipment, and lamps.

In rooms where constant maintenance of sterility is required (operating rooms, dressing rooms, treatment rooms, manipulation rooms, maternity rooms, etc.), general cleaning and disinfection are organized much more often, at least once a week.

IMPORTANT!
On a sanitary day, no operational activities are carried out in the operating unit. During the actual cleaning of the clinic, sanitary personnel must have personal protective equipment with them, and all operating equipment must be labeled.

Disinfection measures in specialized premises in accordance with medical SanPiN can be carried out after the fact - if the need arises (epidemiological indications, or poor results of laboratory tests of microbial contamination external environment)

General cleaning of the clinic premises begins with disinfection of the walls, by irrigating them or wiping them with a working disinfecting solution to the entire height - from floor to ceiling. Then the floors, window sills, doors, furniture surfaces and equipment are sterilized.

After carrying out disinfection measures, sanitary personnel must change personal protective equipment and once again wipe all surfaces with clean cloth napkins soaked in plain water. Finally, the air in the room is disinfected.

Upon completion of cleaning, all used mops are soaked for some time in a working disinfectant solution, rinsed in running water and dried.

The operating procedure of the treatment room based on changes

The activities of the treatment room must be organized in accordance with the changes in the content of SanPiN 2.1 3.2630-10 that occurred in 2016. Although the division of the treatment room into separate zones is not regulated by law, the new amendments include hygienic requirements regarding the layout and structure of the rooms in which medical procedures are carried out. Medical institutions can comply with the hygienic requirements of the new SanPiN by zoning premises, thus creating favorable conditions for high-quality implementation of medical procedures and compliance with the sanitary and anti-epidemic regime. In addition, zoning helps to debug technological processes, preventing flows that differ in the degree of epidemiological risk from intersecting.

Speaking about the division of the room, the following zones of the treatment room are distinguished:

• a place where medical procedures are performed or documentation is processed. In this area of ​​the treatment room, as a rule, there are two tables - a work table and a manipulation table and a couch for patients;
• a treatment room area reserved for the storage of medications and clean materials, preferably in a specially designed medical cabinet; another table for manipulation is also installed here;
• an area where instruments are disinfected and waste after medical procedures is collected in a special container. In the so-called “dirty area of ​​the treatment room” you can wash your hands , and also treat reusable instruments after use with disinfectants stored there.

For comfortable and safe work you need to seriously approach the issue of organizing space in a room and consider it taking into account ergonomics. The procedural nurse should not have problems with access to the patient. The room should be equipped in such a way that during operation there is always access to the necessary equipment and tools, no obstacles are created during cleaning, and at the same time sanitary and hygienic standards are observed (Appendices to SanPiN 2.1 3.2630-10) regarding area, number of square meters per person , illumination and other indicators.

If procedures are carried out in the office that involve the use of reagents (methyl methacrylates, psychotropic drugs, organic solvents, phenols and formaldehydes, etc.) that emit volatile harmful substances, it is necessary to equip the room with a fume hood. If such procedures with reagents are not carried out, then a fume hood is not needed, you should refer to the requirements for the air environment of premises in Section 6 of Chapter I SanPiN 2.1 3.2630-10, where the standardized parameters of the air environment are established.

Premises for vaccination and inhalation taking into account changes in SanPiN

Different treatment rooms have different degrees of epidemiological risk and therefore must be located separately from each other. Treatment rooms, while distinct in their purpose, also exclude the possibility of co-location. Thus, according to paragraph 10.10 of Chapter I of SanPiN 2.1 3.2630-10, the inhalation room, as part of the physiotherapy department, should be located separately from other treatment rooms. Inhalation areas must be equipped with supply and exhaust ventilation, creating conditions that guarantee constant air exchange in the office at least 10 times per hour and maintaining the room temperature at +20°C. In the area where preparation for medical procedures and disinfection of medical devices is supposed to be carried out, there must be a sink divided into two parts, a boiler for disinfection, a supply of hot and cold water, in addition, a fume hood must be in use in this part of the room.

Based on the content of paragraph 6.4 of MU 3.3.1891-04 “Organization of the work of the vaccination office of a children's clinic, the immunoprophylaxis office and vaccination teams,” a medical institution must have an office in which vaccination prophylaxis will be carried out; the equipment of the office must meet the requirements of the above document.

Installation of office equipment in the treatment room area

There are no instructions in the regulatory documents prohibiting the installation of a computer in the areas of treatment rooms. But it is important to remember that when installing office equipment, the separation of flows with varying degrees of epidemiological danger must be maintained.

According to the principles of ergonomic space distribution, the area of ​​the room directly depends on the number of equipped workstations; accordingly, adding a new workstation with a computer installed there means that the normalized area of ​​the room must be increased. Area allocated for workplace where a monitor based on a cathode ray tube is installed must be at least 6 sq.m., with a liquid crystal or plasma monitor at least 4.5 sq.m.

Devices for copying and duplicating documents - printers, scanners, copiers - take up additional space, which also needs to be taken into account when placing equipment. Taking into account sanitary and anti-epidemic requirements, a computer located in treatment room, should be regularly treated with disinfectants to prevent environmental contamination.

