This blog is brought to you by our strategic partner MSL Healthcare Consulting.
Developing a process to ensure that your ventilation systems are functioning properly can present a challenge. Surveyors from TJC will use the “tissue test” to ensure your critical areas meet Table 7.1 in the 2010 edition of the Guidelines for Design and Construction of Healthcare Facilities unless you can demonstrate that your rooms were designed to a different standard. Be aware that the Guidelines for Design and Construction of Healthcare Facilities is a design guide for new and newly renovated areas. Your spaces must comply with the edition of the Guidelines that was in effect at the time of original design.
This is especially important when looking at the required number of air changes per hour (ACPH) for a room. For example, older hospital operating rooms were designed for 15 air changes per hour instead of the 20 air changes required in the 2010 edition. If your systems were not designed for 20 air changes per hour you’ll be unable to achieve those rates. Also note that even pressure differential requirements have changed for Endoscopy and unless there is compelling data suggesting that the original design is in some way contributing to higher than normal infection rates, there is no reason to expend capital funds to upgrade the systems to meet the current requirements.
Therefore, it is important for each organization to establish their own testing standards based on their facility’s design. We recommend that you establish benchmarks for each of these critical areas based on the original design specifications and be sure to describe this process in your “Utilities Management Plan”. Ensure that temperature and relative humidity is monitored in all anesthetizing areas and rooms where sterile products are stored.
We are frequently asked if continuous monitoring through a Building Automation System (BAS) is enough to meet these requirements. Although these systems provide a wealth of valuable data, you must be able to organize the data to show reports of when rooms were out of compliance and provide evidence that staff in the area monitored were alerted to conditions being outside the desired range and also note follow-up actions taken to correct the situation. Air pressure differentials and even air flow / air change rates can be monitored by a BAS. However, facilities using a BAS must ensure appropriate testing and calibrating of their monitoring system according to manufacturer recommendations. Manual daily recording of temperature and relative humidity by staff in the area allows immediate knowledge when conditions are out of range. Follow-up can then be as simple as “called Engineering” as long as the problem does not continue to the next time conditions are recorded. Sterile storage areas can have something as simple as a “max-min” thermometer to demonstrate that temperatures are maintained within the range required for products being stored.
Finally, be sure not to overlook filtration efficiencies. The standard details minimum filtration requirements and in most cases our documentation of filter changing is all that is kept. However, it is important to ensure that properly rated filters are properly installed in each unit per the original design and filters changed according to the manufacturer’s pressure differential recommendations. All of this information should be recorded on the unit’s PM record in your CMMS, such as FacilityDude’s MaintenanceEdge.
Wayne Klingelsmith, MBA, FASHE, CHFM is a Principal at MSL Healthcare Consulting Inc. Wayne has over 30 years of experience as a healthcare facilities director and 10 years of national consulting experience in the Environment of Care™, Life Safety and facilities management.