NABH Guidelines

Dr. T. NIRMAL FREDRICK

 MD, Nirmals' Eye Hospital, Tambaram

 Editor in Chief, Journal of Ophthalmic Science and Research

 Principal Assessor, (NABH) National Accreditation Board for Hospital and

Health Care Providers, Quality Council of India.

 Member Secretary, Technical Committee of NABH for Eye Hospitals, Eye Bank
Accreditation Programme.

 Member, Managing Committee, All India Ophthalmic Society AIOS. 2009-17

 State Council Member, IMA TNSB

 President, Tambaram Ophthalmic society

The very first requirement in a
hospital is that it should do the
sick no harm
Florence Nightingale
Provide a safe and secure environment for patients, their
families, staff and visitors.

Comply with relevant rules and regulations,

Infection control, safety for staff and patients

Plan for emergencies within the facilities and the

community.
 Access, Assessment and continuity of Care
(AAC)
 Patient Rights and Education (PRE)
 Care of Patient (COP)
 Management of Medication (MOM)
Hospital Infection control (HIC)
 Continuous Quality Improvement (CQI)
 Responsibility of Management (ROM)
Facility Management and Safety (FMS)
 Human Resource Management (HRM)
 Information Management System (IMS)
6
 Relevant State & Local
Body Regulations
 Indian Standards
▪ IS 12433 Part I ▪ IPHS ( Indian Public Health
▪ IS 12433 Part II Standards )
▪ IS 10905 Part I ▪ For PHCs
▪ IS 10905 Part II ▪ For 30 - 100 Beds
▪ IS 10905 Part III ▪ For 101 - 200 Beds
▪ For 201 - 300 Beds
▪ For 301 - 500 Beds
▪ IS 10500 ( For Potable
Water )
 National Building Code
The NBC is for adoption by government and private sector
and covers administrative regulations, controls rules and
building guidelines.

The NBC is typically known for the fire prevention and

protection systems requirements listed out in Part IV – Fire
and Life Safety.

The NBC, however, covers the entire spectrum of building

construction and operations through the 12 sections (11
Sections till NBC 2005) which are split into two volumes.
Part 8, Sub Section 3 which deals with air conditioning,
heating and mechanical ventilation.

Covers , from design, noise and vibration, coverage of

various types of air conditioning systems, energy
conservation and installation or commissioning.

- Part 12 – Asset and Facility Management. overall

building lifecycle.
F3.1.4. Group C-Institutional Buildings:
Main occupancies here are used for medical care, child care, home
for the aged, and as jails and mental asylum homes.
The common feature in all these, is that liberty of inmates is
restricted.
(a) Sub Division C-1 Hospitals & Sanatoria:
This is an important group covering a wide range ofhealth care
institutions.
(b) Sub Division C-2 Custodial Institutions:
Childrens homes and homes for the aged are grouped under C-2.
(c) Sub-Division C-3 Penal & Mental Institutions:
Jails, prisons, mental hospitals etc, are grouped under this category
Hospitals Are Classified As Group C-1 In NBC

Corridors 2400 Mm / 7.8 Feet

HVAC systems should
add to the safety,
Doors Width 2 Meters infection control and
easy maintenance
Staircase Width 6.6 Feet / 2 Meters

Fire Exit Doors 3.35 X 2 Feet Width And 7.5 Feet In Height, Two
Leaf, 30 Meters Distance For Travel, Open Outwards.
 180 Page Document
 Classification Of Building As Per Fire Safety
 Types Of Construction
 General Requirements
 Life Safety / Fire Protection
 Additional Occupancy
IMPORTANT: concealed spaces within a
 Annexures
building such as space between ceiling and false
▪ C . For High Rise Buildings
ceiling,
▪ E. Fire horizontal
Safety Plan and vertical ducts, etc, tend to act
as flues/tunnels during a fire.

Provision should,therefore, be made to provide fire stopping within

such spaces.
 Hospital shall ensure that
Heating, ventilation and Air-conditioning (HVAC)

Shall protect the environment & not contaminate

the environment in any form.
Guidance Note: (ASHARE) guidelines and (ISHRAE/RAMA/AHRI) Standard
365 - 2009 resource.