Requirements for medical clothing according to SanPiN

Medical institutions usually have departments with different hazard classes, and in order to avoid the intersection of flows with varying degrees of epidemiological risk, the wearing of protective clothing by staff must be regulated. Clothes should be changed as needed.

SanPiN 2.1 3.2630-10 specifies the standards and requirements for medical clothing of personnel and when it should be replaced. These rules are based on several factors: the nature of the manipulation being performed (surgery or cleaning the room), the content of microorganisms in the air, depending on the type of room (department for infectious patients, diagnostic room, treatment room). So, at the beginning of the working day, SanPiN employees put on medical/working clothing, which must be changed if it is necessary to enter a sterile room or when there is a change in occupation. The GOST R ISO 14644-5-2005 standard formulates standards for wearing protective clothing in a clean room and rules for leaving it; this information is presented in the reference appendix to the above standard.

We provide a fragment of an indicative list of objects recommended for control within the framework of the PPC, indicating the frequency of inspection activities under the responsibility of head nurse, with the participation of middle and junior medical personnel.

You can download the full list below.

Sanitary rules establish sanitary and epidemiological requirements for placement, design, equipment, maintenance, anti-epidemic regime, preventive and anti-epidemic measures, working conditions for personnel, catering for patients and personnel of organizations carrying out medical activities.

Sanitary rules are intended for individual entrepreneurs And legal entities regardless of their organizational and legal form and form of ownership, carrying out medical activities, and are binding on the territory of the Russian Federation. Design, construction, reconstruction, major repairs, redevelopment, operation of healthcare facilities are carried out in accordance with these rules.

Designation: SanPiN 2.1.3.2630-10

Russian name: Sanitary and epidemiological requirements for organizations engaged in medical activities

Status: active (Registered with the Ministry of Justice of the Russian Federation on August 9, 2010. Registration N 18094)

Replaces: SanPiN 2.1.3.1375-03 “Hygienic requirements for the placement, design, equipment and operation of hospitals, maternity hospitals and other medical hospitals” SanPiN 2.1.3.2195-07 “Hygienic requirements for the placement, design, equipment and operation of hospitals, maternity hospitals and other medical hospitals. Amendment No. 1 to SanPiN 2.1.3.1375-03" SP 3.1.2485-09 "Prevention of nosocomial infections in surgical hospitals (departments) of medical organizations. Addendum No. 1 to SanPiN 2.1.3.1375-03" SanPiN 2.1.3.2524-09 "Sanitary and hygienic requirements for dental medical organizations. Amendment No. 2 to SanPiN 2.1.3.1375-03" SanPiN 3.5.2528-09 "Organization of disinfection and sterilization measures in medical and preventive organizations. Addendum No. 2 to SanPiN 2.1.3.1375-03" SanPiN 2.1.3.2576-10 "Hygienic requirements for the location, design, equipment and operation of hospitals, maternity hospitals and other medical hospitals. Amendment No. 3 to SanPiN 2.1.3.1375-03"

Effective date: 09/16/2010

Developed by: Rospotrebnadzor 127994, Moscow, Vadkovsky per., 18/20
Approved by: Chief State Sanitary Doctor of the Russian Federation (05/18/2010)

1. Sanitary maintenance of premises, equipment, inventory

(Excerpt from Sanpin 2 1 3 2630 10)

11.1. All premises, equipment, medical and other supplies must be kept clean. Wet cleaning of premises(processing of floors, furniture, equipment, window sills, doors) must be carried out at least 2 times a day, using detergents and disinfectants approved for use in the prescribed manner. The administration of health care facilities organizes preliminary and periodic (at least once a year) briefing of personnel involved in the sanitary and hygienic regime and cleaning technologies.

11.2. Storage detergents and disinfectants must be carried out in the manufacturer’s container (packaging), equipped with a label, on racks, in specially designated places.

11.3. It is necessary to have separate containers with working solutions of disinfectants used to treat various objects:

— for disinfection, for pre-sterilization cleaning and for sterilization of products medical purposes, as well as for their preliminary cleaning (when using products with fixing properties);
— for disinfection surfaces in premises, furniture, apparatus, instruments and equipment;
— for disinfection of cleaning material, for the disinfection of waste of classes B and C (in the absence of disinfection installations).

Containers with working solutions of disinfectants must be equipped with tight-fitting lids, have clear inscriptions or labels indicating the product, its concentration, purpose, preparation date, and expiration date of the solution.

11.4. When working with disinfectants, all precautions must be observed, including the use of personal protective equipment specified in the instructions for use.

11.5. Cleaning equipment(carts, mops, containers, rags, mops) must be clearly marked or color-coded taking into account the functional purpose of the premises and types of cleaning work and stored in a designated room. Color coding scheme located in the inventory storage area. Washing machines for washing mops and other rags are installed in the areas where cleaning carts are assembled.

