Environment of CareEnvironment of CareEstablishing a Protective Environment Establishing a Protective Environment

Environment of CareEnvironment of CareEstablishing a Protective Environment Establishing a Protective Environment

October 25, 2013October 25, 2013

Larry Rubin, CPE, CHFM, CHSP, CEMLarry Rubin, CPE, CHFM, CHSP, CEM

Senior Director, Facilities ManagementSenior Director, Facilities Management

IntroductionIntroductionIntroductionIntroduction

• CMS/TJC Compliance for CMS/TJC Compliance for Pressure Differential RoomsPressure Differential Rooms- Operating RoomsOperating Rooms

- Isolation RoomsIsolation Rooms

- Sterile ProcessingSterile Processing

- MonitoringMonitoring

In a Hospital……………. “Which way does the wind blow?”

Always clean, not dirty!Always clean, not dirty!

• Sicken 9.8 billionSicken 9.8 billion

• Kill over 99,000Kill over 99,000

• Almost 5000 deaths per Almost 5000 deaths per year from construction year from construction related hazardsrelated hazards

• Adds more than $28 Adds more than $28 billion to health care billion to health care costscosts

What’s the Risk?According to the CDC According to the CDC every yearevery year

hospital acquired infections;hospital acquired infections;

Killed by ACME Killed by ACME HospitalHospital

John Q. PatientJohn Q. Patient

What’s the Risk?““The Centers for The Centers for

Medicare & Medicare & Medicaid Services Medicaid Services

are no longer are no longer reimbursing for the reimbursing for the extra costs extra costs of treating patients of treating patients for some hospital-for some hospital-acquired infections acquired infections

that reasonably that reasonably could have been could have been

prevented. prevented.

Private insurers are Private insurers are sure to follow.”sure to follow.”

–EC.02.05.01 EP6EC.02.05.01 EP6

In areas designed to In areas designed to control airborne control airborne

contaminants (such as contaminants (such as biological agents, gases, biological agents, gases,

fumes, dust) the fumes, dust) the ventilation system ventilation system

provides provides appropriate appropriate pressure relationshipspressure relationships

air exchange air exchange rates, and filtration rates, and filtration

efficienciesefficiencies

Establishing a Protective EnvironmentWhat does The Joint Commission say?

Establishing a Protective EnvironmentWhat does The Joint Commission say?

–EC.02.05.01 EP6EC.02.05.01 EP6

Note- Areas designed for control of airborne contaminants Note- Areas designed for control of airborne contaminants include spaces such as:include spaces such as:•Operating roomsOperating rooms•Special procedure roomsSpecial procedure rooms•Delivery rooms for patients diagnosed with or suspected Delivery rooms for patients diagnosed with or suspected of having airborne communicable diseases (such as- of having airborne communicable diseases (such as- pulmonary or laryngeal tuberculosis)pulmonary or laryngeal tuberculosis)•Patients in “protective environment” rooms (such as- Patients in “protective environment” rooms (such as- those receiving bones marrow transplants)those receiving bones marrow transplants)•LaboratoriesLaboratories•Pharmacies & Sterile supply roomsPharmacies & Sterile supply rooms

What Pressurization is Required by FGI-2010?What Pressurization is Required by FGI-2010?

Room TypeRoom Type Air Changes per Air Changes per Hour (ACH)Hour (ACH)

PressurePressure

Class B and C ORs 20 Positive

Delivery Rooms 20 Positive

NICU 6 Positive

Trauma 15 Positive

Medical/anesthesia gas storage 8 Negative

Procedure Room 15 Positive

Protective Environmental room 12 Positive

AII room 12 Negative

Laboratory Varies Negative

Pharmacy 4 Positive

Endoscope Cleaning 10 Negative

Soiled or Decontamination Room 6 Negative

What’s the Risk?

• Think 3-dimensional,

Think 3-dimensional,

who’s above, below

who’s above, below

adjacent?

adjacent?

• Proximity to “at risk”

Proximity to “at risk”

patientspatients??

