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HVAC and indoor thermal conditions in hospital operating rooms

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DOI: 10.1016/j.enbuild.2006.09.004

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 Energy and Buildings 39 (2007) 454–470
www.elsevier.com/locate/enbuild

HVAC and indoor thermal conditions in hospital operating rooms

Constantinos A. Balaras *, Elena Dascalaki, Athina Gaglia
Group Energy Conservation, Institute for Environmental Research and Sustainable Development, National Observatory of Athens,
Ioannou Metaxa & Vas. Pavlou, GR 152 36 P. Penteli, Greece
Received 31 July 2006; received in revised form 5 September 2006; accepted 6 September 2006

Abstract
Hospital operating rooms (ORs) require efficient HVAC installations to secure the highly demanding indoor environmental conditions for
patients and medical personnel. This paper reviews published standards and guidelines on design, installation, commissioning, operation, and
maintenance of HVAC installations in hospital ORs, indoor thermal conditions, and summarizes measured data from short monitoring of indoor
thermal conditions along with audit results and main characteristics of 20 ORs in 10 major Hellenic hospitals. Measured indoor temperature ranged
from 14 to 29 8C, and relative humidity from 13 to 80%. The number of air changes per hour ranged from 3.2 to 58 ACH. The commonly
encountered problems include insufficient indoor air exchange, poor control on indoor thermal conditions, bad space ergonomics that influence the
ventilation system operation, poor technical installations maintenance and understaffed technical departments. However, there are still
opportunities for energy conservation, without sacrificing comfort, and overall quality of patient care or services.
# 2006 Elsevier B.V. All rights reserved.

Keywords: Hospital operating rooms; Operating theatres; Operating suites; HVAC; Indoor thermal conditions; Audits

1. Introduction
Hospitals and health care buildings are among the most
complex indoor facilities with numerous different end uses of
indoor spaces and functions. In particular, the most demanding
independent indoor zones are hospital operating theaters
(suites) that comprise operating rooms (ORs) or surgical
theatres, their interconnecting hallways and ancillary work
areas. The indoor environmental quality (IEQ) in ORs,
including thermal, visual and acoustical comfort and indoor
air quality, affects the working conditions, well-being, safety
and health of the medical personnel who work in these
environments. About 50% of the total number of doctors work
in the ORs, as surgeons or with other responsibilities (e.g.
anesthesiologists), while about 10% of the total medical staff
also work in the OR. Heating, ventilating and air-conditioning
(HVAC) installations control indoor air quality and aseptic
conditions, and secure healthy, safe and suitable indoor thermal
(i.e. temperature, humidity, air quality and airflow) conditions
for surgeons and medical staff, and of course, the patients.
The air in an OR must be aseptic, at a reasonably constant
temperature and humidity and have relatively low velocity in
* Corresponding author. Fax: +30 210 8103236.
E-mail address: costas@meteo.noa.gr (C.A. Balaras).
0378-7788/$ – see front matter # 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.enbuild.2006.09.004
order to avoid drafts and swirls that promote the recirculation of
microbes and may disrupt the procedures during an operation.
The ventilation rate is expressed as the volumetric air flow
through the space divided by the volume of the space, e.g.
number of air changes per hour (ACH). The desirable
conditions can be met by proper design, installation, operation
and maintenance of the electromechanical equipment, such as
the HVAC equipment and lighting systems of the space. Due to
their demanding indoor conditions, operating theatres con-
stitute the most expensive sector of the healthcare establish-
ment mandating an efficient management [1], reaching 33% of
the total cost [2].
First documented surgical facilities date from 500 BC [3].
New ORs have become high tech, with automatic controls for
adjusting indoor thermal and visual environmental conditions,
indoor air quality (e.g. proper air circulation, clean air supply
and exhaust of indoor contaminants), and are even equipped
with temperature and humidity displays, and decision-support
tools to alert medical staff. On the other hand, a great number of
existing ORs face serious problems with ageing HVAC
installations, and sometimes even luck fundamental services.
An OR can be considered a clean space with an emphasis on
controlling specific types of contamination rather than the
quantity of particles present. The airborne particulate cleanli-
ness level is differentiated by referring to class numbers
 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
specified by the maximum allowable number of particles per
cubic meter of air. According to the International Organization
of Standardization (ISO) Classification Air Cleanliness [4]
there are nine class levels, from Class 1 up to 9. An OR should
be at least ISO Class 7 (formerly Class 10,000 according to the
U.S. Federal Standard 209E, Airborne particulate Cleanliness
Classes in Clean Rooms and Clean Zones, 1992), which is an
atmospheric environment that contains less than 352,000
particles 0.5 mm in diameter per cubic meter of air. For ISO
Class 8 (formerly Class 100,000) atmospheric environment
contains less than 3,520,000 particles 0.5 mm/m3. Most
national standards have been or are currently being amended
to align with the ISO Standard [5,6].
Hospitals have the highest energy consumption per unit floor
area, in the buildings sector. The high-energy consumption is
due to the high space heating, cooling and ventilation loads,
continuous 24 h operation for the majority of the facilities, and
the high number of medical equipment. From an energy audit
campaign of Hellenic health care buildings in the early 1990s,
the average annual total energy consumption was reported as
407 kWh/m2 [7]. In another national investigation, the annual
total energy consumption was reported at 371.5 kWh/m2 [8].
More recent data from 10 hospitals in Athens, reported in this
paper, revealed an average annual total energy consumption of
about 426 kWh/m2.
Significant variations of energy consumption may occur
between different facilities, mainly due to differences in HVAC
installations; the majority of Hellenic hospitals are not fully air-
conditioned (central HVAC is mainly used in new hospitals).
For example, fully air-conditioned hospitals may reach annual
energy consumption close to 700 kWh/m2. The National Health
Service (NHS) in the U.K. has initiated an effort to reduce
primary energy consumption by 15% and eliminate the
emission of at least 15 million kg of carbon equivalent during
this decade and has published benchmarking values for best
practice [9]. Accordingly, U.K. healthcare facilities are audited
on an annual basis to monitor energy performance. The target is
for all existing buildings to improve to a level of 53 GJ/100 m3
(or about <445 kWh/m2) for good practice and 66 GJ/100 m3
(or about <550 kWh/m2) for typical total energy consumption,
while new premises are required to achieve a benchmark of less
than 55 GJ/100 m3 (or about <459 kWh/m2).
Hospital facilities managers are experiencing first hand the
higher energy operating costs and according to a recent survey
of U.S. hospital facilities managers [10] more than 90% of the
respondents reported higher energy costs over the previous
year, and more than half cited increases in double-digit
percentages. Ninety-three percent of respondents reported that
they will be implementing energy-savings initiatives in their
construction/renovation projects for the next 3 years.
While hospitals are increasingly interested in constructing
and maintaining green buildings, only a handful has become
deeply involved [11]. For example, in the U.S., of a total of
about 450 buildings nationwide that have registered for
certification from the leadership in energy and environmental
design initiative (LEED), only seven are health care institu-
tions. The Papageorgiou teaching hospital in Thessaloniki,
455
Greece is a prime example of an environmentally conscious
design that includes: naturally shaded exterior spaces to provide
better microclimatic conditions and amenity, use of daylight
whenever feasible for better and healthier lighting conditions
and reduced energy consumption, effective solar control to
reduce direct solar gains and cooling loads while allowing
proper daylighting, increased thermal insulation to reduce
heating and cooling loads, use of ceiling fans as hybrid cooling
systems in various spaces, natural ventilation where applicable
and elaborate energy saving systems for the building services
[12]. The annual energy consumption of the 600-bed
(70,000 m2) hospital is 156 kWh/m2, which is about 35%
lower than average Hellenic hospitals.
This paper focuses on indoor thermal conditions for ORs,
including temperature, humidity, and ventilation, providing
general HVAC design guidelines. It also summarizes the
findings from an investigation of 20 ORs at 10 Hellenic
hospitals, which included an audit of the HVAC installations
along with complementary measurements of indoor thermal
conditions in the ORs.
2. General design
Operating theatre design has responded to changes in
surgical needs and practice [13]. The size and number of ORs in
a hospital depends on the total size of the facility, the number of
beds and the type of medical treatment. Usually, the number of
ORs in Hellenic hospitals is about 2.5% of the total number of
hospital beds, although it strongly depends on the hospital
functions. The size of Hellenic ORs is at least 25 m2, while for
operations that require the use of several types of medical
equipment, the size of the OR may reach 75 m2; for minor
septic operations, the size may be smaller, down to 10 m2 [14].