11.6. Window glass cleaning should be carried out as necessary, but at least 2 times a year.

11.7. General cleaning of premises ward departments and other functional rooms and offices should be carried out according to a schedule at least once a month, with the treatment of walls, floors, equipment, inventory, lamps.

11.8. General cleaning of the operating room, dressing rooms, maternity rooms, treatment rooms, manipulation rooms, sterilization rooms and other rooms with aseptic conditions are carried out once a week. On the day of the event spring cleaning There are no planned operations performed in the operating unit.

Off schedule general cleaning carried out in case of unsatisfactory results of microbial contamination of the external environment and for epidemiological indications.

To carry out spring cleaning personnel must have special clothing and personal protective equipment (robe, cap, mask, rubber gloves, rubber apron, etc.), labeled cleaning equipment and clean cloth napkins.

11.9. When carrying out general cleaning The disinfectant solution is applied to the walls by spraying or wiping them to a height of at least two meters (in operating units - to the entire height of the walls), windows, window sills, doors, furniture and equipment. At the end of the disinfection time (the staff must change their overalls), all surfaces are washed with clean cloth napkins moistened with tap (drinking) water, and then the air in the room is disinfected.

11.10. Used cleaning equipment disinfected in a disinfectant solution, then rinsed in water and dried. Cleaning equipment for the floor and walls must be separate, have clear markings, and be used separately for offices, corridors, and bathrooms.

If it is not possible to use disposable cloth napkins, reusable napkins must be washed.

11.11. Storage cleaning equipment must be carried out in a specially designated room or cabinet outside the office premises.

11.12. To disinfect air in rooms with aseptic conditions, equipment and/or chemicals approved for this purpose should be used.

Treatment technology and air disinfection modes are set out in the relevant regulatory and methodological documents and instructions for the use of specific disinfection equipment and disinfectants.

In order to reduce air pollution to a safe level, the following technologies are used:
- exposure to ultraviolet radiation using open and combined bactericidal irradiators used in the absence of people, and closed irradiators, including recirculators, allowing air disinfection in the presence of people, the required number of irradiators for each room is determined by calculation in accordance with current standards;
— exposure to aerosols of disinfectants in the absence of people using special spraying equipment (aerosol generators) during final disinfection and during general cleaning;
— the use of bacterial filters, including electric precipitators.

11.13. For cleaning(except for class A premises) it is allowed to attract professional cleaning companies, operating around the clock, for which it is necessary to provide separate premises. Cleaning company staff When cleaning the OOMD, he must comply with these rules. Requirements for working conditions of personnel cleaning companies, working in a health care facility, are defined in paragraph 15 of Chapter I of these rules.

11.14. Elimination of current finishing defects (elimination of leaks on ceilings and walls, traces of dampness, mold, filling of cracks, crevices, potholes, restoration of peeling tiles, defects in floor coverings and others) must be carried out immediately.

11.15. Collection of dirty laundry carried out in closed containers (oilcloth or plastic bags, specially equipped and labeled linen trolleys or other similar devices) and transferred to the central pantry for dirty linen. Temporary storing dirty laundry in departments (no more than 12 hours) is allowed in rooms for dirty linen with waterproof finishing of surfaces, equipped with a washbasin and a device for air disinfection. The premises and equipment are washed and disinfected daily.

11.16. In hospitals and clinics, central storerooms are provided for clean and dirty linen. In low-power medical organizations, clean and dirty linen can be stored in separate cabinets, including built-in ones. The pantry for clean linen is equipped with racks with a moisture-resistant surface for wet cleaning and disinfection. The central pantry for dirty linen is equipped with floor racks, a washbasin, exhaust ventilation and an air disinfection device.

11.17. Processes related to transportation, loading, and unloading of linen must be mechanized.

11.18.Washing clothes should be carried out in a laundry room as part of a medical organization. The laundry washing regime must comply with current hygienic standards.

11.19. Transporting clean linen from the laundry and dirty linen to the laundry should be carried out in packaged form (in containers) by specially designated vehicles.

Transportation of dirty and clean linen in the same container is not allowed. Washing fabric containers (bags) should be carried out simultaneously with laundry.

11.20. After discharge (death) of the patient, as well as as they become dirty, mattresses, pillows, and blankets must be subjected to chamber disinfection treatment. If covers made of material that allows wet disinfection are used to cover mattresses, chamber processing is not required. The patient's bed and bedside table must be disinfected. A medical organization must have an exchange fund of bedding, for the storage of which a special room is provided.

11.21. In healthcare facilities under construction and reconstruction, it is recommended to install bed treatment points with subsequent provision of bedding.

11.22. During the period of current or major repairs, the operation of the premises must be stopped.

If repairs are necessary in an existing building, it is allowed to carry out repair work while ensuring reliable isolation of functioning premises (including technical ones) from those being repaired. When repairing catering units, meals for patients and staff are provided by other organizations catering who have permission to prepare medical food.

11.23. There should be no synanthropic arthropods, rats or mouse-like rodents in the OOMD. Carrying out disinsection and deratization must be carried out in accordance with sanitary rules by specialized organizations.