1. Environment (Protection) Act, 1986 and Rules

2. National Ambient Air Quality Monitoring Series; NAAQMS/2003-04

3. Guidelines for Ambient Air Quality, Monitoring, CPCB, April 2003

4. Carbon Dioxide Monitoring for Indoor Air Quality, Application Note:

AN1/2012/04

5. Revised NABH OT Guidelines 2016 / 4th edition.

 Hospital shall have a plan for maintaining good
indoor air quality, lighting and ventilation.

Remarks:

Guidance Note: WHO, 1987. Air Quality Guidelines for Europe, World Health
Organization, Regional Office for Europe, European series, No 23, Copenhagen,
Denmark.
23
WHO, 2002. Health Effects of Indoor Air Pollution in Developing Countries. 41 pp.

National Ambient Air Quality Monitoring Series: NAAQMS/ 2003-04, Guidelines for
Ambient Air Quality, Monitoring, CPCB, April 2003

Carbon Dioxide Monitoring for Indoor Air Quality, Application Note: AN1/2012/04
Air (P & C. P) Act, 1981 and the applicable rules there under
costs can be minimised by intelligent design / adoption of
effective operating and maintenance practices. Areas should be
considered:
· Climatic Design

· Natural Ventilation Heating/Cooling/Ventilation:

Shall be provided - to ensure reasonable

· Services Selection comfort in all patient
service areas and appropriately manage
the risks identified
· Energy Management
 Planning and designing
Safe and optimal critical care areas in
Hospital
 Patient
safety &
infection Operation Theatre Medication
Management
control

Equipment Staff training &

management management

OT
safety
 OT planning /design
The design should support
- Functional segregation of OPD,
- Inpatients, Diagnostic services and
supportive services
So that mixing of patient flow is
avoided.

Separate critical areas like OT,

ICU, Labour wards, Burns unit
from general traffic.

Avoid air movement from areas

like laboratories and OP
 Critical areas like
Operation theater : the sanctum sanctorum

Design & structure

• Walls, floor, ceiling, fomites, surroundings
• Air & water

Equipment & disposables

• Manufacturers
•
•
Suppliers
Transportation
Form
• Storage
Maintenance of OT follows
• Patient function
• Personnel
 OT STANDARDS – ZONING
Zoning should be finalised at the planning stage itself

4 well defined zone:

• Protective,
• Clean,
• Sterile
• Disposal
Zoning /layout
 The science of controlling
infections caused by The rates at which particles
airborne microorganisms is settle are a function of
a complex mixture of their size, shape, density,
engineering, particle and of course, air
physics, microbiology, and movement.
medicine.
Health care HVAC systems must be
installed, operated, and maintained
in spatial and functional
conjunction with a host of other
essential building services.

Including emergency and normal

power, plumbing and medical-gas
systems,
automatic transport, fire protection,
and myriad IT systems

All within a constrained

building envelope.
HVAC Perform several vital functions that
systems
affect environmental conditions,
Objectives infection and hazard control, and
building life safety.
Staff and patient comfort, and the
provision of therapeutic space
conditions, facilitate optimum patient
treatment outcomes.
Environmental conditioning for
electronic data storage, supporting it
systems, special imaging and other
medical equipment is critical
 HVAC systems – How?
• Through containment, dilution, and removal
of pathogens and toxins, the HVAC system is
a key component of facility safety and
infection control.

• To respond properly to fire emergencies - the

HVAC system to support vital smoke
exhaust and building compartmentation
features of the life safety system.

• HVAC system interact with the architectural

building envelope - control the entry of
unconditioned air, together with outdoor
contaminants and moisture
HVAC systems can impact HAIs by affecting

• Dilution (By Ventilation),

• Air Quality (By Filtration),

• Exposure Time (By Air Change

And Pressure Differential),

• Temperature,

• Humidity,

• Organism Viability (By

Ultraviolet [UV] Treatment)

• Airflow Patterns.
whether or not an infection occurs depends on
Aerosol and droplet transmission dynamics

• Nature of dust levels

• Health and condition of individual’s

nasopharyngeal mucosal linings
• Population density

• Ventilation rate

• Air distribution pattern

• Humidity

• Temperature
REVISED GUIDELINES FOR
AIR CONDITIONING
IN OPERATION THEATRES
All about providing a safer environment for patients and staff.
Basic difference between air conditioning for healthcare facility and other building types:

1. The need to restrict air movement in and between the various departments
(no cross movement).

2. The specific requirements for ventilation and filtration to dilute and reduce contamination in
the form of odor, airborne micro organisms and viruses, and hazardous chemical and radioactive
substances. Ventilation effectiveness is very important to maintain appropriate indoor air
quality.
3. The different temperature and humidity requirements for various areas and
the accurate control of environmental conditions.