A typical layout of an OR facility includes the main operating
room area, a reception patient area, the anesthesia room, the
sterile material rooms (clothes, tools, etc.), the scrub room, the
recovery room and auxiliary spaces (e.g. staff locker rooms,
storage areas). A corridor separates the septic and aseptic areas.
A proper space layout must isolate the OR from direct
communication with the other secondary use spaces (e.g.
offices, storage, locker rooms, etc.) in order to secure aseptic
conditions and minimize the risk of microbe migration. A well-
designed space layout can minimize functional problems in the
OR and improve the employees’ performance.
Common OR design problems include:
(a) Space availability: Several ORs are characterized by lack of
space availability and small dimensions. It is a common
practice in existing hospitals that in order to satisfy the need
to increase the capacity of the ORs, they resort to
renovations that simply increase the number of ORs by
reducing their dimensions and space availability. Even new
facilities sometimes have the minimum dimensions. This
creates adverse working conditions for the medical staff and
constitutes a common employee complaint.
(b) Space function: Some ORs include spaces with improper
functions (e.g. sterilization rooms), which could be moved
456 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470

outside since they may unnecessarily compromise the
indoor air quality with chemical substances, particles,
vapors, etc. Accordingly, spaces with this kind of function
should be moved to another part of the hospital, provided
sufficiently adjacent locations facilitate effective support by
the functions of the OR needs. The freed up space can then
be used to satisfy other needs.
(c) Secondary use spaces: The availability of spaces for storing
medical supplies and sterile equipment and instruments is
crucial for the proper function of the facility. Otherwise,
placing lockers for medical supplies and other equipment
inside the main OR area reduces the available free space,
although the OR may have the necessary dimensions. In
addition, these objects may pose a health and safety risk,
since they may constitute a pollution source, especially
when they are aged and not properly maintained. Septic and
aseptic spaces should be located on different floors to
minimize pollution risks.
In general, pathogenic microorganisms do not readily adhere
to walls or ceilings unless the surface becomes moist, sticky, or
damaged [15]. Little evidence exists that walls and ceilings are
a major potential source of infections. Wall coverings should be
fluid resistant and easily cleaned, especially in areas where
contact with blood or body fluids may occur, like in the case of
ORs. Firnishings around plumbing fixtures should be smooth
and water resistant. In addition, pipe penetrations and joints
should be tightly sealed. Acoustical tiles should be avoided in
high-risk areas because they may support microbial growth
when wet. False ceilings may harbor dust and pests that may
contaminate the environment if disturbed. Accordingly, they
should be avoided unless adequately sealed. Ideally, walls and
ceilings should have a smooth, impervious surface that is easy
to clean with minimal likelihood of dust accumulation.
3. Indoor conditions
The ORs are usually the most demanding areas in a hospital
for maintaining aseptic conditions and favorable thermal,
visual and acoustic conditions. In addition to ensuring proper
working conditions, which is a concern like in most working
environments, the other serious problem that may be
encountered are surgical site infections (SSI) that may involve
both patients and health care professionals who may be at risk
due to their long term exposure during their career.
Surgical site infection is the leading complication of surgery
[5]. While surgical methods have improved since modern
antiseptic surgery began in the 1860s, each year, some 700,000
patients in the United States suffer from SSI [16]. Data from the
U.S. shows that the direct cost of additional health care of these
SSI cases is at least $3.5 billion annually. The full cost
including time away from work, degraded life style, suffering
and death is surely much higher and demands the attention of
every profession involved.
Altogether, hospital acquired infections contribute to high
operating costs and even loss of human lives [17–19]. They are
now the fourth leading cause of death in the United States,
exceeding 100,000 annual deaths, behind heart disease, cancer
and strokes, according to the centers for disease control (CDC).
Most hospital infections may be preventable by appropriate
engineering design and maintenance of HVAC installations that
could contribute in reducing the risks for medical professionals
as well as for patients.
Infections are influenced by several factors [20,21], including
the type of surgery and the environment in which the procedure
takes place [22], ventilation or air-conditioning systems [23],
asepsis [24], sterile supplies [25] and equipment [26,27], and
even building works in and around hospitals [23,28].
3.1. Temperature
The indoor air temperature must be maintained within the
recommended ranges to ensure acceptable conditions. The
indoor air temperature must be uniform within the space. In the
OR, special care must be taken to account for the different
internal loads (e.g. surgical lamp) by proper design of the air-
conditioned supply and exhaust vents and temperature of the air
supply stream.

Table 1
Recommended indoor conditions for operating rooms
Temperaturea (8C) Relative humidity (%) Ventilation Source/references
20–23 30–60 Positive pressurization. Minimum 15 ACH, of which at least 3 ACH American Institute
should be outdoor air. Filter all recirculated and fresh air through of Architects [29]
min 90% efficient filters. In rooms not engineered for horizontal
laminar airflow, introduce air at the ceiling and exhaust air near the floor
17–27 45–55 Positive pressurization. Minimum 25 ACH with minimum 5 ACH of outdoor air ASHRAE [30]
20–24. 30–60 Positive pressurization (at least 2.5 Pa). Primary Supply Diffusers, non-aspirating. ASHRAE [31]
Minimum 20 ACH with minimum 4 ACH of outdoor air
22–26b 50–60 Positive pressurization. The air changes should be 60 m3/m2/h, German Institute
if the room height is 3 m, or else 20 air changes per hour for Standardization [32]
18–24 50–60 Positive pressurization with 15% excess air. Air flow rates Technical Chamber of
70–85 m3/h. Airflow can be reduced down Greece [33,34]
to 30% of the full load conditions during off-use hours Hellenic Health Ministry [35]
a
Use of lower or higher temperature is acceptable when patients’ comfort and/or medical conditions require those conditions, e.g. 17 8C for specialized procedures
such as cardiac surgery.
b
Reference supply airflow rate 0.67 m3/s.
 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
The desirable indoor air temperature is usually 20–24 8C,
according to international regulations and standards (Table 1).
Use of lower or higher temperature is acceptable when patients’
comfort and/or medical conditions require those conditions. For
example, for specialized procedures, such as cardiac surgery,
the indoor air temperature may be set as low as 17 8C; on the
other hand, pediatric surgeries usually demand a higher indoor
air temperature because children are more sensitive to lower
temperatures. In any event, a high indoor air temperature may
cause discomfort and offers more favorable growing conditions
for bacteria or their mitigation from and to the patient.
Practically, it is not possible to provide all occupants with
100% acceptable indoor thermal conditions. Similarly, the
medical staff working in an OR may have a different perception
of prevailing indoor conditions due to different levels of activity
and even working positions within the OR. In general, surgeons
tend to feel from ‘‘slightly warm’’ to ‘‘warm’’ [36]. Regulatory
sweating is also present very often. Anesthetists and nurses, by
contrast, experience from ‘‘slightly cool to cold’’ thermal
sensation. This is especially true for temperatures below 21 8C,
mainly because of the low cooling insulation. These are in
agreement with other studies where preferable thermal comfort
conditions were reported for anesthetics (23–24 8C), for nurses
(22–24.5 8C) and for surgeons 18–19 8C. For patient’s, the
recommended air temperature ranges between 24 and 26 8C.
Medical clothing will have a direct impact on personnel’s
thermal comfort conditions. Surgical scrub garments are
typically worn by OR personnel to control airborne contam-
ination, although there is no scientific data to support this
practice as a means for preventing transmission of infection
[37]. Heavier gown requirements used by the surgical team for
protective reasons during an operation (i.e. because of AIDS)
may require an indoor temperature down to 18 8C or even
lower.
Finally, asymmetric thermal radiation from surgical lights
on the surgical staff is a potential source of thermal discomfort
[36]. Thermal radiation emitted from surgical lights, results to a
radiant asymmetry ranging from 6 to 7 8C over the operating
table and from 10 to 12 8C over the floor level (at a height of
1.1 m), regardless of the indoor air temperature.
3.2. Humidity
Air humidity must be maintained at acceptable levels
because it is closely related to the space hygiene and thermal
comfort conditions. Humidity control is most often accom-
plished by treating the ventilated air for lowering (dehumidi-
fication) or increasing (humidification) its water content, using
proper equipment and controls. Using a rule of thumb, e.g.
54 L/(s kW), or a traditional temperature-only design approach
often leads to a system that is unable to meet the strict indoor
OR requirements [38]. Accordingly, various HVAC system
configurations can achieve the temperature and humidity
targets for an OR by delivering the required supply air
conditions, without energy waste.
High humidity levels favor the growth and transfer of
bacteria that can be easily become airborne on water molecules.