11.24. The collection, temporary storage and disposal of waste of various hazard classes in the OOMD is carried out in accordance with sanitary rules for the management of medical waste.

11.25. Garbage bins installed at the entrances to buildings and on the territory (every 50 m) must be cleared of garbage daily and kept clean.

11.26. OOMD must be ensured required quantity technological equipment for handling waste of different hazard classes (trolley racks, packages, sacks, containers, including puncture-resistant ones, etc.).

I. General requirements to organizations engaged in medical activities
1. General provisions and scope
2. Requirements for the location and territory of treatment and prevention organizations (HPO)
3. Requirements for buildings, structures and premises



7. Requirements for natural and artificial lighting

9. General requirements for the organization of preventive and anti-epidemic measures
10. Sanitary and epidemiological features of the organization of units of various profiles
11. Sanitary maintenance of premises, equipment, inventory
12. Rules for treating the hands of medical personnel and the skin of patients
13. Requirements for the rules of personal hygiene of patients
14. Requirements for patient nutrition
15. Requirements for working conditions of medical personnel
II. Organization of disinfection and sterilization activities in organizations engaged in medical activities
1. General provisions
2. Requirements for disinfection, pre-sterilization cleaning and sterilization of medical devices
3. Ensuring the implementation of disinfection and sterilization measures
III. Prevention of nosocomial infections in surgical hospitals (departments)
1. Organization of measures to prevent nosocomial infections
2. Epidemiological surveillance
3. Basic principles of prevention of nosocomial infections
4. Prevention of nosocomial infections in the operating room and dressing rooms
5. Prevention of nosocomial infections in intensive care units and intensive care units
6. Disinfection and sterilization measures
IV. Prevention of nosocomial infections in obstetric hospitals (departments)
1. Organization of activities for the prevention of nosocomial infections in obstetric hospitals
2. Organization of the anti-epidemic regime
3. Rules for the maintenance of structural units of obstetric hospitals and perinatal centers
4. Organization and implementation of disinfection and sterilization measures
5. Epidemiological surveillance of nosocomial infections
6. Investigation and elimination of group nosocomial diseases among newborns and postpartum women
V. Sanitary and hygienic requirements for dental medical organizations
1. General provisions
2. Requirements for the location of dental medical organizations
3. Requirements for interior decoration
4. Equipment requirements
5. Requirements for microclimate, heating, ventilation
6. Requirements for natural and artificial lighting
7. Provision radiation safety when placing and operating X-ray machines and rooms
8. Sanitary and anti-epidemic measures
VI. Sanitary and epidemiological requirements for the design, equipment and operation of medical and obstetric stations and outpatient clinics
1. General provisions
2. Hygienic requirements for accommodation and territory
3. Hygienic requirements for buildings, structures and premises
4. Requirements for interior decoration
5. Requirements for water supply and sewerage
6. Requirements for heating, ventilation, microclimate and indoor air environment
7. Hygienic requirements for natural and artificial lighting
8. Requirements for inventory and technological equipment
9. Sanitary and anti-epidemic measures
10. Hygienic requirements for working conditions and personal hygiene of medical and service personnel
Appendix 1 Minimum areas of premises No. Name of premises Area (m2)
Appendix 2 Composition, set and minimum recommended areas of premises of a dental medical organization** Name of premises Minimum area, m2
Appendix 3 Cleanliness class, recommended air exchange, permissible and design temperature
Appendix 4 Maximum permissible concentrations (MPC) and hazard classes medicines in the air of the premises of medical organizations
Appendix 5 Standardized indicators of natural, artificial and combined lighting of the main premises of medical organizations
Appendix 6 List of medical equipment and medical devices used in medical and pharmaceutical activities and subject to sanitary, epidemiological and hygienic assessment
Appendix 7 Permissible levels of physical factors created by medical equipment products
Appendix 8 Maximum permissible levels (MPL) of electromagnetic radiation at the workplace of medical personnel
Appendix 9 Permissible sound levels of medical equipment in the premises of medical and preventive organizations
Appendix 10 Maximum permissible sound levels and equivalent sound levels in workplaces for labor activity different categories of severity and intensity, dBA
Appendix 11 Maximum permissible levels of airborne ultrasound at workplaces
Appendix 12 Emergency prevention of parenteral viral hepatitis and HIV infection
Appendix 13 List of registered nosological forms of postoperative infections
Appendix 14 The procedure for cleaning the premises of various structural departments of the obstetric hospital
Appendix 15 List of registered nosological forms of infectious diseases in obstetric hospitals

Sanitary rules and regulations (SanPiN) are established at the state level and apply to all medical institutions without exception that have a license to carry out medical activities.

They can significantly reduce the risk of free circulation of infection during human contact in hospitals and clinics.

Today, sanitary rules and regulations are implemented at a sufficient level, and this makes it possible to maintain a safe sanitary environment in every medical organization.

↯ More articles in the magazine

The main thing in the article

SanPiN 2.1 3.2630-10: latest changes

SanPiN 2.1 3.2630-10 “Sanitary and epidemiological requirements for organizations engaged in medical activities” is normative document, containing the requirements for the functioning of a medical institution, namely:

1. to location and territory.
2. For heating, water supply and sewerage, ventilation of hospital buildings and clinics.
3. Natural and artificial lighting, microclimate, indoor air environment.