4. The design sophistication to minimize the risk of transmission of airborne

pathogens and preserve a sterile and healing environment for patients and staff.
 NABH Guidelines
The air conditioning requirements for
Operation Theatre in a HCO have been
deliberated at length with
manufacturers, engineers, technical
committee members and other stake
holders and the following guidelines
have been finalized.
 Category of Operation Theaters
Super specialty OT: Super specialty OT means operation
theatres for Neurosciences, Orthopedics (Joint
Replacement), Cardiothoracic and Transplant Surgery
(Renal, Liver etc).

General OT: This includes operation theatres for

Ophthalmology, District hospital OTs, FRU OT and all other
basic surgical disciplines.

Day care centre: Day surgery is the admission of selected

patients to hospital for a planned surgical procedure,
returning home on the same day, would fall under the
category of general OT.
 For OT Standards
 The following basic assumptions have been kept in view:
 Occupancy: Standard occupancy of 5-8 persons at
any given point of time inside the OT is considered.
 Equipment Load: Standard equipment load of 5-7 kW
considered per OT
 Ambient temperature & humidity at each location to
be considered while designing the system
 OPERATION ROOM, ICU, LABOUR WARDS
- CRITICAL AREAS IN THE HOSPITAL

STRUCTURE – INFRA / SUPRA STRUCTURE

PROCESS – ADMISSION TO ASSESSMENT TO

PROCEDURE TO TRANSFER / DISCHARGE

OUTCOME – DATA / DOCUMENTATION /AUDIT /

RESULTS
 REQUIREMENTS – Super Specialty OT

1. Air Changes Per Hour:

• Minimum total air changes should be 20 based on

international guidelines although the same will vary with
biological load and the location.

• The fresh air component of the air change is required to be

minimum 4 air changes out of total minimum 20 air
changes.
 Air handling in the OT

Air is supplied through HEPA filters in the

AHU.
The return air should be picked up/ taken
out from the exhaust grille
HEPA filters of efficiency 99.97% down to
o.3 microns
The AHU of each OT - dedicated one and
should not be linked
• 100 % outdoor ventilation air systems are not
mandatory. If HCO chooses to have 100% fresh air
system than appropriate energy saving devices like
heat recovery wheel, run around pipes etc. should be
installed.
• The supply & return air ducts must be of non-
corrosive material.
• No internal insulation or acoustic lining must be done
on ducts as they can become breeding grounds.
1. Air Velocity: The vertical down flow of air coming out
of the diffusers should be able to carry bacteria
carrying particle load away from the operating table.

2. The airflow needs to be unidirectional and

downwards on the OT table.

3. The air face velocity of 25-35 FPM

(feet per minute) from non-aspirating unidirectional
laminar flow diffuser/ceiling array is recommended.
Positive Pressure: There is a requirement to maintain
positive pressure differential between OT and adjoining
areas to prevent outside air entry into OT.

Positive pressure will be maintained in OT at all times

(operational & non-operational hours)

• Laminar flow boxes/diffusers should be installed in

the OT for supplying majority air and also majority
return air should be picked up 75-150 mm above floor
level.

The minimum positive
pressure recommended is
2.5 Pascal (0.01 inches of
water)
Air handling in the OT
including air Quality: Air is
supplied through Terminal
HEPA (High-efficiency
particulate arrestance)
filters in the ceiling
Outdoor Air intakes: The location of
outdoor air intake for an AHU must
not be located near potential
contaminated sources like DG
exhaust hoods, lab exhaust vents,
vehicle parking area.
The HEPA can be at AHU
level if it not feasible at
terminal level inside OT.
 Air handling in the OT

Air is supplied through HEPA filters in the

AHU.
The return air should be picked up/ taken
out from the exhaust grille
HEPA filters of efficiency 99.97% down to
o.3 microns
The AHU of each OT - dedicated one and
should not be linked
 Operating Room Ventilation

Continuous air purifying

Temperature 20-23º c

Relative humidity 30-60%

Air movements from clean to less clean areas

Air changes -minimum 15 total air changes

per hour
How to maintain / monitor
the standards?
• Validation of system to be done as per ISO 14664 standards and should include:

✓ Temperature and Humidity check

✓ Air particulate count
✓ Air Change Rate Calculation
✓ Air velocity at outlet of terminal filtration unit /filters
✓ Pressure Differential levels of the OT wrto ambient
/ adjoining areas
✓ Validation of HEPA Filters by appropriate tests like DOP
(Dispersed Oil Particulate) /POA (Poly Alpha Olefin) etc.;
repeat after 6 month in case HEPA found healthy.

