Ventilation, Temps and Humidity
Requirements
PO Box 3187
Charleston, WV 25332
www.mckennaconsulting.com
304-988-1047
Inquisit
February 6, 2014
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Ventilation, Temps and Humidity
Requirements

Relevance
Without high quality ventilation
 Healthcare workers, patient visitors
can become infected
 Poorly ventilated – pathogen
particles very high
 Higher concentrations, higher efforts
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Ventilation, Temps and Humidity
Requirements



Relevance
CMS – draft worksheets under
Infection Control
TJC – Focus on temperature, humidity,
and pressure gradients
State Surveyors – Focus on
temperature, humidity and pressure
gradients (sometimes have higher
requirements)
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Ventilation, Temps and Humidity
Requirements
Findings for TJC
 EC.02.05.01
46%
 EC.02.06.01
36%
 IC.02.02.01
47%
Healthcare organizations fail
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Ventilation, Temps and Humidity
Requirements
Findings for CMS

Section 1.A.5 Infection control/prevention
program and resources
 at least 6 (existing facility) or 12 (new
construction/renovation) air changes per
hour or per state licensure rules) and;
 direct exhaust of air to outside, if not
possible air returned to air handling
system or adjacent spaces if directed
through HEPA filters and;
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Ventilation, Temps and Humidity
Requirements
Findings for CMS

Section 1.A.5 Infection control/prevention
program and resources
 when AIIR is in use for a patient on
Airborne Precautions, documentation that
monitoring of air pressure is done daily
with visual indicators (smoke tubes, flutter
strips), regardless of differential pressure
sensing devices (i.e. manometers)
 AIIR door kept closed when not required
for entry and exit
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Ventilation, Temps and Humidity
Requirements
Findings for CMS

Section 1.D.7 Personnel Education
System / Infection Control Training
 The hospital infection control system
ensures that respiratory fit testing is
provided at least annually to
appropriate healthcare personnel
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Ventilation, Temps and Humidity
Requirements
Findings for CMS

Section 4.H Isolation: Airborne Precautions
 4. H.1 NIOSH-approved particulate respirators
(N-95 or higher) are available and located near
point of use
 4. H.2 Signs indicating patient is on Airborne
Precautions are clear and visible
 4. H.3 Patients on Airborne Precautions are
housed in airborne infection isolation rooms
(AIIR)
 4. H.4 Hand hygiene is performed before
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entering patient care environment
Ventilation, Temps and Humidity
Requirements
Findings for CMS

Section 4.H Isolation: Airborne Precautions
 4. H.5 HCP wear a NIOSH-approved
particulate respirator (N95 or higher) upon
entry into the AIIR for patients with confirmed
or suspected TB. Facility policies are followed
for other pathogens requiring AIIR
 4. H.6 Facility limits movement of patients on
Airborne Precautions outside of their room to
medically-necessary purposes (note policy
should address that patient wear surgical
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mask)
Ventilation, Temps and Humidity
Requirements
Findings for CMS

Section 4.H Isolation: Airborne Precautions
 4. H.7 If a patient on Airborne Precautions
must leave their room for medically
necessary purposes, there are methods
followed to communicate that patient’s
status and to prevent transmission of
infectious disease (note policy should
address that patient wear surgical mask
when transported)
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Ventilation, Temps and Humidity
Requirements
Findings for CMS

Section 5.A Protective Environment (e.g. Bone
Marrow patients)
 5. A.1 Positive pressure [air flows out to the
corridor].
 5. A.2 Twelve (12) air changes per hour
 5. A.3 Supply air is HEPA filtered
 5. A.4 Well sealed rooms so that there are no
penetration spaces in walls, ceilings, or windows
 5. A.5 Self closing door that fully closes on all
room exits
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Ventilation, Temps and Humidity
Requirements
Findings for CMS

Section 5.A Protective Environment (e.g. Bone
Marrow patients)
 5. A.6 Documents and demonstrates that
failures are addressed
 5. A.7 For patients requiring a Protective
Environment, the hospital ensures that
ventilation specifications are monitored
using visual methods (e.g. flutter strips,
smoke tubes) and observations
documented daily
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Ventilation, Temps and Humidity
Requirements
Space Ventilation

Air movement
 Generally from clean to less clean
 Variable air volume or load shedding for
energy conservation cannot compromise
the minimum air exchanges
 Ventilation rates provide comfort as well
asepsis/odor control
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Ventilation, Temps and Humidity
Requirements
Space Ventilation

Air Exchanges
 Supply in positive pressure
 Exhaust in negative pressure
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Ventilation, Temps and Humidity
Requirements
Space Ventilation

Air Filtration
 Well defined for specific areas
 Filter banks
 Efficiency ratings
 HEPAs – some areas including Protective
Environment
 Must have access to clean and to inspection
 Pressure measuring devices
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Ventilation, Temps and Humidity
Requirements
Space Ventilation

Humidifier
 Outside humidity and internal moisture
insufficient
 Provided by healthcare facility air
handling systems – many specs
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Ventilation, Temps and Humidity
Requirements
Isolation Rooms

Negative Pressure
 Airborne Infecting Isolation (AII)
 Transmitted by airborne routes
 Bacteria / virus suspend in air – carried
long distances
• TB
• Varicella (chickenpox)
• Zoster (shingles)
• Measles
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Ventilation, Temps and Humidity
Requirements
Room Pressure Monitor
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Ventilation, Temps and Humidity
Requirements

Negative Pressure
 - . 01 N
 Staff should know what pressure
should be
 Alarms should not be bypassed when
an airborne isolation room is in use
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Ventilation, Temps and Humidity
Requirements

CMS
 Measure at least daily – not just gauge
 Tools
Pressure Monitor/Smoke or flutter
Tissue (problems)
Documentation should be clear
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Ventilation, Temps and Humidity
Requirements
Pressure Gradients

Negative Pressure Model
 Exhaust
(directly
outside)
Patient Room

Lower pressure

Higher pressure
(air into room)
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Ventilation, Temps and Humidity
Requirements
Test
 Smoke Test
Smoke goes into the room – it is
negative
 Flutter
Flutters when it is exposed to
the airflow
Negative-outside room doesn’t
flutter inside-does flutter
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Ventilation, Temps and Humidity
Requirements
Problem Areas
 Airborne Isolation Rooms
 Protective isolation Rooms
 Surgical Areas
 Decontamination Areas
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Ventilation, Temps and Humidity
Requirements
See Findings - Word doc
See Ventilation Requirements Chart –
PDF
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References
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
Draft Worksheets:
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/Downloads/Surveyand-Cert-Letter-13-03.pdf
AIA ACADEMY OF ARCHITECTURE FOR HEALTH, UNITED
STATES. DEPT OF HEALTH AND HUMAN SERVICES.
Guidelines for design and construction of hospital and
health care facilities. American Institute of Architects Press,
2010
Joint Commission (2014). Comprehensive Accreditation
Manual, Department of Publications and Education Joint
Commission Resources, Oakbrook Terrace, Illinois, 2014
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Thank you
jatkins@mckennaconsulting.com
McKenna Consulting
Post Office Box 3187
Charleston, WV 25332
304-988-1047
www.mckennaconsulting.com
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