457
High humidity levels cause thermal discomfort. The ventilation
requirements influence humidity control. Depending on
climatic conditions, additional ventilation may increase the
dehumidification load more than the sensible cooling, imposing
a disproportionate demand on the HVAC equipment. Low
humidity levels (dry air) favor blood coagulation, which is
undesirable during a surgery. In addition, moisture can be
absorbed into the duct lining and building materials where it
may support microbial growth. With the heavy use of electric
equipment in the OR, low humidity levels may cause problems
associated with static electricity on medical equipment and
surfaces. In addition, this may even pose a fire hazard, as there
may be flammable gases present in the environment.
The recommended levels of indoor relative humidity are 30–
60%, according to international regulations and standards
(Table 1). Most regulations establish that ORs where the use of
in-flammable anesthetic gases is possible, volatile liquids are
used frequently, and in order to prevent the accumulation of
static electricity should maintain a humidity of about 60% [32].
Humidification may be necessary to increase low humidity
levels, commonly encountered during winter. Special care must
be exercised with humidification to assure that there is no
potential for transferring bacteria to the OR through the
ventilation system, since humidifiers may provide favorable
environment for bacteria growth. Proper maintenance and
cleaning practices will minimize this kind of risks. Humidifica-
tion is best accomplished by supplying dry steam. Cold-water
humidifiers in HVAC systems must be connected to a domestic
water source and provided with a drain line to remove the water
[39]. Stand-alone, console-type humidifiers that recirculate
water for humidification should not be used because the water
in these systems becomes contaminated with microorganisms
rapidly and have been linked to outbreaks of Legionnaires’
disease.
3.3. Ventilation
Separate rooms for surgery were recommended in the 18th
century but this was mainly for teaching and demonstration
purposes. It was only after the Second World War, and the
experience of dealing with major trauma, that official
documents recommended positive-pressure ventilation as a
means to reduce airborne infection [13,40]. Ever since, there
have been significant developments in OR ventilation in
relation to the design concepts in OR layout, pressurization and
ventilation, particularly the evolvement of ultra-clean ventila-
tion (UCV) [41,42].
Contamination by air was recognized by Pasteur in the mid-
19th century [43]. He soaked wounds and hands in dilute
carbolic acid solution and subsequently disinfected the air with
spray. The death rate from sepsis following amputation fell
from 46 to 15%. Carbolic spray was toxic and was subsequently
replaced by aseptic surgical techniques.
Today, proper OR ventilation has an important role on
occupant safety and health, including airborne contamination
[44] and infection and control [45,46], although infection rates
are still unacceptably high [47]. The optimum is complete
458 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
asepsis (exclusion of infective agents which might contaminate
the sterile inside of the body during surgery), but this may not
be possible in all cases.
About 80–90% of bacterial contamination found in a wound
comes from the ambient air [48]. OR air contains items such as
skin squames or other particles like lint, respiratory droplets,
aerosols [49], and waste medical gases used for anesthesia. The
air may also contain other particles, like lint, dust, respiratory
droplets and aerosols, and medical gases which may be used for
anesthesia. The primary source of bacteria in the OR are
squames, or skin scales, which are of the order of 10–20 mm in
diameter and are shed from exposed regions of skin, both from
the surgical staff and also by the patient [5,13,30,44,50] or may
even pass through the interstices of the standard cotton fabric
which has a pore size of 80  100 mm or pass from the bottom
of theatre garments to mix with the air circulating in the OR
[20]. It has been calculated that for a procedure lasting
approximately 1 h, the total number of bacteria-carrying
particles falling on a wound is about 270 cm 2, but the risk
of infection will depend on how many of these bacteria are
viable at the time of wound closure, the species and virulence of
the bacteria, the precise site of lodgment and the integrity of the
patient’s host defenses [40].
The main chemical parameters found in the indoor air of the
operating rooms are anesthetic gases, as well as disinfection
and sterilizing substances. Adverse health effects and
discomfort have been detected to OR personnel by the
occupational exposure to anesthetic gases (e.g. nitrous
protoxide and halogenated agents); thus, personnel exposure
should be limited [51,52]. Accordingly, anesthetic gases must
be recovered using scavenging equipment.
Prophylactic antibiotics are now used for a variety of
different procedures but are best given for clean prosthetic
implant procedures and in clean-contaminated operations [40].
In contaminated and dirty operations the use of antibiotics is
therapeutic and may need to be continued for longer than the
single dose used for prophylaxis. In Hellenic hospitals, the
prevalence of antibiotic use is quite high, reaching 51.4%
according to a nationwide investigation, while literature
reported data indicates significantly lower rates in other
European countries, ranging from 26 to 34% [53]. However,
antibiotic prophylaxis does not always guarantee proper
prophylaxis. According to a study by [54], 87% of those
who developed SSI had received antibiotic prophylaxis.
Accordingly, proper ventilation remains the primary
objective for securing a safe and healthy indoor OR
environment in order to: (1) reduce bacteria, viruses and dust
concentration to acceptable levels, so that the indoor air
satisfies the aseptic levels in accordance to health guidelines for
the patients and space occupants; (2) remove anesthetic gases
and odors released during an operation, which may perma-
nently or temporarily disturb the occupants; (3) provide
optimum and comfortable working conditions for the occupants
to facilitate their demanding work during an operation.
The air handling unit (AHU) used to serve the OR can be one
(single) or two (double) stage that is without or with a terminal
unit (TU). Accordingly, if the AHU is used to serve one or two
zones (spaces) with identical indoor conditions then it is
possible to use a single stage AHU. Alternatively, a double
stage AHU is used if an AHU serves more than two zones
(spaces) with different loads and indoor requirements. In this
case, there is one main AHU unit and more than two TUs. Each
terminal unit serves one zone. A TU includes a reheat coil and a
third class absolute filter (S). The supplied air from the main
AHU is supplied at the local TU at some specific conditions
(temperature and humidity). The desirable conditions of the
supply air are then adjusted at the TU by using the reheat coil.
This way it is possible to meet the different requirements for the
connected spaces/zones. In practice, the reheat coil is only used
to make small adjustments on the delivered air temperature (i.e.
a few degrees). Accordingly, if two zones have distinctively
different loads and desirable indoor air conditions, then there
should be best served by two independent AHUs.
3.3.1. Filters
The type and number of filters used in an AHU designated to
serve an OR must meet strict demands similar only to clean
room applications. The main filter groups include: (1) filters for
removing solid and liquid particles (viscous impingement and
dry screen available in renewable, cleanable and throwaway
variations, fibrous, electrostatic and air washers); (2) filters for
removing gases and vapors (e.g. activated carbon and chemical
filters); (3) filters for removing bacteria (e.g. ultraviolet or
germicidal lamps).
The control of microbial contaminants concentrations in
ORs is usually accomplished through the use of high efficiency
particulate air (HEPA) filters, ultraviolet germicidal irradiation
(UVGI), and strict hygiene procedures. However, particular
attention should also be given to the prevention of microbial
growth indoors and in the AHU, thus proper maintenance is of
great importance.
Three stage filters are commonly used. The first stage filter
B2, is a prefilter, placed right after the air intake of the AHU,
filtering the outdoor air. The prefilter (30–50% efficiency) can
arrest large dust particles and solid particles (>0.3 mm) and
improve the overall filter effectiveness. When properly
maintained, prefilters can reduce the growth of bacteria on
the main filter. The second stage filter C, is a thin filter (95%
efficiency) can arrest particles with a diameter less than 0.3 mm.
They are placed at the exit of the air from the AHU and may
also serve to withhold water vapor (droplets) or microorgan-
isms that may become airborne from the cooling coil. The third
stage filter S (special filter), has an even higher efficiency of
about 99.97%. This type of filters are placed as close as possible
to the OR, in order to clean the air from any particles that may
have escaped the previous filters or may have been drawn in
from the AHU itself or the ducts. Automatic dampers are placed
before the filters to isolate them when the AHU does not operate
and to prohibit any backward air flow from the OR to the AHU.
Airborne contaminants are usually attached to dust particles
or water molecules. Studies have shown that 99.9% of all
bacteria present in a hospital are removed by 90–95% efficient
filters [30]. This is because bacteria are typically present in
colony forming units that are larger than 1 mm. Viruses are
 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
more difficult to control since airborne infective viruses are
much less than 1 mm in size.
The use of UVGI to disinfect room air and air streams dates
to about 1900 [55]. In current commercial practice, UVGI using
either ventilation duct irradiation or upper-room air irradiation
(germicidal lamps with a primary wavelength of about 254 nm)
deactivates viruses, mycoplasma, bacteria, and fungi, and has
become popular in battling tuberculosis. However, human
exposure to ultraviolet C may cause some health side effects
and requires protection of the skin and the eyes of people
exposed to levels above recommended exposure limits.