Separately, the sanitary and epidemiological features of the organization of treatment and diagnostic units of a medical organization - resuscitation and intensive care units, obstetric and gynecological hospitals, perinatal centers, and emergency departments are given.

Special attention in SanPiN 2.1 3.2630-10 is paid to the requirements for the organization and implementation of sterilization and disinfection measures and the prevention of hospital infections in medical institutions of various profiles.

Last year, changes were made to this document. Clause 10.8.4 has been changed - according to new edition, specialized tuberculosis hospitals and anti-tuberculosis dispensaries, other specialized anti-tuberculosis institutions and their structural divisions, as well as the separate buildings and structures that comprise them, are repurposed depending on how high the potential risk of infection of the territory of the institution and its premises with Mycobacterium tuberculosis is.

According to the degree of possible risk of infection with tuberculosis microbacteria, the following classes of objects are distinguished:

• class A (non-hazardous) - facilities that are not intended and have not previously been used for diagnosis, treatment, accommodation of persons with confirmed tuberculosis (administrative buildings, catering units, workshops, checkpoints, garages, pharmacies, etc.);
• class B (potentially dangerous) - facilities in which examination, treatment and placement of patients with extrapulmonary forms of tuberculosis were previously carried out;
• class B (hazardous) - facilities where examination, treatment and placement of patients with pulmonary forms of the disease, including those caused by drug-resistant microorganisms, were previously carried out (clinical diagnostic and microbiological laboratories, pathology departments, wastewater treatment plants, etc. ).

If a building has several rooms or departments belonging to different hazard classes, the entire building must be classified as the highest of them.

The decision to repurpose organizations involved in the prevention and treatment of tuberculosis is made by the health authorities of the constituent entities of the Russian Federation with the participation supervisory authorities State Sanitary and Epidemiological Service.

Medical examinations for health workers: when the mandatory minimum of examinations needs to be supplemented

What volume of research includes preliminary and periodic medical examinations of health workers, in which cases the mandatory minimum must be supplemented in order to avoid penalties, read in the magazine "Home" nurse" Who needs a special examination by a dermatologist? Why psychiatric examination Can't it be replaced by a regular examination by a psychiatrist?

In this case, it is necessary to determine the class of potential danger of infection of an object with Mycobacterium tuberculosis.

Re-profiling work is carried out taking into account the following requirements:

• class A objects are repurposed only after the final disinfection of the building by an authorized organization;
• class B objects are repurposed after the final disinfection of the building by an authorized organization and major repairs, during which the ventilation system, as well as wooden doors, floors, window frames, cladding panels and other wooden structures must be completely dismantled; plaster, paint, tile covering are completely removed;
• class B objects are repurposed after final disinfection and conservation for a period of at least 3 years, after which a major overhaul of the object is carried out with the complete dismantling of ventilation systems and all wooden and porous structures (floors, windows, frames, doors, cladding panels), removal of plaster and paint , tiled covering; After completion of repair work, the building is disinfected again.

After the final disinfection of an object has been carried out, it is necessary to monitor its effectiveness using laboratory methods.

About mandatory laboratory research as part of production control over the circulation of medical waste, read in the System Head nurse.

Repurposing of class B and C objects located in wooden buildings is unacceptable. These facilities are subject to dismantling and building structures are burned.

When repurposing organizations that provide prevention and treatment of tuberculosis in a hospital setting, it is also necessary to reclaim the soil in the designated area.

The second change in SanPiN concerns the very term “medical and preventive institution” or “therapeutic and preventive organization”. It must be replaced with the term “medical organization” in the appropriate case throughout the text of the document.

Also, in the first sentence of paragraph 2.2 of Chapter I, the word “hospitals” must be replaced with the phrase “medical organizations providing medical care in inpatient settings, providing round-the-clock medical observation and treatment (hereinafter referred to as hospitals).”

Requirements for general cleaning

The new SanPiN 2016, intended for medical organizations, imposes special requirements for general cleaning of hospitals and clinics.

They are designed to prevent the spread of infection through contact between people in medical institutions.

According to the new requirements, all premises of a medical organization, as well as equipment and necessary equipment must be kept clean.

Wet cleaning, including washing floors, window sills, doors, equipment and furniture, should be carried out at least 2 times a day using detergents and disinfectant solutions.

The management of the institution organizes preliminary and periodic briefing of the personnel responsible for the cleanliness of the premises on sanitary and hygienic conditions and cleaning technology.

Procedure for general cleaning

We will tell you in the Chief Nurse System which personnel are allowed to perform cleaning, how to carry it out, which mode and method of disinfection to choose, what to base the purchase of disinfectants on and how to control the quality of cleaning.

