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A Guide to Best Practices in Hospital IAQ
By Andrew J. Streifel
November 19, 2007
In hospitals, it is critical maintaining IAQ. Excess moisture in wall spaces can foster mold growth.
Above, a Fluke 971 Temperature Humidity Meter collects humidity and temperature measurements.
1AQ isa significant issue in health care, Airbome organisms common in the environment can pose a
serious threat to a patient who is immune-compromised. A patient ill with a respiratory infection can
spread dangerous microbes to other patients, staff, and visitors. Yet, it’s easy to understand the steps
required to establish, monitor, and maintain safe, comfortable air quality and prevent airborne
nosocomial (hospital-acquired) infections
To deliver IAQ appropriate for an environment of care, facility managers, contractors, and maintenance
personnel should take action in four areas:
1. Set up administrative controls. These are policies and procedures to identify and manage risk
2, Understand facility function and design requirements. For instance, hospitals must provide
contaminant control facilities to protect immune-compromised patients and isolate those with infections
that can be spread through the air, such as tuberculosis.
3. Monitor and document air quality and system performance to guide system operation and
maintenance.
4, Develop contingency plans to guide responses when construction and renovation projects arise or
emergencies occur, such as leaks, spills, and floods.
‘The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has outlined some
basic environment of care standards:
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+ Hospitals must assess and control risks, including those related to HVAC and other utility systems
+ They must regularly inspect, test, and maintain those systems
+ They must design, install, and maintain ventilation equipment to serve airborne contaminant control
facilities, and document their maintenance activities.
In addition, hospitals are expected to carefully assess the risks construction activity raises for air quality
and infection control. Bottom line: There is plenty to consider in order to maintain appropriate [AQ in a
health care surrounding
ESTABLISHING PROTECTIVE ENVIRONMENTS
Some medical procedures and patient conditions increase risk of exposure to airborne microorganisms
Air quality management is vital in reducing these risks.
The Centers for Disease Control (CDC) provides detailed hospital rooms guidelines for managing the
risk of airborne infection
+ Operating rooms: In operating rooms, patient tissues and organs are exposed to the air, creating
opportunity for airborne microbes to enter the surgical site, In addition, use of cautery and lasers can
release materials and organisms into the atmosphere. An effective operating room ventilation system
introduces HEPA-filtered air through laminar flow from the ceiling and removes exhaust air through
returns at the margins of the room. Positive pressure in the room keeps air moving from clean (within the
room) to dirty. Use of negative-pressure anterooms and attention to keeping doors closed helps maintain
correct pressure relationships.
+ Protective environment rooms: Immune-compromised patients, such as organ transplant patients
receiving immunosuppressive treatment, may be unable to resist infection by common organisms such as
Aspergillus Fumigatus, a common soil fungus that is able to live and reproduce in the warmth and
moisture of the human lung. Aspergillosis is difficult to diagnose and treat, and is fatal more than 80
percent of the time. In rooms housing such patients, supply HEPA-filtered air at a rate of six to 10 air
changes an hour to maintain positive pressure (pressure differential greater than 0.01 inches water gauge
[2.5 Pal) and keep air flowing from the room out
+ Patient isolation rooms: Negative-pressure isolation rooms house patients with infectious diseases
spread by air (M. tuberculosis is one example). Air exhaust volume exceeds air intake by about 10
percent, or more than 125 cubic feet per minute, so that air flows from corridor or anteroom into the
patient space. Carefully seal ducts, doors, walls, and windows to maintain negative pressure and help
control airflow direction. You can take further steps - such as placing local exhaust ventilation near the
patient’s head, supplying surgical masks for the patient, and placing ultraviolet light fixtures in the room
- to reduce the concentration of airborne bacteria
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Using a Fluke 922, a technician in a hospital tests the pressure differentials between all spaces (or
construction zones) and adjacent uncontrolled areas to verify that pressures meet specifications and air is
flowing as required, from clean to dirty. Contractors can also test to verify that temporary enclosures,
barriers, and negative-air machines are correctly installed and functioning in a hospital environment.
PERFORMANCE MONITORING
Even in a well-designed facility, performance can decline over time. Blowers fail. Filters do their jobs
but eventually become clogged, reducing airflow. A door left open or a window improperly sealed can
disrupt pressure and airflow. A planned program of performance monitoring and maintenance can give
you the base of information you need to detect and remedy such problems before they compromise air
quality and health.