CLEANDIRTY -0.01

CORRIDORTB

ISOLATIONROOM

Negative Pressure Differential

CDC- “TB isolation rooms CDC- “TB isolation rooms should be checked daily for should be checked daily for negative pressure while being negative pressure while being used for TB isolation. The used for TB isolation. The minimum pressure difference minimum pressure difference necessary to achieve and necessary to achieve and maintain negative pressure maintain negative pressure that will result in airflow that will result in airflow into a room is very small into a room is very small (0.01 inch of water) (0.01 inch of water) and and pressure-sensing devices pressure-sensing devices should incorporate an audible should incorporate an audible warning with a time delay.”warning with a time delay.”

How NEGATIVE is NEGATIVEHow NEGATIVE is NEGATIVE

• Differential pressure shall be a Differential pressure shall be a minimumminimum of of 0.01” water gauge (2.5 Pa)0.01” water gauge (2.5 Pa)

• Table 7-1 note n : The verification of airflow Table 7-1 note n : The verification of airflow direction can include a simple visual method direction can include a simple visual method such as;such as;• Smoke trailSmoke trail• Ball-in-tubeBall-in-tube• FlutterstripFlutterstrip

Negative PressureFGI Guidelines

Measuring PressureSmoke Trail

Toilet Paper Test

Measuring PressureFlutter Strip

Measuring PressureBall in Tube

Measuring PressureBall in Tube

Measuring PressurePortable Monitor

Operating RoomsOperating Rooms

Establishing a Protective Environment

–EC.02.05.01 EC.02.05.01 OR RoomsOR Rooms

The ventilation The ventilation system provide system provide appropriate appropriate pressure pressure relationships, air relationships, air exchange rates exchange rates and filtration and filtration efficiencies (and efficiencies (and relative humidity relative humidity between 20% and between 20% and 60%).60%).

Establishing a Protective Environment

• There is no period for the OR testing implied There is no period for the OR testing implied

• Many hospitals just set up their building automation systems Many hospitals just set up their building automation systems (BAS) to trend the systems. They also set up alarms in the BAS (BAS) to trend the systems. They also set up alarms in the BAS if the parameters go out of bounds.  if the parameters go out of bounds. 

• The OR staff should be trained to recognize conditions that are The OR staff should be trained to recognize conditions that are not consistent with the normal environmental parameters.not consistent with the normal environmental parameters.

• Even though there is not a "D" by the EP, Surveyors still ask for Even though there is not a "D" by the EP, Surveyors still ask for documentation during a survey, but cannot write the finding documentation during a survey, but cannot write the finding unless there is no program at all unless there is no program at all

• The hospital should have a policy that is approved by Facilities The hospital should have a policy that is approved by Facilities Management and Infection Control and has been fully Management and Infection Control and has been fully implemented.implemented.

Leo Gehring, CHFM, CHC, FASHE Leo Gehring, CHFM, CHC, FASHE (25 OCT 11)(25 OCT 11)Gehring Health Facility ResourcesGehring Health Facility Resources

References- OR

• Because there is no specific frequency we survey to the Because there is no specific frequency we survey to the organization policyorganization policy

• Generally twice a year (may be reduced to annual based on Generally twice a year (may be reduced to annual based on trending) trending)

• If the organization has a Building Automation System (BAS) If the organization has a Building Automation System (BAS) that monitors (and alarms when out of range) they might test that monitors (and alarms when out of range) they might test annually (calibration of the BAS).  It really depends on the annually (calibration of the BAS).  It really depends on the organization policyorganization policy

George Mills, MBA, FASHE, CEM, CHFM, CHSP George Mills, MBA, FASHE, CEM, CHFM, CHSP (25 OCT 11)(25 OCT 11)Senior EngineerSenior EngineerStandards Interpretation GroupStandards Interpretation GroupThe Joint CommissionThe Joint Commission

References- OR

Sterile ProcessingSterile Processing

DECON

DISINFECTCLEAN

STORAGE

Establishing a Protective Environment

Any Hospital, USA

Establishing a Protective Environment

Establishing a Protective EnvironmentFGI

MonitoringMonitoring

-0.01

What is that key switch for? What is that key switch for?

Does it effect the operation or Does it effect the operation or readout of the monitorreadout of the monitor?