Detergents and disinfectants must be stored in the manufacturer’s packaging, equipped with a label, in specially designated storage areas outside of work rooms. Working solutions of disinfectants for processing objects are stored in separate containers. They are used:

• for disinfection, pre-sterilization cleaning and sterilization medical products;
• for disinfection of surfaces, equipment, devices and devices;
• for disinfection of cleaning material, as well as class B and C waste.

Containers with working solutions of disinfectants must have a tight-fitting lid, as well as a clear inscription or label indicating the name of the solution, its concentration, date of preparation, expiration date, and purpose.

When working with these products, all precautions must be taken, including the use of personal protective equipment.

Approximate form of a log of the organization’s consolidated estimated need for disinfectants, sterilants, pre-sterilization cleaning products, skin antiseptics

Name	Name	Demand in the billing period
disinfectants	divisions of the organization			half year

Cleaning equipment (mops, rags, containers, carts) must be labeled or color-coded based on the purpose of the premises and the types of cleaning in them, and must have a place for storage.

There should be a color coding scheme in the inventory storage area. Washing machines should be located in areas where cleaning carts are assembled.

Windows are washed as needed, but at least 2 times a year. General cleaning of wards and other rooms and offices in departments of a medical organization is carried out according to a schedule at least once a month. It should include washing floors, treating walls, inventory, equipment, and lamps.

In the operating unit, dressing rooms, treatment rooms, manipulation rooms, maternity rooms and other rooms that maintain aseptic conditions, general cleaning is carried out at least once a week. On the day of general cleaning, no operations are carried out in the operating unit.

Cleaning personnel must have personal protective equipment, and all necessary equipment must be labeled.

General cleaning can be carried out unscheduled - for epidemiological reasons or as a result of unsatisfactory results of microbial contamination of the external environment.

Templates for cleaning documents in medical organizations

So that in conditions of shortages and staff turnover, the chief nurse can ensure uninterrupted and high-quality cleaning of premises in a medical organization, the editors of the magazine “Chief Nurse” have prepared a selection of local document templates, a selection of local document templates, which were approved by an expert from Rospotrebnadzor.

The disinfection solution is used to irrigate or wipe the walls of rooms at a height of at least 2 meters, and in operating rooms and maternity rooms - to the entire height to the ceiling. Floors, window sills, doors, furniture, and equipment are also treated.

At the end of the disinfection time, personnel should change protective equipment and wipe surfaces with clean cloth wipes moistened with water. IN last resort The air in the room is disinfected.

Equipment used for cleaning is soaked in a disinfectant solution, then rinsed with water and dried. Equipment for walls and floors must be separate and labeled.

Separate equipment is also used for bathrooms, corridors, and offices. If it is not possible to use disposable cloth napkins for every cleaning, reusable napkins must be washed. Inventory should be stored in a specially designated closet or room, but not in the office.

How to choose a disinfectant

Active ingredient	Activity	Advantages	Flaws
Quaternary ammonium compounds (QAC)	Efficacy against gram-positive and gram-negative vegetative forms of bacteria, fungi, and some viruses	Effective in low concentrations, do not damage treated surfaces, are of little danger if inhaled	There is no sporicidal or tuberculocidal effect, selective action against viruses. Long-term use leads to the development of microbial resistance
Guanidines	Effective against gram-positive and gram-negative vegetative forms of bacteria, fungi, some viruses, mold	Low-toxic compounds due to inhalation with prolonged antimicrobial action	No sporicidal or tuberculocidal effect, selective action against viruses
Chloroactive compounds	Effective against bacteria (including mycobacteria), fungi, viruses, bacillus spores	Low cost, high activity, speed of action	Causes corrosion of metals and destruction of tissues; irritating effect on the mucous membranes of the eyes and upper respiratory tract
Hydrogen peroxide	Wide spectrum of activity against microorganisms, including bacilli spores	Removes organic contaminants. Odorless. Safe for the environment	Incompatible with metals: brass, zinc, copper, nickel
Peracetic acid	Broad spectrum of activity against microorganisms, including bacilli spores	High level disinfection. Fast acting at low concentrations	Unstable at long-term storage, has a pungent odor and irritating effect on the mucous membranes of the eyes and upper respiratory tract

SanPiN 2.1 3.2630-10: requirements for organizing the work of the treatment room

SanPiN 2.1 3.2630-10 as amended in 2016 imposes a number of requirements for organizing the work of the treatment room.

This applies, in particular, to its zoning, the presence of fume hoods and a computer, and the conduct of inhalations and vaccinations.

Zoning the treatment room: instructions

In order to ensure infection safety in the treatment room, the System expert Chief Nurse developed working instructions for dividing the room into functional zones - aseptic, working and utility.

Note: The current sanitary legislation does not regulate the requirements for the zoning of treatment rooms.

Allocation of zones in the treatment room

Zoning of treatment rooms in medical organizations is not regulated by law. However, SanPiN 2.1 3.2630-10 contains hygienic requirements for the structure, architectural, planning and design solutions of premises intended for various manipulations, including treatment rooms.

Fulfilling these requirements allows you to:

• provide the best conditions for the treatment process, compliance with the sanitary and anti-epidemic regime and labor medical workers;
• put technological processes on stream and eliminate the possibility of crossing streams with varying degrees of epidemiological danger.

