ANSI/ASHRAE/ASHE Standard 170-2013

CDC 2003 Ventilation Requirements Table B2

Texas Administrative Code: 25 TAC 133.169(c)
Texas Children’s Hospital Policy: Adopt TAC 133.169 (c)
THE
PLAN
Adopt a nationally recognized standard and create a policy.
Create an inventory of Pressure Dependent Spaces
Update the Space Management Policy to include:
Auditing rooms
Reporting non-compliance of room usage (current function) vs. room
design intent
All pressure dependent spaces to be defined by
nomenclature in the standard
Ensure room signage matches the standard (ensure current room names
correlate to current room functionality)
Ensure designated pressure dependent spaces meet the requirements of the
adopted standard
Develop a process to review space usage against requirements on a periodic
basis
Determine how spaces will be monitored and insure monitoring solution also
accounts for temperature and humidity requirements
Determine how often spaces will be tested
Develop a training program:
How to recognize a space has a pressure
requirement
HOW?

Form multidisciplinary Working Group

Compare nationally recognized standards
Adopt the most stringent requirements
Perform a risk assignment for conflicting
standards
Insure space policy mandates standardized room names and signage
For visibility, create a symbol for room signage
Insure space policy provides process for repurposing space or requesting new
space that will have pressure dependent requirements
Define standards for the monitoring of spaces. We set up four tiers:
Tier I: Most critical spaces. These spaces are monitored for pressure, temperature,
humidity, and air exchanges. Local display and linked to BAS for critical monitoring by
engineering and archiving of data.
Tier II: Monitoring pressure only. Local display and linked to BAS for monitoring by
engineering and archiving of data.
Tier III: Monitoring pressure only locally, however, not remotely via BAS.
Tier IV: Monitoring of construction projects
Create a pilot project (i.e., an Ambulatory Surgery area)
Create policy for testing these spaces
Create a training program
Monitoring at Room
Ball in the wall: Pressure
Lamiflow: Pressure
Presura: Pressure
Primex: Temp, Humidity & Pressure
Sure Flow: Temp, Humidity & Pressure
L-VIS Panels: Temp, Humidity &
Pressure
 Monitoring through BAS
Group: Medical Center Campus
Location: WT OR #6
Serial No: 001EB38F4E41
Current Maximum Average Current Minimu Maximu
Temperatur e Minimum Temperatur e Temperatur e Current Minimum Maximum Average Pressur m m Average
Date Time Temperature Humidity Humidity Humidity Humidity e Pressure Pressure Pressure
12:34:00 64.2 64 70 68.5
Service 5/1/2016 AM
12:46:00
45% 29.00% 50.00% 40.50% 0.02 0.005 0.025 0.015
69.1 66 72 69
Response 5/2/2016 AM
12:14:00
44% 42.00% 49.00% 45.50% 0.02 0.020 0.030 0.025
73 69 74 71.5
Center: 5/3/2016 AM
12:49:00
43% 41.00% 51.00% 46.00% 0.02 0.020 0.030 0.025
72.3 70 75 72.5
5/4/2016 AM 42% 41.00% 49.00% 45.00% 0.02 0.020 0.030 0.025
Mustreceivecritical 12:52:00 71.6 64 73 68.5
5/5/2016 AM 41% 43.00% 50.00% 46.50% 0.02 0.020 0.030 0.025
alarms24/7 12:54:00 72.3 66 72 69
5/6/2016 AM 45% 42.00% 49.00% 45.50% 0.02 0.020 0.030 0.025
Musthaveaccessto 12:57:00 71.8 69 74 71.5
5/7/2016 AM 44% 41.00% 51.00% 46.00% 0.02 0.020 0.030 0.025
reports 12:41:00 67.6 70 75 72.5
5/8/2016 AM 43% 41.00% 49.00% 45.00% 0.02 0.020 0.030 0.025
12:39:00 68.2 64 73 68.5
5/9/2016 AM 42% 43.00% 50.00% 46.50% 0.02 0.020 0.030 0.025
Nursing: 5/10/201
6
12:38:00
AM
72.1 66 72 69
41% 42.00% 49.00% 45.50% 0.02 0.020 0.030 0.025
Musthaveaccessto 5/11/201
6
12:42:00
AM
75.7 69 76 72.5
45% 41.00% 51.00% 46.00% 0.02 0.020 0.030 0.025
graphicaldisplay 5/12/201
6
12:45:00
AM
68.7 70 75 72.5
44% 41.00% 49.00% 45.00% 0.02 0.020 0.030 0.025
Musthaveaccessto 5/13/201
6
12:33:00
AM
74.8 64 75 69.5
43% 43.00% 50.00% 46.50% 0.02 0.020 0.030 0.025
reports 5/14/201
6
12:35:00
AM
72.5 66 72 69
42% 42.00% 49.00% 45.50% 0.02 0.020 0.030 0.025
5/15/201 12:18:00 67.6 69 74 71.5
6 AM 41% 41.00% 51.00% 46.00% 0.02 0.020 0.030 0.025
5/16/201 12:06:00 68.2 70 75 72.5
6 AM 45% 41.00% 49.00% 45.00% 0.02 0.020 0.030 0.025
5/17/201 12:08:00 67.8 64 73 68.5
6 AM 44% 43.00% 50.00% 46.50% 0.02 0.020 0.030 0.025
HOW?
Local monitoring devices that staff can easily understand
Alarms for critical spaces tied to your BAS
Rounding on spaces for functionality vs. design (i.e., EOC rounds)
Annual audits of spaces
Calibration of devices
Testing of rooms via instrumentation (in-house or outsourced)
Verification of pressure using the tissue or smoke test
Training:
What are the spaces?
How do I know the proper pressure, temperature, humidity, etc.?
What do I do if they are not correct?
What do I do if I need to use an isolation room?
Space polices and procedures
EOC rounds
Monitoring and testing