Health and comfort depend on a number of air quality factors, including the following:
+ Temperature - Primarily a comfort factor, though temperature extremes could affect health.
+ Relative humidity - In combination with temperature, humidity is an important comfort factor.
+ Pressure relationships - These govern the direction and speed of airflow.
+ Airborne particle sizes and numbers - They can indicate effectiveness of filtration and suggest the
need for further analysis to determine particle content,
Phe nature of airborne particles - Some particles are inert and harmless. Others can trigger allergies,
and some microorganisms, such as airborne viruses and bacteria and even common fungus spores, such
as A. Fumigatus, can cause infection.
Surface temperatures - Surfaces below the dew point can cause condensation. Damp surfaces in tum
help create conditions for mold growth.
SIMPLE TECHNIQ
MEASUREMENT
FOR AIR QUALITY
Key to your ability to control these air quality parameters is measurement. A consistent program to
monitor and measure indoor air conditions serves to verify that targeted air quality conditions are being
met; provide early warning when conditions change, so corrections can be made; and create evidence of
sound management oversight, (Your track record could prove useful in the event of a question or
litigation.)
You must base an effective air quality program on measurable air quality standards. Establish air quality
target levels and pressure requirements appropriate for the function of the space in question. Air quality
acceptable in a cafeteria, for instance, would not meet standards for a patient isolation room. Most
restrooms don’t need a HEPA-filtered air supply, but they should have negative pressure.
Next, set a schedule for monitoring and measuring air quality and air-handling performance. People
change things. For instance, they open and close doors, windows, and air vents. Blower motors and
drives fail. Technicians may install filters incorrectly, or fail to replace them on schedule.
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Measurement of the following items using the appropriate instruments/processes will help you identify
emerging issues:
+ Pressure and flow - Air pressure sensors installed in patient isolation facilities show from the outside
whether the room is meeting pressure requirements. A hand-held pressure test probe inserted under the
door provides a check. A smoke tube provides a visible indication of airflow.
+ Temperature and humidity - A hand-held tester provides a quick reading of relative
humidity /temperature parameters,
+ Particles: Number and nature - A hand-held particle counter shows numbers and sizes of airborne
particles. Use the counter to check filter performance (air downstream from a 90 percent filter should be
much cleaner than the air upstream, while air downstream from a HEPA filter should be virtually
patticle-free). Access ports installed in air ducts make it easy to test particle levels upstream and
downstream of filters
Many factors can cause an increase in particle numbers. Is the entrance open to a dusty construction
zone? Have hospital staffers rushed to a room to deal with an emergency situation? (Humans shed one-
half million particles each minute.) Or has a plumbing leak enabled a colony of mold to grow? Particle
counters determine the number but not the nature of airborne particles. Verifying the nature of particles
requires the capture of samples on a test medium, which is then cultured and analyzed to determine the
species and concentration of fungi (the most likely health threat) present. This process can require several
days.
+ Tracking airborne gases - CO2 is a natural byproduct of human respiration, so it ean be used as an
indicator of IAQ. If CO2 levels are excessive, you can assume that other gases - such as volatile organic
compounds (VOCs) emitted by building materials, paints, and carpets - are also building up. CO2 levels
beyond 1,000 ppm may show that not enough fresh outside air is being mixed into the indoor air supply
to dilute gases. You can measure CO2 levels with a hand-held meter.
Carbon monoxide is a poison. You can use both fixed and hand-held CO testers to detect the presence of
this dangerous gas.
+ Measuring filter performance - Air filter efficiency actually increases during use as trapped particles
increase the density of the filter medium. Over time, however, the accumulation of particles impedes
airflow. Install monitoring devices, such as manometers, or gauges to measure the pressure drop across
the filter. When the pressure drop exceeds the filter manufacturer's specifications, replace the filter.
+ Moisture and mold - Moisture meters measure moisture levels on and within materials, such as
wallboard, concrete, and wood, These materials can absorb significant amounts of water and, when the
moisture remains and temperature is right, provide a base for the growth of mold, which rele:
into the air.
