HOSPITAL NAME
CRITICAL PRESSURE SENSITIVE ROOMS
POLICY NUMBER: XXXX
PURPOSE
To minimize the risk of infection to patients, visitors, and staff within our environment of care by
ensuring appropriate pressurization and ventilation rates in critical areas designated by Infection
Prevention and Control. To provide guidance on testing rooms that are used for patients with
known or suspected communicable infections.
L O C AT I O N / S I T U AT I O N – I S O L AT I O N R O O M S
Building
Floor
Room
Description
Minimum
ACH
Recommended
Differential
Pressurization
Requirements
Pressure
Direction
Requirements
10
-0.01
Negative
10
+0.01
Positive
10
-0.01
Negative
10
+0.01
Positive
10
-0.01
Negative
10
+0.01
Positive
10
-0.01
Negative
10
+0.01
Positive
10
-0.01
Negative
10
+0.01
Positive
10
-0.01
Negative
10
+0.01
Positive
10
-0.01
Negative
10
+0.01
Positive
T E S T I N G P R O C E D U R E S F O R N E G AT I V E P R E S S U R E R O O M S
1. Negative pressurization will be monitored by the Engineering Building
Automation System (select areas) and tested for all high-risk locations at the defined
frequencies (refer to risk assessment table) using a digital manometer. If the digital
manometer does not provide conclusive results or the pressure relationship is
approaching a value closer to neutral, then a smoke trail test will be performed.
The smoke tube is to be held near the bottom of the door and approximately 2 inches
in front of the door. A small amount of smoke is generated by gently squeezing the
bulb. The smoke tube should be held parallel to the door, and the smoke should be
issued from the tube slowly to ensure the velocity of the smoke from the tube does
not overpower the air velocity. If the room is at negative pressure, the smoke will
travel under the door and into the room. If the room is not under negative pressure,
the smoke will be blown outward or will stay stationary.
2. This test must be performed while the door is closed and the windows in the room
must be closed.
TESTING PROCEDURES FOR POSITIVE PRESSURE ROOMS
1. Positive pressurization will be monitored by the Engineering Building Automation
System (select areas) and tested for all high-risk locations at the defined frequencies
(refer to risk assessment table) using a digital manometer. If the digital manometer
does not provide conclusive results or the pressure relationship is approaching a
value closer to neutral, then a smoke trail test will be performed.
The smoke tube is to be held near the bottom of the door and approximately 2 inches
in front of the door. A small amount of smoke is generated by gently squeezing the
bulb. The smoke tube should be held parallel to the door, and the smoke should be
issued from the tube slowly to ensure the velocity of the smoke from the tube does
not overpower the air velocity. If the room is at positive pressure, the smoke will
travel away from the door and out of the room. If the room is not at positive pressure,
the smoke will be drawn into the room or will stay stationary.
2. This test must be performed while the door is closed and the windows in the room
must be closed.
COMPLIANCE MONITORING
1. The differential pressures for the operating rooms can be monitored by the
Building Automation system (select locations) or locally via the hallway differential
pressure monitors. The hallway differential pressure monitors alarm locally and
through the building automation system. The alarm conditions are viewable remotely
at the nurse’s stations. Alarms are also generated by the building automation system
for dispatch.
2. The differential pressures for the Isolation rooms can be monitored locally via the
hallway differential pressure monitors. The hallway differential pressure monitors
alarm locally and through the building automation system. Alarms are also generated
by the building automation system for dispatch.
COMPLIANCE TESTING
1. All isolation and pressure sensitive rooms will be tested, at least annually, to verify
that the pressure relationships are in compliance. During this time the pressure
monitor at the door will be verified for accuracy.
2. A certified air balancing company will determine whether or not the room is in
compliance with State Code requirements.
3. The X Hospital X floor operating rooms, X Hospital Labor and Delivery operating
rooms, X Hospital Day Surgery, X Hospital Central Service, and X Health Care
Center Minimally Invasive Urology Unit are to be balanced, at least annually, for
proper ventilation rates.
4. A certified air balancing company is to measure the air flow and air changes per
hour of each of the areas selected to determine whether or not the room is in
compliance.
5. Other areas of the hospital will be tested for pressurization and ventilation rates
based on our internal risk assessment, working with Infection Prevention and
Control. All testing will be performed by a certified air balancing company.
R E S P O N S E TO I N C O R R E C T P R E S S U R E P R O C E D U R E S
If Air Systems Associated with Isolation Rooms Require a Shutdown for Emergency or
Maintenance Purposes.
1.
Notification: The On-Call Nursing Administrator will be contacted via pager
(ext. xxxx), Infection Prevention & Control (ext. xxxx), and Environmental
Services (ext. xxxx) shall be notified prior to the planned shutdown and
maintenance. In addition, the Director Engineering shall notify all Facilities
Management staff that maintenance is being planned.
2.
Actions: The following procedures shall be followed for annual preventive
maintenance on any contaminated air stream system.
a.
If possible, all work will be done when there are no patients in the
isolation room. If this is not possible, Nursing Administration will
arrange for patients to be placed in demistifier tents within the
isolation room.
b.
The exhaust fan shall run for a predetermined time after the patient is
discharged from room or placed in the demistifier tents in order to
sufficiently purge the system properly. Infection Prevention & Control
shall assist with issuing the predetermined amount of time.
c.
After the predetermined time has passed as per b. above, the fan may be
shut down for servicing. Fan maintenance shall include at a minimum:

Correcting any problems

Changing the belts

Evaluating the inboard and outboard bearing, replace as
necessary

Lubricating the motor and fan

Lubricating all dampers, checking all EP's and damper motors

Checking all modes of damper operation

Checking all shutdown modes
After completion of the work, the fan should be turned on and the
affected isolation room tested to ensure negative pressure and that the
room pressure monitors work properly.
d.
After the maintenance is completed, the fan shall be operated and
negative pressure at each patient room verified.
e.
Upon satisfactory completion of the above d, Nursing Administration,
Infection Prevention & Control, and Environmental Services shall be
notified that the fan has been put back in service.
If Operating Room Monitoring System Detects Pressure Imbalance
1.
Each of the operating rooms in TH 6, 8 and 11 and HCC 2 have the ability
to monitor the pressure relationship, temperature and humidity of each of
the operating rooms via the Building Automation system. Each of the
operating room doors has a pressure differential monitor that alarms locally
and via the BAS system if the rooms are not positive pressure with respect
to the corridor. There is a 5 minute delay prior to the alarm to allow the
rooms to reach pressure equilibrium.
2.
If the alarm activates, the operating room staff should ensure that the door
to the operating room is closed. If the door is not closed, then the door
should be closed and allow the BAS system to reset.
3.
If the alarm continues, Facilities Management staff should be notified via
extension xxx. In addition, an email record for the alarm should be
generated and sent to the Director of Engineering.
4.
Facilities Management staff should respond within 30 minutes and
determine the cause of the imbalance.
5.
Facilities Management should then confer with the operating room staff to
determine the status of the patient (example: if the corrective action can
occur within 30 minutes, it may be safe for the patient to remain in the
operating room).
6.
An incident report of such occurrence shall be developed by the Director of
Engineering with the appropriate follow-up.
7.
The Directors of Environmental Health and Safety, Infection Prevention
and Control and operating Room shall be copied on the incident report.
8.
Facilities Management shall present periodic reports of pressure imbalances
to the Infection Prevention and Control Committee for follow-up and other
actions, as the committee deems necessary.
Approved By:_____________________________
Date:____________
Director of Engineering
Approved By:_____________________________
Director of Infection Control
Date:____________