Enclosing the UVGI sources in the ventilation system, human
exposure is eliminated. Illustrative examples with design,
performance and operating guidelines along with representative
figures to compare the cost of HVAC installations and UVGI
installations that give an equivalent number of air changes
based on equal levels of reduction in airborne microorganisms
are available in [43,55–57]. Studies on the effects of UVGI on
infection transmission rates show some statistically significant
effects, but little practical significance in reduction rates of
airborne infectious disease [58]. UVGI theatres have not been
adopted in the U.K. but are used in the U.S.A. and Sweden [43].
Outdoor pollutants can add to rather than dilute the indoor
chemicals and pose a significant problem if not properly
handled by molecular filtration [59]. Concentrations are
expressed as parts per billion (ppb) or parts per million
(ppm) and since they are in general 1000 to 10,000 times
smaller than a fine dust particle, they can pass through the finest
particle filters. Depending on the molecule diffusion gradient,
molecules diffuse through the indoor space from a high
concentration to a lower concentration area. Gas-phase air
filtration is possible with filters based on adsorption condensa-
tion or chemisorption processes.
3.3.2. Air changes and distribution
Laminar airflow (LAF), defined as airflow that is pre-
dominantly unidirectional when not obstructed and commonly
attained with an air velocity of 0.45  0.10 m/s, can either be
directed vertically (from the ceiling) or horizontally (from the
wall), with and without fixed or movable walls around the
operating table [30]. Laminar airflow systems were introduced
in the 1960s [60].
Ultra-clean ventilation air (UCV) is produced by using
laminar air flow supplied from the ceiling with low-level
exhaust outlets at the room periphery [40,61–64]. It is
combined with a HEPA filter located directly in the room
inside the air intake of the OR, and is usually necessary for ORs
used for high-risk operations, e.g. orthopedic implant surgery,
and not for general surgery or in the adjacent spaces. Such a
unidirectional downward laminar air flow pattern is achievable
with an air velocity at 0.46 m/s or below. UCV theatres are
scarce due to their high cost, while there are also practical
problems in keeping all medical staff and exposed instruments
within the UCV airflow, which is normally in a 2.8 m by 2.8 m
space [62]. Outside the UCV zone the flow is basically
turbulent, depending on the location of the exhaust vents and
possible flow obstructions or heat sources. However, a
459
unidirectional airflow ceiling diffuser area of about 9 m2
provides excellent screening effect that is suitable for complex
interventions and provide flexibility in order to cover amended
requirements for a wide range of surgeries [65], thus increasing
the utilizability of an OR.
The most widely used installation in general purpose ORs is
plenum—conventional ventilation [43]. However, it is difficult
to identify the best practice for all design applications of the
ventilation system, since there are advantages and disadvan-
tages [5,66]. For example, laminar flow systems are recognized
for providing lower general concentration levels in the OR, but
they are sometimes blamed for higher infection rates than more
conventional systems since they cause impingement on the
wound site. However, this probably depends on the use of high
laminar flow velocities at supply. On the other hand, vertical
laminar flow units are superior to horizontal airflow units
because clean air is directed over the operative field, while
UCV has been shown to reduce infections after total hip or knee
arthroplasty [40]. People, surgical lamps and equipment will
obstruct the airflow flow and constitute heat sources, even
resulting to minor air turbulence in vertical flow systems and
disrupting the unidirectional air flow of horizontal flow systems
[5,63,64,67]. A combination of vertical and horizontal flow,
known as exponential laminar air flow with the form of an
upside-down trumpet, is also possible.
For existing facilities, a new method introducing a mobile
screen supplying ultra-clean exponential LAF has been
developed [26]. The system is designed to work independently
as an addition to basic OR ventilation or in situations with
insufficient ventilation. The system contains a HEPA filter as
well as enclosed UVC-light for bacterial control.
The air supply diffusers vary in size and geometry depending
on the specific design. Air diffusers must have good throw
performance over a wide range of discharge velocities
depending on the function and geometry of the space, to
facilitate appropriate indoor air mixing of supply and indoor air,
and eliminate air drafts. Diffuser sound ratings should also be
taken into consideration before making a final selection. The
location and number of diffusers depends on the air volume to
be supplied into the space, the space layout and load
distribution, and temperature differential between the indoor
and supply air. Non-aspirating diffusers are recommended and
sized to provide a face velocity of 127–178 L/(s m2) in
accordance with current research recommendations [68].
The air return vents also vary in size and geometry
depending on the function of the space. According to
regulations, there should be at least two air-exhaust outlets
inside the OR. One position is close to the floor, in order to
remove the various anesthetic gases that may be released in the
space and because they are heavier than the air they are most
likely to be found at floor level. Anesthetic gases must be
removed because they may cause health problems or
discomfort to the medical team inside the OR. At the same
time they pose a fire hazard. The second position is high on the
wall in order to most effectively remove any bacteria or other
microorganisms and chemical substances that may become
airborne during a surgery. The breakdown of the air exhaust is
460 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
Fig. 1. Various examples of obstructing objects placed in front of ventilation air-exhaust outlets. (A) Vent blocked by a closet (pulled to the right to reveal the vent);
(B) vent partially blocked by a cabinet (left) and medical equipment (right); (C) vent partially blocked with oxygen bottles.
about 25% from the ceiling level air outlets and 75% from the
floor level outlets. The optimum layout of the air-exhaust
outlets is to have at every corner of the OR, one floor and one
ceiling height mounted exhaust. That makes a total of four floor
and four ceiling mounted exhausts. This layout also contributes
to a more uniform air circulation inside the space.
However, special care should be exercised to account for
possible obstructions of the airflow, for example, due to regular
occupancy, possible obstructions by equipment and other
furniture that may alter the flow path or even block the vents
(Fig. 1), and thermal buoyancy from medical equipment,
lighting, staff, or even the patient’s wound.
The most commonly recommended number of air changes
per hour is about 20 ACH (Table 1) to maintain the OR at a
positive pressure, while the outdoor air requirements for
acceptable indoor air quality must be at least 51 m3/h person
according to ASHRAE Standard 62 [69]. Special requirements
and pressure relationships may determine different minimum
ventilation rates and filter efficiencies. Procedures generating
specific indoor contaminants may also require higher air change
rates.
Each air change will, assuming perfect mixing, reduce
airborne contamination to 37% of its former level [20]. Little
further improvement occurs in the bacterial count after 20
ACH, unless the air is supplied from a high-volume vertical
supply that negates the effects of turbulence [40]. Turbulence
created by staff movement and the heat from operating lamps is
overcome by UCV systems that exclude contamination from
outside the ultra-clean area. Few countries have set bacterial
threshold limits for conventionally ventilated ORs, for
example, the German standard focuses on control of airborne
bacteria concentrations around the operating table and
instrumentation under specific limits, while the Chinese
standard emphasizes that the operating area is controlled by
bacterial concentration and air cleanliness [70]. However, most
national standards and guidelines recommend 20 ACH to
obtain 50–150 colony forming units (cfu)/m3 of air [5].
In the U.K., clean areas (operating theatre and preparation
room) should have ventilation equivalent to at least 20 ACH
[21]. The air change rate in preparation rooms used for laying-
up sterile instruments should be around 37 ACH; a greater air
change rate than in theatres (the main route of airborne
contamination entering surgical wounds is probably via
instruments). If preparation rooms are used only as sterile
pack stores, the ventilation rate should be around 11 ACH.
Effective air changes will only occur if airflow is turbulent and
there is no short-circuiting. These should have been established
by smoke testing.
The systems usually require 100% outdoor air. Some
national regulations and guidelines allow for a limited
recirculation under favorable outdoor conditions and for
certain types of surgeries, for example, the German [71] and
Swiss [72] guidelines. The indoor air that is exhausted from the
OR must not mix with the fresh outdoor air supply. Outdoor air
intakes must be placed away from the system’s exhaust air or
other building’s emission points (e.g. flue stacks and other
exhaust vents, cooling towers), at a distance of 3–23 m from
contaminant sources, with 7.6 m most common [31] or street
level emission sources (e.g. automobile exhaust), so that the
bottom of the air intake is at least 1.8 m above grade or 0.9 m
above roof level [31]. Prevailing winds, building geometry,
adjacent buildings or other obstructions, must be taken into
account. Outdoor air intakes must exclude wind-driven
precipitation, contain features for draining away precipitation,
and be equipped with a bird screen mesh.
The air distribution pattern in an OR is equally important to
the number of air changes [68]. In some cases, the airflow may
even convey airborne particles towards the wound, given the
close proximity of OR staff near the operating table. For
example, when the surgeon leans over the wound in such an
airflow direct airborne wound contamination increases 27-fold
[44] and is considered as a source equivalent to as many as 1000
airborne particles/min [73]. On the other hand, in convention-
ally ventilated theatres, around 70% of airborne contaminants
 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
that end up in the wound, do so after first landing on exposed
‘‘sterile’’ instruments [62].
