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The Joint Commission is spending time during survey evaluating pressure differentials in a variety of spaces. What are they looking for and why?
The standard in question is EC.02.05.01, EP 6, “In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies.”
In an effort to reduce the risk of hospital acquired infections (HAIs), JC is checking to make sure that air is flowing from clean to dirty spaces. Hence, soiled areas are to be under negative pressure and clean areas are to be under positive pressure. Areas are defined in the ANSI/ASHRAE/ASHE standard 170-2008, “Ventilation of Healthcare Facilities,” found at the back of the Guidelines for Design and Construction of Health Care Facilities, 2010 edition, administered by the Facility Guidelines Institute and published by the American Society for Healthcare Engineering (ASHE). This document also defines an appropriate pressure differential as 0.01 inches of water column, whether positive or negative.
There is no regulatory requirement on how to measure the pressure differentials or how frequently, but it is critical that the differentials be correct when the surveyor evaluates them, typically with a tissue test. Our recommendation is that the differentials be measured AT LEAST annually and verified quarterly. (FacilityDude’s MaintenanceEdge can help schedule these measurements and provide documentation that they were reviewed.) Not only is the JC element of performance scored as a direct impact, but non-compliance often rolls up to a CMS condition-level deficiency. This will bring in CMS for a full survey and also a return visit from JC within 30 days.
But the bottom line rationale is the patients. Hospital acquired infections are responsible for about 100,000 deaths annually, 5% of which are due to airborne contaminants. If we can prevent even some of those 5000 annual deaths, we have made hospitals a safer environment.
Susan B. McLaughlin, MBA, FASHE, CHFM, CHSP, MT(ASCP) SC, is managing director of MSL Healthcare Consulting Inc. Susan is a nationally known speaker in the field of healthcare safety and regulatory compliance, and has authored numerous articles and books on related topics.
1. Joint Commission Resources, 2013 Hospital Accreditation Standards, Oakbrook Terrace, IL, 2013.
2. Facility Guidelines Institute, Guidelines for Design and Construction of Health Care Facilities, Chicago, IL, 2010.