1. 1 Ventilation, Temps and Humidity Requirements PO Box 3187 Charleston, WV 25332 www.mckennaconsulting.com 304-988-1047 Inquisit February 6, 2014

2. 2 Ventilation, Temps and Humidity Requirements Relevance Without high quality ventilation  Healthcare workers, patient visitors can become infected  Poorly ventilated – pathogen particles very high  Higher concentrations, higher efforts

3. 3 Ventilation, Temps and Humidity Requirements Relevance CMS – draft worksheets under Infection Control TJC – Focus on temperature, humidity, and pressure gradients State Surveyors – Focus on temperature, humidity and pressure gradients (sometimes have higher requirements)

4. 4 Ventilation, Temps and Humidity Requirements Findings for TJC EC.02.05.0146% EC.02.06.0136% IC.02.02.0147% Healthcare organizations fail

5. 5 Ventilation, Temps and Humidity Requirements Findings for CMS Section 1.A.5 Infection control/prevention program and resources  at least 6 (existing facility) or 12 (new construction/renovation) air changes per hour or per state licensure rules) and;  direct exhaust of air to outside, if not possible air returned to air handling system or adjacent spaces if directed through HEPA filters and;

6. 6 Ventilation, Temps and Humidity Requirements Findings for CMS Section 1.A.5 Infection control/prevention program and resources  when AIIR is in use for a patient on Airborne Precautions, documentation that monitoring of air pressure is done daily with visual indicators (smoke tubes, flutter strips), regardless of differential pressure sensing devices (i.e. manometers)  AIIR door kept closed when not required for entry and exit

7. 7 Ventilation, Temps and Humidity Requirements Findings for CMS Section 1.D.7 Personnel Education System / Infection Control Training  The hospital infection control system ensures that respiratory fit testing is provided at least annually to appropriate healthcare personnel

8. 8 Ventilation, Temps and Humidity Requirements Findings for CMS Section 4.H Isolation: Airborne Precautions  4. H.1 NIOSH-approved particulate respirators (N-95 or higher) are available and located near point of use  4. H.2 Signs indicating patient is on Airborne Precautions are clear and visible  4. H.3 Patients on Airborne Precautions are housed in airborne infection isolation rooms (AIIR)  4. H.4 Hand hygiene is performed before entering patient care environment

9. 9 Ventilation, Temps and Humidity Requirements Findings for CMS Section 4.H Isolation: Airborne Precautions  4. H.5 HCP wear a NIOSH-approved particulate respirator (N95 or higher) upon entry into the AIIR for patients with confirmed or suspected TB. Facility policies are followed for other pathogens requiring AIIR  4. H.6 Facility limits movement of patients on Airborne Precautions outside of their room to medically-necessary purposes (note policy should address that patient wear surgical mask)

10. 10 Ventilation, Temps and Humidity Requirements Findings for CMS Section 4.H Isolation: Airborne Precautions  4. H.7 If a patient on Airborne Precautions must leave their room for medically necessary purposes, there are methods followed to communicate that patient’s status and to prevent transmission of infectious disease (note policy should address that patient wear surgical mask when transported)

11. 11 Ventilation, Temps and Humidity Requirements Findings for CMS Section 5.A Protective Environment (e.g. Bone Marrow patients)  5. A.1 Positive pressure [air flows out to the corridor].  5. A.2 Twelve (12) air changes per hour  5. A.3 Supply air is HEPA filtered  5. A.4 Well sealed rooms so that there are no penetration spaces in walls, ceilings, or windows  5. A.5 Self closing door that fully closes on all room exits

12. 12 Ventilation, Temps and Humidity Requirements Findings for CMS Section 5.A Protective Environment (e.g. Bone Marrow patients)  5. A.6 Documents and demonstrates that failures are addressed  5. A.7 For patients requiring a Protective Environment, the hospital ensures that ventilation specifications are monitored using visual methods (e.g. flutter strips, smoke tubes) and observations documented daily

13. 13 Ventilation, Temps and Humidity Requirements Space Ventilation Air movement  Generally from clean to less clean  Variable air volume or load shedding for energy conservation cannot compromise the minimum air exchanges  Ventilation rates provide comfort as well asepsis/odor control

14. 14 Ventilation, Temps and Humidity Requirements Space Ventilation Air Exchanges  Supply in positive pressure  Exhaust in negative pressure

15. 15 Ventilation, Temps and Humidity Requirements Space Ventilation Air Filtration  Well defined for specific areas  Filter banks  Efficiency ratings  HEPAs – some areas including Protective Environment  Must have access to clean and to inspection  Pressure measuring devices

16. 16 Ventilation, Temps and Humidity Requirements Space Ventilation Humidifier  Outside humidity and internal moisture insufficient  Provided by healthcare facility air handling systems – many specs

17. 17 Ventilation, Temps and Humidity Requirements Isolation Rooms Negative Pressure  Airborne Infecting Isolation (AII)  Transmitted by airborne routes  Bacteria / virus suspend in air – carried long distances TB Varicella (chickenpox) Zoster (shingles) Measles

18. 18 Ventilation, Temps and Humidity Requirements Room Pressure Monitor

19. 19 Ventilation, Temps and Humidity Requirements Negative Pressure  -. 01 N  Staff should know what pressure should be  Alarms should not be bypassed when an airborne isolation room is in use

20. 20 Ventilation, Temps and Humidity Requirements CMS  Measure at least daily – not just gauge  Tools  Pressure Monitor/Smoke or flutter  Tissue (problems)  Documentation should be clear

21. 21 Ventilation, Temps and Humidity Requirements Pressure Gradients  Negative Pressure Model Patient Room  Lower pressure  Higher pressure (air into room) Exhaust (directly outside) 

22. 22 Ventilation, Temps and Humidity Requirements Test  Smoke Test  Smoke goes into the room – it is negative  Flutter  Flutters when it is exposed to the airflow  Negative-outside room doesn’t flutter inside-does flutter

23. 23 Ventilation, Temps and Humidity Requirements Problem Areas  Airborne Isolation Rooms  Protective isolation Rooms  Surgical Areas  Decontamination Areas

24. 24 Ventilation, Temps and Humidity Requirements See Findings - Word doc See Ventilation Requirements Chart – PDF

25. 25 References Draft Worksheets: http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey- and-Cert-Letter-13-03.pdf AIA ACADEMY OF ARCHITECTURE FOR HEALTH, UNITED STATES. DEPT OF HEALTH AND HUMAN SERVICES. Guidelines for design and construction of hospital and health care facilities. American Institute of Architects Press, 2010 Joint Commission (2014). Comprehensive Accreditation Manual, Department of Publications and Education Joint Commission Resources, Oakbrook Terrace, Illinois, 2014

26. 26 Thank you jatkins@mckennaconsulting.com McKenna Consulting Post Office Box 3187 Charleston, WV 25332 304-988-1047 www.mckennaconsulting.com