The delivery of air from the ceiling, with a downward
movement to several exhaust inlets located on opposite walls
[66], is probably the most effective air movement pattern for
maintaining the concentration at an acceptable level [30]. The
air should be supplied at the ceiling and exhausted or returned
from at least two locations near the floor. Supply diffusers
should be unidirectional, while high-induction ceiling or
sidewall diffusers should be avoided.
The indoor air flow patterns in the OR must ensure that the
air masses are directed from the most demanding zones, in
terms of air quality, to the less demanding zones, and that there
are no pockets where the air can be trapped. The main air flow
pattern should not encounter any obstacles, especially in the
direction towards the main pollution sources around the
operating table (i.e. medical staff and patient). The air velocity
must be maintained at low levels to avoid drafts and turbulence
that will cause air mixing and the dispersion of bacteria and
airborne particles. The primary air supply diffuser array should
provide a unidirectional airflow, from the top downwards, with
an average velocity of the diffusers 0.127–0.178 m/s, in order to
maintain laminar flow and minimize strong drafts [31]. The
diffusers shall be concentrated to provide an airflow pattern
over the patient and surgical team, covering an area that extends
0.3–0.5 m on each side beyond the footprint of the operating
table. Additional supply diffusers may be required to provide
additional OR ventilation to meet the loads and satisfy indoor
thermal comfort conditions. Indoor air quality can improve
considerably by using scavenging equipment to recover
anesthetic gases.
Ensuring the appropriate airflow can contribute towards
infection control. The specific surgical procedures must also
be taken into account and optimize the air distribution system
accordingly [74]. Different levels of bacteriological contam-
ination can be observed in identical ORs, with the same
occupancy rate, air-conditioning systems and air distribution
with a definite turbulent pattern, depending on the type of
surgeries performed [73]. For example, the bacterial con-
centrations over the operating table in the case of dirty
wound operations usually exceed the contamination levels
encountered during traumatology surgery (e.g. with clean
wounds).
Previous studies reviewed in [47] have concluded that
reducing air contamination in the operating theatre reduces
wound contamination, ultra-clean air reduces deep infections
after joint replacements, the use of hats and masks decrease the
bacterial count in laminar flow theatres, wearing of non-woven
clothing decreases both the bacterial count in theatre and the
rate of postoperative wound infection, the passage of bacteria
through fabrics used in the operating room has been identified
as a source of wound contamination.
3.3.3. Design considerations and operation
Several key design considerations that determine the success
in maintaining aseptic conditions and avoiding the transfer of
bacteria, viruses and other contaminants from or to the OR and
461
the surrounding indoor or outdoor environment include the
following.
The OR is maintained at a positive pressure with respect to
corridors and adjacent areas. The minimum pressurization is
2.5 Pa [31,75]. Maintaining a positive pressure minimizes the
air from entering into the OR from the more contaminated
spaces. Zone pressurization introduces specific control require-
ments that can be accomplished by different methodologies like
flow tracking and differential space pressurization [76]. Each
entry door to the OR should be sealed on its top and sides
(including astragal vertical joint seal for leaf or double doors)
and include an adjustable bottom seal. A sliding entry door is
preferred over a swing door. If swing door is used, it should
open into the OR.
The air flow patterns are determined by the placement of the
air supply and exhaust vents in order to effectively collect and
control the dispersion of contaminants, eliminate zones with
trapped air or strong swirls and provide the desirable indoor
conditions throughout the conditioned space. Studies have
shown that when surgery is carried out in a substantially
downward and outward flow of microbiologically clean air over
an area large enough to encompass the wound and all things that
come into contact with the wound, sepsis is reduced by at least
50% [48].
Proper air circulation can be accomplished by various
arrangements. In general, outlets for air supply should be
located on the ceiling, with perimeter or several exhaust inlets
near the floor [30]. This arrangement provides a downward
movement of clean air through the activity zone (i.e. around the
operating table) to the contaminated floor area for exhaust. The
OR shall be provided with at least two low sidewall return
grilles with the bottom of these grilles installed approximately
15 cm above the floor [31]. In any event, as medical treatments
and other factors change over time for a particular type of
surgery, the relative importance and optimum design char-
acteristics of the air distribution system might also change [74].
Staff movement, especially entering and leaving the OR,
should be kept to a minimum, since the number of
microorganisms in the OR is directly proportional to the
number of people in the room, having a direct impact on the
ventilation system and on the concentration of microorganisms
and particles [20,44,49,60,63,77,78].
Historically, different ACH have been investigated in an
effort to correlate airflow rates and bacteria in the air and
their role in SSI, and assess their impact on OR indoor
environmental quality [77]. Recently, given current advances of
computational fluid dynamics, CFD analysis has become a
powerful and efficient tool for the parametric study on room
airflow and contaminant dispersion of the entire OR space
[42,50,66,79,80].
Considering a range of different air change rates, from 15 to
150 ACH, and different ventilation system designs, it appears
that laminar flow conditions are the best choice, although some
care needs too be taken in their design [50,66]. A face velocity
of around 0.15–0.18 m/s, is sufficient from the laminar diffuser
array, provided that the size of the diffuser array is appropriate.
The main factor in the design of the ventilation system is the
462 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
control of the central region of the OR where the operating
lights and surgical staff constitute a large heat source. Increased
ACH results in excellent removal of particles via ventilation,
but does not necessarily mean that the percentage of particles
that impinge on the wound site are also decreased. A lower
percentage of particles hit the site with 20 ACH, than with 150
ACH. In a system that provides a laminar flow regime, a
mixture of exhaust location levels works better than either low
or high level locations only. However, the difference is not
significant enough that the low- or high-level location systems
are not viable options.
Ideally, an AHU should serve only one OR and possibly an
additional secondary use space (e.g. scrub room) and should not
serve more than two ORs. However, this can also be handled by
other design means but need independent zone control. It is
recommended to maintain backup ventilation equipment (e.g.,
portable units for fans or filters) for emergency ventilation of
ORs, and take immediate steps to restore the fixed ventilation
system [81]. When two ORs are served by a common AHU,
they must operate with the same time schedule to minimize
energy losses. The independent operation of the HVAC
equipment in each OR must provide the means for adjusting
the indoor conditions, without affecting the performance and
the indoor conditions in the other ORs. The AHUs should be
located near the ORs in order to minimize the duct length for
the distribution of the supply air. This will reduce pressure drop,
fan energy consumption and energy losses.
The ventilation system should operate continuously, during
surgery and even when the OR is not being used, but possibly at
a reduced ventilation rate, in order to maintain continuous
aseptic indoor conditions and stand-by operation. Electro-
nically adjusting the fan speed using an inverter, can efficiently
meet different ventilation rates according to the load. This way,
it is also possible to meet the varying operating conditions
according to the pressure drop variations because of the
different filter conditions. When the ORs are not in use, the air
supply rate should be adjusted to 30% of the full load
conditions. Similarly, the fan for the exhaust air should also
have a minimum of two speeds for adjusting the exhaust rate
down to 30% of full capacity. Depending on the ventilation
system, implementing a proper control strategy during the off-
use hours can reduce the total air change rate and thus reduce
energy consumption [82]. An OR will be usable 15 min after
full ventilation has been restored, provided that pressure
relativities are maintained during setback [21], while vertical
laminar flow theatres need only 5 min to replace the full volume
of air in the theatre [20]. Control of setback is normally on a
timed basis and there should be an override linked to the
operating light or a movement detector so that setback does not
occur when lists over-run. There must be a setback override to
allow for unforeseen use of the theatre to occur.
In Germany, it is usual to reduce the volume of the circulated
air by 15–50% at times when the OR is not in use, while
regulations in Austria allow shutting down the ventilation
system [63]. In the U.S.A., according to the CDC [81], HVAC
systems serving offices and administrative areas may be shut
down for energy conservation purposes, but the shutdown must
not alter or adversely affect pressure differentials maintained in
the ORs. Whenever possible, avoid inactivating or shutting
down the entire HVAC system. In Greece, the airflow can be
reduced down to 30% of the full load conditions during off-use
hours [83]. Provided that measures are taken to ensure timely
restarting of the ventilation system prior to surgery (at least
30 min before the OR is used), findings suggest that shutting
down the OR ventilation system during off-duty periods does
not result in an unacceptably high particle count or microbial
contamination [63]. The time required for airborne contaminant
removal depends on the number of air changes per hour [81],
for example, for two ACH the minimum time is 138 min (for
99% efficiency) and 207 min (for 99.9% efficiency), for 10
ACH the minimum time is 28 min (99%) and 41 min (99.9%),
and for 50 ACH it can be reduced to 14 min (99%) and 21 min
(99.9%).