• Preventive Maintenance of the system: It is

recommended that periodic preventive maintenance be
carried out in terms of cleaning of pre filters, micro vee at
the interval of 15 days.

• Preventive maintenance of all the parts of AHU is carried

out as per manufacturer recommendations.
 Maintenance of the system
• During the non-functional hours AHU blower will be
operational round the clock (may be without temperature
control).

• Variable frequency devices (VFD) may be used to

conserve energy.

• Air changes can be reduced to 25% during non-operating

hours thru VFD provided positive pressure relationship is
not disturbed during such period.
Engineering standards
 Assessors Checklist during NABH Audit

1. To check the temperature, humidity inside OT.

2. The differential pressure inside & outside OT.
3. Maintenance record of AHU & filter cleaning
frequency.
4. Last HEPA filtration report & HEPA validation
report.
5. Is Air-conditioning done through split AC or AHU?
 Indian Healthcare 60 – 70 small hospitals
 Cost of installation / maintenance – Huge
 Adds to cost of care delivery
 Innovations - to improve safety, reduce maintenance
cost, simplify processes

 Working as a team to provide safe Air within Hospital

Engineering standards / Technology requirements
must be met

Clinical needs wrf to infection control must be

considered

Patient and team Safety is a major factor

Accepted Standards and Guidelines to be followed

No such Buttons
for us....
 Contact Transmission

Contact transmission is the most important and frequent

mode of transmission of infections (nosocomial).

subdivided into direct-contact transmission and indirect-

contact transmission.

a) Direct-contact transmission involves direct body to

body contact for the transfer of micro-organisms from an
infected person to a susceptible host.
b) Indirect-contact transmission involves the
contamination of an inanimate object (such as
instruments or dressings) by an infected person.
 Droplet Transmission

Droplet transmission occurs when an infected person generates

droplets containing microorganisms which are propelled at a short
distance through the air and deposited on the conjunctivae, nasal
mucosa or mouth of a host.

Droplets do not remain suspended in the air, so special air handling

and ventilation are not required to prevent droplet transmission. (Do
not confuse droplet transmission with airborne transmission.)

A person’s coughing, sneezing and talking generate droplets. Other

procedures such as suctioning and bronchoscopy are also a source of
droplets.
 Airborne Transmission

 Airborne transmission occurs when either airborne droplet nuclei or dust particles disseminate
infectious agents.

 a) Droplet nuclei - The high velocity with which coughing and sneezing expel droplets from the
respiratory tract results in large numbers of bacteria or viruses entering the air in smaller droplets.

 These droplets rapidly evaporate in the air leaving a residue of typically 5 µm or smaller in size.
These droplet nuclei settle so slowly that they remain airborne in occupied spaces and circulate on
air currents until mechanically removed by the ventilation system.

 Control of environmental factors (such as special air handling and ventilation) is necessary to
prevent nosocomial airborne transmission of microorganisms.

 b) Dust - Dust contaminated by viable infectious agents may build up as a reservoir capable of
causing an outbreak of infection, even after the departure of the infectious patient from whom the
pathogens originated.

 Dust may become contaminated when dried sputum and other infectious secretions suspended in
the air as dust particles mix with environmental dust.
 How does above classification affect
HVAC designer?

The differentiating factor between “AII” and “PE” rooms is the pressure relationships.

The protective environments (PE) are set at POSITIVE air pressure relative to adjoining
spaces.

These areas require frequent air exchanges (>12 per hour) and require all supply air
passing through high efficiency particulate air (HEPA) filters.

The isolation rooms housing infectious patients (AII) must be maintained at NEGATIVE
pressure. These areas require frequent air exchanges (>12 per hour) and require all
supply air to be exhausted without recirculation.
Both these areas require inline monitoring to ensure that they remain under set pressure.

Doors to the rooms should be self-closing, and the walls, windows, ceiling, floor, and
penetrations well sealed.