Zoning in the treatment room allows you to fulfill these requirements.

Conventionally, several zones can be distinguished:

1. Area for storing drugs and sterile materials (“clean”).
2. Area for performing manipulations and maintaining medical records (working).
3. Medical device disinfection area reusable, collection and disinfection of medical waste (“dirty”).

In the “clean” area it is recommended to install a medical cabinet with medicines and packaged sterile materials, as well as a manipulation table. The “work” area usually contains a patient couch, a refrigerator, a work table and a second manipulation table.

The “dirty” area is equipped with a sink for tools and a sink for washing hands. There is also a place for storing disinfectant solutions and a container for collecting medical waste.

You need to organize your workspace based on the principles of ergonomics. The procedural nurse must have free access to the patient, and the room as a whole and inventory, tools and equipment must be available for cleaning, operation and maintenance, taking into account sanitary and hygienic standards, which are given in the appendices to SanPiN 2.1 3.2630-10 (area, number sq. m per employee, microclimate, lighting, noise, etc.).

Fume hoods in the treatment room

When working with cytostatics, methyl methacrylates, psychotropic drugs, organic solvents, phenols and formaldehydes, aniline dyes and other reagents, accompanied by the release of toxic substances, treatment rooms are equipped with local exhaust devices.

If work accompanied by the release of toxic substances into the air is not performed in the treatment room, local fume hoods are not required, and air exchange is organized in accordance with the requirements of Section 6 of Chapter I of SanPiN 2.1 3.2630-10.

20 cleaning violations for which the head nurse can be punished

Carrying out vaccinations and inhalations in the treatment room

The treatment room, vaccination room and inhalation room are treatment rooms that differ in functionality and degree of epidemiological risk. Therefore, their placement should be separate.

The inhalation facility is part of the department of physiotherapy and rehabilitation treatment and must meet the requirements set out in paragraph 10.10 of Chapter I of SanPiN 2.1 3.2630-10.

The inhalation room must be separated from other premises. It must contain:

• supply and exhaust ventilation, which will provide air exchange in the room up to 10 times per hour and help maintain a constant air temperature at +20°C;
• additional box for preparing treatment procedures, sterilization and disinfection of medical devices, equipped with a fume hood, a sink with two compartments and a rotary tap with cold and hot water, disinfection boilers.

To carry out vaccination prophylaxis, a medical organization must have a separate vaccination room, equipped in accordance with the requirements of paragraph 6.4 of MU 3.3.1891-04 “Organization of the work of the vaccination room of a children's clinic, the immunoprophylaxis room and vaccination teams.”

Vaccination room: 5 misconceptions about organizing your workspace

Misconception: Furniture in an office should be placed around the entire perimeter.

To eliminate movement losses, make the work cell more compact. Reduce the working perimeter as much as possible, move it towards the entrance to the office. Detailed recommendations expert of the magazine "Chief Nurse".

Computer in the vaccination room

Current healthcare legislation does not contain direct prohibitions on the installation of office equipment in the treatment room. That is, it is possible to equip a nurse’s workplace with a computer, but subject to accuracy technological process work and avoiding the crossing of flows with varying degrees of epidemiological danger.

When organizing your workspace and placing equipment and machinery, you should adhere to the principles of ergonomics. The standardized area of ​​the treatment room (12 sq. m) should be increased taking into account the number of workstations equipped with computers. The area of ​​one user's workplace should be:

• 6 sq. m - for users of computers with VDT based on a cathode ray tube;
• 4.5 sq. m - for users of computers with VDT based on flat discrete screens (LCD, plasma).

These standards for increasing the area are given without taking into account auxiliary devices - printers, scanners, copiers.

Office equipment should be placed based on the requirements of the sanitary and anti-epidemic regime. A computer is a potential source of air and surface pollution in a room, so it must be thoroughly cleaned in a timely manner using disinfectants.



The procedure for wearing and changing a gown when working in a treatment room

The procedure for wearing and changing medical clothing is dictated by the requirements of distinguishing flows with varying degrees of epidemiological risk. It is also necessary in order to prevent contamination of the production environment of premises with different cleanliness classes.

Requirements for staff uniforms and their replacement, depending on the level of contamination of indoor air with microorganisms (operating unit, wards, dressing room, procedure and vaccination rooms, infectious diseases department) and the type of manipulation performed (surgical and parenteral interventions, cleaning, changing linen, etc.) defined in SanPiN 2.1 3.2630-10.

According to the rules, medical staff must put on special clothing before starting work and when entering a sterile room and change it when moving from one type of manipulation to another.

GOST R ISO 14644-5-2005 prohibits the removal of protective clothing from the “clean” room area, however, the typical procedure for medical workers wearing and leaving the “clean” room is described in the reference appendix to this document.

Operating time with sterile tray

Unpackaged sterilized instruments are used for their intended purpose immediately or stored on a sterile table for no more than 6 hours.

Storing such instruments in open form strictly prohibited. If necessary, it is allowed to store sterilized, unpackaged instruments in bactericidal chambers for the period specified in the operating instructions for medical equipment.