S spores
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Construction can generate large amounts of dust and debris, made worse by movement of workers and
equipment in and out of containment zones. Taking regular particulate measurements with a laser particle
counter is considered the best way to identify and troubleshoot these problems. (In use above is a Fluke
983.)
RESPONDING TO ABNORMAL CONDITIONS AND
INCIDENTS
Ifnot managed correctly, construction can trigger changes that damage air quality and threaten patient
welfare. Hospital accreditation guidelines suggest that hospitals conduct a proactive risk assessment
when planning construction, and addressing impacts on air quality and infection control, as well as other
factors,
Construction may disturb spaces like ceilings and walls that may have received no maintenance or
cleaning for decades. Even the most careful contractor will inevitably create dust and fumes. New
building materials may release VOCs
In addition, construction may entail changes to ventilation systems and the building envelope that create
pathways for airborne pollutants and water to enter patient spaces.
To reduce such threats, carefully seal construction areas off from protected environments, You may want
to use a portable air filter unit to reduce particulates within the construction area, Set up exhaust fans to
make the construction area a negative pressure zone and cut pollutant infiltration into patient areas.
Like construction projects, water leaks, floods, and spills are common in a health care setting. If building
materials remain wet for more than 72 hours, they may become a base for mold growth.
Combating such problems starts before the moisture arrives. When planning new construction, it is good
practice to specify building materials that do not provide a food source for mold
When leaks and spills do occur, take immediate action. Test for moisture and dry soaked materials within
72 hours. Replace water-damaged materials and those that cannot be dried, or show evidence of mold
growth.
CONCLUSION
‘When it comes to air quality issues, hospital facility managers face a significant challenge. Hospitals
house patients highly vulnerable to airborne infection, as well as those whose coughs and sneezes can
spew out dangerous microorganisms. A large and busy staff is constantly on the move within an
extremely complex physical infrastructure, Construction and renovation projects and maintenance issues
are commonplace.
All of these factors place a high priority on air quality management. The process begins with
understanding the air quality requirements of specific hospital fimetions and patient populations, HVAC
systems are designed and operated to deliver the required air quality and pressure in special-purpose
facilities, such as protective environment rooms. Finally, system performance is consistently monitored
to ensure air conditions meet the institution’s standard of care.
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The use of hand-held air quality test instruments makes this maintenance and operation oversight easier
Such tools are accurate, convenient, and easy to use, Most important, they give the technician clear
evidence of what is happening in the invisible world of air quality - data that forms the foundation for
effective decisions.
Sidebar: Facility Design
Architects and engineers must design health care HVAC systems to control airborne infectious agents
and pollutants, manage air pressure and direction of flow, and deliver other air conditions required for the
health and comfort of patients and staff. The principles they work with include:
+ Control air pressure and flow. A key step is to establish pressure relationships that move air from
clean environments (higher pressure) to dirty or contaminated areas (lower pressure). You can create
pressure differentials by using exhaust fans (as in a restroom or construction area) to reduce pressure, by
increasing air supply to boost pressure, and by combining these measures. By stopping leaks in duc
windows, ceilings, and doors, you can reduce uncontrolled air movement that can disrupt airflow
patterns.
+ Establish appropriate air filtration. Filter air to reduce airborne particle counts to levels appropriate
for each facility and function, Minimum filter efficiency should be 90 percent of particles 0.5 microns
and larger. In facilities where patients are at greatest risk of airbome infection, such as operating rooms
and rooms for bone marrow transplant patients, deliver supply air through high-efficiency particulate air
(IEPA) filters.
+ Add fresh air to the mix. To reduce the levels of gaseous contaminants such as CO2 (a product of
human respiration that can be used as an indicator of air exchange levels), add filtered, conditioned
outside air to the atmosphere within the facility. Untreated outside air is likely to have more particulates
but less CO2 and other gases than inside air
+ Monitor system performance. Keep an eye on system function by measuring and logging air quality
(relative humidity, temperature, particle levels, and gases) and air pressure and flow regularly, using a
combination of fixed and hand-held instruments
Publication date: 11/19/2007
Andrew Streifel is a hospital environmentalist at the University of Minnesota (Minneapolis), with the
Department of Environmental Health and Safety, Streifel can be reached by e-mail through Chris
Rayburn at Fluke: Christopher Raybum@fluke.com,
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