The air-exhaust outlet should also be located a minimum of
3 m above ground level and away from doors, occupied areas
and operable windows. Preferred location for exhaust outlets is
at roof level projecting upward away from the outdoor air
intakes [30]. Prevailing winds, adjacent buildings or other
obstructions and discharge velocities must be taken into
account.
3.4. Controls
Controls are essential for optimally controlling and
maintaining desirable indoor conditions. Good control systems
and strategies also improve energy efficiency. There are various
strategies, techniques and systems that can be used, each with a
different complexity, cost and effectiveness.
Each AHU that serves an OR should be provided with one
thermostat and humidistat for temperature and humidity
regulation, respectively, from each OR. This way the surgeon
or authorized medical staff can personally set the temperature
and humidity that is most appropriate for each procedure. The
operating controls usually available on the AHU itself are not
sufficient. They do not allow easy access since only technical
personnel are authorized or knowledgeable to make such
adjustments.
A humidistat can be connected with the AHU to adjust
system operating modes, according to actual indoor conditions.
When indoor humidity drops below the desirable levels the
humidifier in the AHU is activated to spray dry steam and
humidify the supply air. When the humidity levels are
excessive, the three-way valve of the chilled water is activated,
to cool the air and condense out the excess water vapor.
Desiccant dehumidification offers an alternative for humidity
control, in a more energy conscious manner, especially at low
temperature.
Building management systems (BMS) provide the most
comprehensive means to control the OR operating conditions.
These are more elaborate systems and are justifiable for large size
facilities, especially when combined with other hospital controls.
For example, a system can control and monitor all hospital’s
main heat and cold production plants and HVAC installations,
e.g. chillers, boilers, hot water system, air-handling units,
 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
including the specialized health-care applications like the ORs,
indoor conditions, alarms, medical gases, steam pressure,
building pressure, etc. [84,85]. An open protocol system, like
BACNet, allows us flexibility for integrating existing and future
equipment or other functions. Properly trained personnel are
needed to take advantage of such elaborate control systems,
although usually graphical interfaces make it relatively easy to
handle.
3.5. Commissioning—maintenance
Commissioning must occur before an OR is first used and
after any major modifications that may affect airflow patterns
(as part of a re-commissioning process), including micro-
biological assessments [21,46]. For effective monitoring of OR
commissioning and upgrading there should be a close
cooperation between the medical staff and the hospital’s
technical department; the requirement for bacteriological
monitoring as part of OR commissioning is well documented,
with practical guidance on when and how this should be done in
conventionally ventilated and UCV ORs [86]. Some national
guidelines include requirements for owners to be provided with
detailed maintenance and operation information at the
completion of a project [68]. This is necessary information
for hospital staff to successfully and efficiently operate their
facilities.
While building, expanding or renovating ORs can be
expensive, proper maintenance can be relatively inexpensive
and following viable options can even improve existing
conditions [87]. Never the less, even in countries with good
resources for health, hospital administrators may find it difficult
to allocate financial resources in order to properly maintain
their hospitals [88]. However, there may be significant
consequences that could critically influence indoor well-being,
health and safety conditions.
Performance will drift away from optimum conditions after
long operation hours. For example, sensors and monitoring
devices should be maintained and calibrated routinely, as they
can become ineffective due to lint accumulation [89];
regulators may fail, a humidifier with recirculation could be
annulled, the air intake may be blocked, the screens and
diffusers may be arbitrarily manipulated both in form and by
the personnel [90].
Regular maintenance can detect potential problems and if
resolved in time, can prevent more serious damage, both in
terms of safety and cost for equipment repair. Given the strict
requirements for all OR installations, only through regular
maintenance for every piece of equipment and system
component is possible to maintain good working conditions,
minimize the risk of failure and secure the high health standards
in accordance to design conditions. Since accumulated dust and
moisture constitute good growing conditions for microorgan-
isms, all AHU, ductwork and other equipment must be
accessible for inspection and necessary periodic cleaning.
Without routine care, devices intended to solve problems can
become a problem. For example, a neglected filter can become
a pollution source.
463
Microbial growth in ventilation systems may contaminate
indoor air and cause a variety of problems [39]. Fungal growth
is potentially the most problematic for air quality. HEPA filters
can be very effective, provided they are tightly installed, and
well maintained. Fungus can grow on HEPA filters as well as
other ventilation components (e.g. fans and heat exchangers)
and, if unchecked, can actually contribute to the problem.
Traditionally, postoperative fungus infections in the eye have
been related to contaminated air-conditioning ventilation
systems [91].
Cleaning is the simplest treatment for controlling fungal
contamination of HVAC installations, because contaminating
fungi on the filter can be removed together with dust by vacuum
cleaning or by washing with water and detergent [92].
Maintenance personnel should have easy access to all
installations and components.
Preventive maintenance assures safe and uninterrupted
operation. Regular monitoring and air sampling can contribute
to early detection of possible defects and problems, although
regular visual checks of installations and system components
can also be helpful [93]. For example, water accumulation near
the AHU may indicate a clogged drain pan that may become a
pollution source by allowing the growth of bacteria [39]. In
another case, moth flies appearing in the eye operating theatre
in a Finnish central hospital, where traced back to the air-
conditioning pipes that were found to harbor several dead
pigeons because the outside grid of the system had broken [91].
Ventilation grilles may also be clogged with (green) fluff,
derived from OR clothing and drapes, and deposited on these
surfaces by electrostatic attraction, air turbulence or gravity
[94]. In particular, the air supply diffusers should allow for
internal cleaning. Sensors and control systems must also be
regularly inspected instead of randomly checked to ensure that
they function properly. For example, humidity sensors
commonly drift over time and give unreliable readings. They
should be recalibrated on an annual basis. Employees should
also be encouraged to report malfunctions or other problems
(e.g. poor indoor conditions, drafts, noise, damages). A
campaign to increase general awareness and encourage
participation can also help.
Proper HVAC operation can also influence the OR utilization
rate, which should average 90% or 100%, with 97% considered
optimal [95]. Current trends in the health care industry place
hospital administrators under increased pressure to maintain a
high level of activity under normal conditions and to ensure that
they provide uninterrupted health care services [96].
The maintenance department must be staffed with properly
trained technical personnel. New technologies and systems
introduce a need for well-trained and qualified personnel, to
monitor, operate and maintain them. Thus, keeping up-to-date
with current advances and new technical information is
essential. In-house training of staff, hiring qualified personnel
or a contractor, is necessary pre-emptive actions. A service file
for all equipment and systems should be kept current and
readily available, including operation, inspection and service
instructions, records and reports of work performed, operating
data and energy consumption, if possible.
464 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
During OR renovation and construction projects
[18,19,91,97] it is essential to ensure environmental air quality
and implement specific infection control measures, for
example, maintaining the integrity of the barrier walls,
controlling dust and construction traffic, environmental
monitoring.
The maintenance and operations staff of the facility should
work as a team to manage the ventilation systems. Infection-
control personnel must convey the importance of ventilation
management to assure that resources are available for
appropriate maintenance [89]. A multidisciplinary team that
includes infection-control staff should coordinate demolition,
construction, and renovation projects and consider proactive
preventive measures at the inception; produce and maintain
summary statements of the team’s activities [81].
3.6. Energy conservation
The operating rooms are among the most demanding areas in a
hospital. They exhibit increased energy consumption needs for
their proper operation. The installed HVAC systems represent the
highest installed electric power capacity. Energy conservation
systems and techniques can reduce energy consumption without
sacrificing comfort or quality of services while improving air
asepsis [98]. Energy savings mean money savings from reduced
running costs that can be invested in other priorities (i.e. medical
equipment) and used to improve other medical services. Energy
efficient design and operation of the mechanical systems can
allow for continuous operation of systems in support of ORs
without the necessity of shutdowns which risk compromising OR
integrity in pursuit of generating cost savings.
In addition to the issues addressed in the previous sections,
some of the potential design concepts for energy efficiency
include:
(1) Variable air volume: Constant volume terminal reheat
systems increase energy consumption. Alternatively, air
change rates can be reduced, provided proper relative
pressure relationships are maintained [99]. Properly
controlled variable air volume systems can be used to
reduce the supply air change rates during unoccupied-time
of the ORs.