Measuring PressureIso-Tek Space Monitor

• Differential Pressure shall be a Differential Pressure shall be a minimumminimum of 0.01” water gauge of 0.01” water gauge

• If alarms are installed, If alarms are installed, allowances shall be made to allowances shall be made to prevent nuisance alarms of prevent nuisance alarms of monitoring devicesmonitoring devices

• The health of people may The health of people may depend on the proper depend on the proper installation, setup, and installation, setup, and maintenance of this devicemaintenance of this device

Measuring PressureIso-Tek Space Monitor

-0.01

-0.01

Measuring PressureIso-Tek Space Monitor

EC.02.05.01 EP 6EC.02.05.01 EP 6 EC.02.05.01 EP 6EC.02.05.01 EP 6

• Ventilation system is unable to provide Ventilation system is unable to provide appropriate pressure relationships, air-exchange appropriate pressure relationships, air-exchange rates and filtration efficienciesrates and filtration efficiencies- Specific areas lack Specific areas lack

• negative or positive pressures in negative or positive pressures in relationship to adjacent areas relationship to adjacent areas

• i.e. Endoscopy Processing Room should bei.e. Endoscopy Processing Room should be

negative to the egress corridornegative to the egress corridor• the correct number of air changes per hourthe correct number of air changes per hour• Improper filtrationImproper filtration• MERV = minimum efficiency reporting MERV = minimum efficiency reporting

valuevalue

SCREENINGSCREENINGSCREENINGSCREENING• Tissue test: only to be used as a pre-screening tool to Tissue test: only to be used as a pre-screening tool to

evaluate if further investigation needs to occurevaluate if further investigation needs to occur- To perform the flutter test take a tissue and let it hang To perform the flutter test take a tissue and let it hang

just off the floor near the bottom edge of a doorjust off the floor near the bottom edge of a door- If the tissue indicates incorrect air flow, stabilize the If the tissue indicates incorrect air flow, stabilize the

area by closing doors and windows, wait a few minutes area by closing doors and windows, wait a few minutes and retestand retest

- If the organization presents a Testing & Balancing report If the organization presents a Testing & Balancing report the following questions should be askedthe following questions should be asked• when was the balancing done (seasonal issues)when was the balancing done (seasonal issues)• are any specific requirements (such as keeping a are any specific requirements (such as keeping a

door closed) needed to achieve satisfactory resultsdoor closed) needed to achieve satisfactory results

SURVEY PROCESSSURVEY PROCESSSURVEY PROCESSSURVEY PROCESS

• EC.02.05.01 EP 6 will generate a CLDEC.02.05.01 EP 6 will generate a CLD

- If the organization can repair the process that led If the organization can repair the process that led to non-compliance the LSCS may reviewto non-compliance the LSCS may review

- Following LSCS review, the LSCS may contact the Following LSCS review, the LSCS may contact the Central Office to discuss the possibility of reducing Central Office to discuss the possibility of reducing the CLD to SLD, with no change to the findingthe CLD to SLD, with no change to the finding

- Resolution should include the area affected by the Resolution should include the area affected by the equipment identified as non-compliant, not just the equipment identified as non-compliant, not just the identified room/areaidentified room/area

- I.e. ensure zone is balancedI.e. ensure zone is balanced

- Is there an ongoing process to assessIs there an ongoing process to assess

• Guidelines for Design and Construction of Health Care Guidelines for Design and Construction of Health Care Facilities, 2010 Edition, administered by the Federal Facilities, 2010 Edition, administered by the Federal Guidelines Institute (FGI) and published by ASHEGuidelines Institute (FGI) and published by ASHE

• The Joint Commission, Environment of Care standard The Joint Commission, Environment of Care standard EC.02.05.01, EP 6EC.02.05.01, EP 6

• CDC "Guidelines for Preventing the Transmission of CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Facilities, Mycobacterium Tuberculosis in Health-Care Facilities, 1994" on October 28, 19941994" on October 28, 1994

References- OR

Pressure Differential Rooms Pressure Differential Rooms Wrap-upWrap-up

Pressure Differential Rooms Pressure Differential Rooms Wrap-upWrap-up

Operating Rooms Operating Rooms Isolation RoomsIsolation Rooms Sterile ProcessingSterile Processing MonitoringMonitoring

Questions,

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