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Many of the organizations that we work with have struggled to identify which areas should be included in the routine testing and what spaces may safely be excluded. Specific area types are mentioned in a note to EC.02.05.01, EP 6 stating, “Areas designed for control of airborne contaminants include spaces such as operating rooms, special procedure rooms, delivery rooms for patients diagnosed with or suspected of having airborne communicable diseases (for example, pulmonary or laryngeal tuberculosis), patients in "protective environment" rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, and sterile supply rooms. In practicality, the list includes:
- Airborne infectious isolation rooms
- Protective Environments
- Operating Rooms, including C-Section Delivery Rooms
- Sterile Core
- Sterile Processing (decontamination, clean workroom, sterile storage)
- Endoscopy Rooms
- Bronchoscopy Rooms
- Endoscopy Scope Cleaning Rooms
- Cardiac Catherization Labs
- Interventional Radiology
- Clean and Dirty Work and Storage Rooms
Although this list will most likely capture all of the appropriate areas for most facilities, each organization should identify their critical spaces using an infection control risk assessment similar to those used when planning a construction project. Items to consider should include patient populations, types of procedures (if applicable), age and maintenance state of the equipment; and, equipment histories. Furthermore, it is important to track staff utilization of spaces. For example, the time to learn that a particular procedure room is being used for bronchoscopies is not during one of TJC’s patient tracers. The “best in practice” programs typically include ongoing communication with Infection Prevention so that they are aware of what has been tested and the results; and can request adjustments to the schedule when use changes or special situations exist. If you need help documenting what has been tested and when, a CMMS like FacilityDude’s MaintenanceEdge can help with documentation and ongoing communication.
Steve Spaanbroek, MBA, FASHE, CHC, CHFM is managing director of MSL Healthcare Consulting Inc. Steve has over twenty years of national consulting experience in the Environment of Care™ and facilities management.
1. Joint Commission Resources, 2013 Hospital Accreditation Standards, Oakbrook Terrace, IL, 2013.