If a small or large instrumental work table is covered in the treatment room, the periods of storage and use of sterile medical products are determined by the terms of its covering.

✪ Methods of working with sterile materials after opening the package: step-by-step algorithm in the Chief Nurse System.✪

Products and instruments that were not used during the procedure must be re-sterilized.

As for the tray, during operation it is laid out on the manipulation table immediately before use for a particular patient. The number of sterile trays and other products and instruments must be sufficient to ensure uninterrupted operation of the treatment room.

Technique for collecting venous blood in the daily practice of a treatment room nurse

Test results may be affected by provider errors during blood collection. Check whether your employees perform this manipulation correctly.

In the journal “Chief Nurse” we present a protocol that describes step-by-step the actions of a nurse during a blood draw using Greiner Bio-One materials as an example:

1. Remove the gray protective cap from the valve part of the reversible needle. An intact perforated label is an indicator of the sterility and integrity of the needle. If the perforation is torn or damaged, discard the needle and get another one.

2. Screw the double-ended needle perpendicularly into the holder. Failure to screw the needle into the holder correctly may result in damage to both the holder and the needle, and subsequent needle fallout.

The full algorithm of actions is available to clients of the “Chief Nurse” magazine.

Separate table for blood collection in the treatment room

The requirements for the equipment of the treatment room are determined by the provisions of the Procedure for the provision of medical care, developed according to its individual types, profiles, diseases or conditions (according to Federal law No. 323-FZ of November 21, 2011 “On the fundamentals of protecting the health of citizens in the Russian Federation”).

However, not a single order contains a requirement for a separate table for blood collection. It cannot be found either in the Resolution of the Chief State Sanitary Doctor of the Russian Federation No. 58 dated May 18, 2010 “On approval of SanPiN 2.1.3.2630-10 “Sanitary and epidemiological requirements for organizations engaged in medical activities”, or in the Resolution of the Chief State Sanitary Doctor of the Russian Federation No. 1 dated 01/11/2011 “On approval of SP 3.1.5.2826-10 “Prevention of HIV infection”.

This requirement is provided only for the equipment of polyclinic consultative and diagnostic centers for examining citizens who live and work in event zones established around chemical weapons storage facilities and chemical weapons destruction facilities in accordance with Order No. 400 of November 5, 1999 “On measures to implement the Government Resolution Russian Federation dated September 22, 1999 No. 1082.”

Object of control	Subject of control	Responsible	Executor	Periodicity
Indoor surfaces, honey. furniture, equipment (including ventilators, anesthesia and respiratory equipment, hemodialysis, artificial blood circulation, dosing equipment, incubators)	Compliance with the frequency of preventive disinfection (routine and general cleaning)	Head nurse of the department	Middle and junior medical staff of the departments	Monthly Weekly (selected)
	The effectiveness of preventive disinfection	Head nurse of the department	LPO Laboratory(*)	2 times a year (select premises according to schedule)
	Efficiency of focal and final disinfection	Head nurse of the department	LPO Laboratory(*)	On every occasion infectious disease And according to epidemiological indications
Indoor air	The effectiveness of preventive disinfection (bacterial contamination of the air, CFU, Staphylococcus aureus) in operating rooms, maternity rooms, treatment rooms, dressing rooms, surgical rooms (including urological, dental, gynecological, endoscopic, procedural), blood transfusion departments, hemodialysis	Head nurse	LPO Laboratory(*)	2 times a year
	Ensuring compliance with the requirements of operational documentation for installations	Responsible person	Nursing staff of departments	Annually
	Maintaining a log of registration and control of air disinfection installations	Older sister	Responsible person	Constantly
Chemicals for disinfection/sterilization	Availability registration certificates, certificates of conformity for the disinfectants used and instructions for their use	chief nurse (responsible person for storing disinfectants funds)		Upon admission each batch
	Availability of a minimum monthly supply of disinfectants	Head nurse	Head nurse of the department	Monthly
	Determination of the concentration of working solutions of disinfectants and sterilants using chemical indicators	Head nurse of the department	Nursing staff working with disinfectants	Weekly (at least one sample of each type)
	Laboratory control (physico-chemical and analytical) DW	chief nurse (responsible person for storage of disinfectants)	chief nurse (responsible person for storage of disinfectants)	At the stage of acceptance of each batch (if there are means of quantitative control of the content of the active substance), in case of unsatisfactory results of chemical control of the concentration of working solutions
	Compliance with the storage conditions of the product and its working solutions, compliance with the values ​​of the mode parameters application (specified concentration, temperature of the working solution and holding time)	Head nurse of the department	Nursing staff of departments	Daily with each treatment (disinfection, sterilization)
(*) In the absence of a laboratory in a health care facility, the performer of the work is determined under an agreement with an organization accredited in the “System of accreditation of laboratories carrying out sanitary epidemiological research and testing” (**) work is carried out under the contract by an analytical laboratory accredited by the accreditation body for analytical laboratories in the system of accreditation of analytical laboratories (SAAL).