(2) Sensible heat recovery: Heat recovery in ventilation
systems, from the exhausted air to the fresh air supply, is
usually accomplished using a plate heat exchanger in the
AHU. There is no mixing of the two air streams and thus no
transmission of any pollutants that may be carried with the
exhausted air from the indoor environment. The fluid flow
arrangement is usually a cross flow. The heat exchanger
performance for heat recovery can be as high as 90%.
Although thermal energy savings can be significant, the air
pressure increase as a result of the heat exchanger presence
must be accounted for and carefully designed for. An air-to-
air heat pipe is another alternative and can be used for heat
recovery in an OR with a high ACH [100].
(3) Energy recovery: A desiccant-based air-conditioning
system is particularly useful for applications with high
outdoor air requirements in areas with high year-round
relative humidity and small ambient air temperature
variations. In addition, high ventilation rates reduce the
dehumidification effectiveness of conventional HVAC units
and create problems with humidity control. Desiccants
remove moisture from air by sorption. Solid desiccants are
usually impregnated into a lightweight honeycomb-shaped
matrix that is then formed into a wheel [101]. The rotating
wheel acts as a heat exchanger between the outdoor and
exhaust air stream that pass through half of the wheel
surface as it slowly rotates. The angular speed of the wheel
is adjusted according to the operating conditions from
8 rpm (revolutions per minute) down to 1/20 rpm. The
airflow can range from 800 to 50,000 m3/h, depending on
the dimensions of the wheel. Caution must be exercised to
ensure that the selected desiccant material limits adsorption
to small particles not larger than the critical diameter of a
water molecule (that is about 2.8 Å or 2.8  10 10 m). To
limit the possibility for pollutant transfer carried by the
exhaust indoor air, it is recommended to use an S-type filter
along the air exhaust flow, before it enters the wheel.
Overall, energy efficiency must be strongly supported at the
highest management levels with the authority and resources
needed for the initiatives to be effective. Energy conservation is
a never-ending battle. Continuous assessment or operating
conditions and new technologies, systems and techniques for
possible incorporation should be kept in consideration. Set
reasonable goals and energy targets that should be reached in
the long run.
4. Audit campaign in Hellenic hospitals
The stock of Hellenic hospitals and clinics exceeds 360
facilities (not including military hospitals) with a total capacity
of 51,788 beds, employing 18,764 doctors and 37,476 staff.
Over 30% of the total number of medical facilities is located in
the greater metropolitan area of Athens [102].
A good number of the Hellenic hospitals are in over-aged
buildings. In terms of ownership, most of the Hellenic hospitals
are public and they serve the great majority of the population, of
which about 80% have public health insurance. The total
number of available ORs in Hellenic hospitals is rather small
and space availability is problematic in most cases. At the same
time, the number of patients that undergo surgery is high in
comparison to the capacity of the hospitals, imposing an
additional burden to the hospital and OR operating conditions.
In most cases, new hospital installations and recently retrofitted
facilities meet the desirable indoor conditions for physical
health and safety according to standards.
An investigation of 20 ORs at 10 Hellenic hospitals included
an audit of the HVAC installations along with complementary
short-term and spot measurements of indoor thermal conditions
in the ORs. The short-term measurements of air temperature
and relative humidity were collected during a 2-week period
during spring. Five portable data loggers (0–75  0.2 8C, 0–
95  4% at 20 8C  0.2%/ 8C) were placed throughout the OR,
Table 2
Summary of the main hospital and operating room HVAC characteristics
Hospitals Operating rooms
No. CD O B HVAC No. TS HP CP AHU IEC AS AE SE
C CH NV LHP BMS S F H RC I E POA OM
1 1991 P SA   1 C HWB 2*/3/3 SB 2*/3/3 C 3*/3/3 DS 3* 3S     100** CO BMS CFLD/2 WO/2 
2 C HWB 2*/3/3 SB 2*/3/3 C 3*/3/3 SS 1 3S     100** CO BMS CPP WRD/6 
2 1975 N M    3 O HWB 3/4/8 C 2/2/5 DS 2 2S  100 NO ACM CSD/6 WO/1
4 O HWB 3/4/8 C 1/2/3 DS 2 3S    100 NO ACM CPP WO/4***

C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470

3 1965 N M  5 O HWB 1/1/3 SB 3/3/7 C 1/1/3 DS 3 3S   100 NO NC CRD/4 WO/2***
6 C SB 3/3/7 C 3/1+/2 DS 2 3S   100 SO NC CFLD/1 WO/3***
4 1977 P SA  7 G AWHP 2/3/6 AWHP 2/3/6 DS 2 3S     80** NO AC CPP WRD/3
8 O AWHP 2/1/3 AWHP 2/1/3 DS 3 3S     80** SO AC CPP WRD/3
5 1974 P SA   9 Ge SB 3/4+/11 C 3/4+/11 DS 2 3S   100** NO AC CFLD/1 WO/3 
10 S SB 3/4+/11 C 3/4+/11 DS 3 3S   100** NO AC CFLD/1 WO/3 
6 1967 N M    11 Ge HWB 2/2/5 C 1/1/3 SS 3 3S 100** NO NC CFLD/1 WO/1
12 Ge HWB 2/2/5 C 1/1/3 SS 3 3S 100** NO NC CFLD/1 WO/1
7 1898 N M    13 A Gy AWHP 1/1/1 AWHP 1/1/1 DS 1 3S     100** SO AC CPP WO/8***
14 A Gy AWHP 1/1/1 AWHP 1/1/1 DS 2 3S     100** SO AC CPP WO/8***
8 1960 N M    15 A Ge HWB 3/2/8 LHP C 1/1/5 LHP SS 5 3S 100 NO AC WSD/1 WO/1 
16 A Ge HWB 3/2/8 LHP C 1/1/5 LHP SS 5 3S 100 NO AC WSD/1 WO/1 
9 1958 N M    17 Ge HWB 3/4+/7 C 2/4/7 DS 2 3S   100 NO ACM CPP WO/8***
18 Ge HWB 3/4+/7 C 2/4/7 DS 3 3S   100 NO ACM CPP WO/8***
10 1930 N M    19 Gy Ot HWB 1/0/1 C 1/1/5 DS 5 1S 100 NO NC WSD/3 WO/1 
20 Ge C 1/1/5 DS 5 1S 100 NO NC WSD/2 WO/1 
Hospital—construction date (CD); ownership (O): national (N), private (P); buildings (B): multiple (M); stand-alone-single (SA); heating, ventilating, air-conditioning (HVAC) system; central HVAC (C); central
heating (CH); natural ventilation (NV); local split heat pumps (LHP); building management system (BMS). Operating room (OR)—type of surgery (TS): abdominal (A), cardiac (C), general (Ge), gynecology (Gy),
orthopedics (O), otorhinolaryngology (Ot), specialized (S); heat production (HP): air-water heat pump (AWHP), hot water boiler (HWB), steam boiler (SB), the numerical values correspond to the number of units/
number of AHUs/number of ORs served; cold production (CP): air-water heat pump (AWHP), chillers (C), local split heat pumps (LHP) for emergency use, the numerical values correspond to the number of units/
number of AHU/number of ORs served; air handling unit (AHU); stages (S): double stage (DS) with a terminal unit, single stage (SS) without a terminal unit, the numerical value indicates the number of ORs being
served by the AHU; filtration (F): first stage filter—B2 (1S), two stage filters—B2 and electrostatic (2S), three stage filters—B2, C and S (3S); humidifier (H); reheat coils (RC); inverter (I), economizer (E) for heat
recovery; percentage (%) of outdoor air (POA); operating mode (OM) of AHU: continuous 24-h operation (CO), night turn off (NO) when OR is not in use, suspend operation (SO) when OR is not in use; indoor
environmental controls (IEC): available controls (AC) with individual thermostats and ON/OFF controls in each OR, available controls but malfunctioning (ACM), building management system (BMS), no local
controls in the OR (NC); air supply (AS): ceiling fixed linear diffusers (CFLD), ceiling perforated plate (CPP); ceiling round diffuser (CRD), ceiling square diffuser (CSD), wall square diffuser (WSD), the numerical
value indicates the number of inlets; air exhaust (AE): wall outlets (WO), wall relief dampers (WRD), unless specified otherwise the outlets are located near floor level; scavenging equipment (SE). *: including a stand-
by unit, **: adjustable air flow to account for pressure drop, ***: located at ceiling and floor height. +: units also serve the AHUs for the remaining hospital, : unit mainly used for cooling. Hot water radiators are used
for heating.

465
466 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
Fig. 2. Energy consumption of the 10 audited hospitals. Missing data was not
available.
usually near the four corners of the OR and one near the
operating table height. Because of practical difficulties to place
the data loggers right next to the operating table, they were
located as close as possible to the main activity area. Data was
recorded on 30-min intervals. The spot measurements were
performed during the walk-through audit, using a small
portable multilogger analyzer ( 50 to 150 8C  0.15 8C, 0–
50 m/s  4%). The data collected include supply air tempera-
ture at the outlet from the AHU, and air velocity at the air
supply and exhaust vents.
A summary of the HVAC installations in the audited
hospitals and ORs are presented in Table 2. Two ORs were
audited in each hospital. The following results are identified by
the hospital number (1–10) or the OR number (1–20). The date
given in the first column refers to the hospital’s date of
construction. Oil is the primary heating fuel for heat production
and only one hospital was in the process of replacing it with
natural gas.
4.1. Findings
The average annual total energy consumption of the 10
hospitals audited during this investigation was 426 kWh/m2
(Fig. 2). Thermal energy consumption for heating averaged
269 kWh/m2, while the average electrical energy consumption
was 168 kWh/m2. The observed variations are mostly attributed
to differences in the HVAC installations; the majority of the
audited hospitals are not centrally air-conditioned, and other
than the ORs most spaces are equipped with local heat pumps
and are naturally ventilated (Table 2). The relatively high
Fig. 3. Measured indoor temperature in the 20 audited operating rooms,
including the minimum (Tmin), maximum (Tmax) and arithmetic mean (Tmean)
temperature in each OR.
Fig. 4. Measured indoor relative humidity in the 20 audited operating rooms,
including the minimum (RHmin), maximum (RHmax) and arithmetic mean
(RHmean) relative humidity in each OR.
percentage of missing data reveals the difficulty to collect even
this basic type of data in some hospitals. It best illustrates that
for some hospitals, the first step should be collect and monitor
energy consumption by organizing their technical department’s
activities and implementing basic housekeeping procedures,
follow-up by benchmarking to identify specific needs and then
consider what follow-up energy saving measures could be
applicable in their case.
The audits carried out during this investigation revealed
several problems with regard to the function of the ORs, which
are attributed to the space layout and ergonomics of the spaces.
Lack of space availability and small OR dimensions were
common, especially in the older facilities. As a result, they are
forced to place medical cabinets and store other equipment in
the ORs despite health and safety risks. Another implication of
bad space ergonomics is the direct impact on proper ventilation
system operation, since numerous blocked air-exhaust vents
were commonly encountered in the audited ORs.
Measured indoor temperature ranged from 13.8 to 28.9 8C
(Fig. 3), and relative humidity from 13 to 80% (Fig. 4),
averaging in the 20 audited ORs 22 8C and 37%, respectively.
For OR-19 and OR-20 the data refer to free floating conditions
since the AHU was not in operation, which operates only during
summer for cooling. The monitored data corresponds to
continuous 24-h measurements and includes periods when the
ORs were not in use or the HVAC systems were not in
operation. Consequently, there were significant temperature
variations, while lack of humidity control in most cases resulted
to significant variations and overall very low levels. Similar
problems were reported by San Jose-Alonso et al. [103]
Fig. 5. Number of air changes per hour (ACH) in the 20 audited operating
rooms. Missing data was not available.
 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
principally due to lack of humidity control in the installations.
Problems with indoor thermal regulations have also been
reported by Mora et al. [36].
The number of air changes per hour ranged from 3.2 to 58
ACH (Fig. 5), according to AHU specifications and data
provided by the technical departments. For the audited ORs
(Table 2), only 10% had a dedicated AHU for the OR, 10% had
a stand-by (backup) AHU, 20% had an indoor thermostat
control, 40% had scavenging equipment to recover anesthetic
gases (an additional 20% were in the process of installing one),
10% operate the AHU continuously, 70% turn off the AHUs at
night and 20% periodically suspend operation when the ORs
are not in use although 22% of these units were equipped with a
fan inverter that could be used to lower the airflow for energy
conservation while maintaining continuous operation to secure
optimum indoor conditions and stand-by operation. Only 35%
of the AHUs had an economizer for heat recovery although
practically all of them operate with 100% outdoor air.
Consequently, there are direct complications in terms of
overall performance and dependability, indoor environmental
quality, and energy performance.
Understaffed technical department was a common problem
in practically cases. For the audited ORs, the available
manpower of the technical department ranged from a total
of 20 employees for all 24-h shifts in a hospital with 240 beds
and a gross area of 19,500 m2, to 45 employees in a hospital
with 127 beds and a gross area of 30,800 m2.
The most common problems in all or the majority of the ORs
identified during the audit campaign of 20 operating rooms in
10 different hospitals, related to the HVAC system operation
and performance, indoor conditions and physical parameters,
were: (1) insufficient number of air changes, mostly due to
obsolete AHUs, improper system sizing or poor maintenance
(e.g. high pressure drop from poorly maintained filters); (2)
unsatisfactory indoor air temperature and spatial variations,
mostly due to malfunctions of AHUs that do not deliver the air
at the desirable conditions or blocked ventilation air outlets; (3)
AHUs either not equipped with a humidification and
dehumidification system, or equipment decommissioned due
to operational problems; (4) no backup for AHUs; (5)
discontinuous operation of AHUs during the night, when the
ORs are out of duty; (6) outdoor air inlets and exhausts very
close to each other and close to other building exhausts; (7) no
air exhaust filters; (8) no odor filters on the outdoor air supply;
(9) understaffed technical departments. In addition, related to
other indoor environmental parameters, the audit campaign in
the Hellenic ORs revealed lack or improper operation of
scavenging equipment, poor indoor lighting, and noise related
problems [104].
For some ORs, the most common problems were: (1)
Operable windows in the older buildings, which are still used
for natural ventilation; windows are allowed in operating
theatres, for purposes of natural light, but they should be sealed
[40]. (2) Use of radiators and split unit heat pumps for heating;
sometimes the split units are also used for supplementary
cooling. They constitute a pollution source and cannot maintain
aseptic conditions, while it is difficult to regulate and maintain a
467
uniform indoor temperature. (3) Missing easily accessible room
thermostats; even central thermostat controls on AHUs, which
are only accessible by the technical staff, not functioning
properly as a result of poor maintenance or improper
installation. (4) AHUs not operating during winter. (5) Poorly
maintained ducts and diffusers. (6) Humidity control is usually
overlooked primarily because of the mild weather conditions.
Some old ORs were not equipped with a ventilation system or
in some cases the system was decommissioned because of
problematic operation.
On the other hand, among the most common positive
characteristics for some of the audited ORs, were: (1) frequent
and efficient maintenance; (2) use of scavenging equipment; (3)
use of economizer for heat recovery; (4) thermostats to control
indoor air conditions.
Among the most common employee complaints and
problems were: (1) poor or stuffy air, because of inadequate
ventilation rates; (2) unsatisfactory indoor air circulation
caused by annoying air drafts; (3) high indoor temperature
during summer and low temperature during winter; (4)
perception of poor HVAC operation and difficult control over
desirable indoor conditions.
5. Conclusions
Measured data from short monitoring of indoor thermal
conditions along with audit results and main characteristics of
20 ORs in 10 major Hellenic hospitals, revealed that indoor
temperature ranged from 13.8 to 28.9 8C, and relative humidity
from 13 to 80%, averaging 22 8C and 37%, respectively. The
number of air changes per hour (ACH) ranged from 3.2 to 58
ACH. In the majority of the audited ORs the indoor conditions
did not conform to the strict optimum indoor thermal conditions
mandated or recommended by various international standards,
regulations and guidelines.
The commonly encountered problems include insufficient
indoor air exchange, poor control on indoor thermal conditions,
bad space ergonomics that influence the ventilation system
operation by blocking air-exhaust vents, poor maintenance of
technical installations and understaffed technical departments.
Related to other indoor environmental parameters, the audit
campaign in the Hellenic ORs revealed lack or improper
operation of scavenging equipment, poor indoor lighting, and
noise related problems. On a positive note, the majority of the
audited hospitals are already in the planning and implementa-
tion phase of several expansion and renovation programmes or
more specific actions, but yet essential, like the installation of
scavenging equipment.
Acknowledgments
This work was performed under contract to the Hellenic
Ministry of Labor and Social Affairs, Centre for Occupational
Health and Safety in the framework of the European project
‘‘Survey of occupational problems and risks related to indoor
conditions in hospitals operating rooms’’ (SOC 97 202362 05
F05) of the European Commission, Directorate General V,
468 C.A. Balaras et al. / Energy and Buildings 39 (2007) 454–470
Employment, Industrial Relations and Social Affairs, Public
Health and Safety at Work Directorate V/F. The authors are
grateful to the heads and the staff of the 10 hospitals where
fieldwork was undertaken for their cooperation during this
study.
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