POLICY:
It is the policy of YOUR HOSPITAL NAME to monitor and record temperature and relative humidity as
well as verify pressure relationship in the Surgical Suites and designated high risk areas defined by
Infection Control (see list of locations below). This is done to maintain an optimal level of humidity to
assure sterile integrity for infection control and to suppress the potential for static electricity.
PROCEDURE:
A.
The temperature and relative humidity is to be monitored and logged daily for all Operating
rooms. This is the responsibility of the Operating Room Assistant or designee. The
following areas are monitored:
1. All Operating Rooms
2. Central Sterile
3. PACU
4. Ambulatory Surgery Building (OSIS)
5. Sterile Processing Clean Room
6. Sterile Processing Decon Room
7. GI Lab (MLK)
8. Peds SPD
9. Cath Lab
10. Pharmacy (Temp Only)
B.
Temperature should be between 68-73 Degrees F, however per Infection Prevention’s
Risk Assessment, Operating Room surgeons are at liberty to demand temperatures
outside of this scale whenever it is deemed necessary for the survivability and best
outcome of the patient- as permitted within the ASHRAE 170 Table footnote (o).
C.
A relative humidity of 30-60% shall be the desired and maintained parameters.
D.
If the relative humidity is below 30% or above 60% for an extended period of time within
an anesthetizing location, the responsible monitoring individual will notify Facilities
Management to request assistance in altering the HVAC system controls s to bring within
desired range. If unsuccessful in maintaining these parameters continuously for more
than 8 hours within any 24 hour period, Infection Prevention will be notified in order to
define necessary actions, if deemed necessary.
It should also be noted the some areas are continuously monitored for relative humidity
and temperatures by Facilities Management via the Building Automation System and
records of these logs are periodically reviewed and shared with Infection Prevention
when measurements are discovered outside the designated parameters for extended
periods of time.
E.
The corrective action taken will be recorded on the back of the Humidity Log and reported
to the responsible department Management.
F.
There are currently log-books located at the ______, ______, ________.
G.
All the above areas are also periodically measured to verify the correct pressure
relationship (typically on a quarterly interval) by third party contract service provider and
the OR and SPD are checked weekly while Isolation Rooms are checked monthly by
UNM Engineering and daily when in use.
RECOMMENDED GUIDELINES for Humidity and Temperature in Surgical Services:
LOCATION
GUIDELINES
Operating Room:
1. Temperature
68-73
2. Humidity
20-60%
3. Air Exchange/Hour
15
4. Pressure to Outside
Positive
Recovery Room/Ambi:
1. Temperature
70-75
2. Humidity
20-60%
3. Air Exchange/Hour
6
4. Pressure to Outside
Not Designated
Sterile Storage:
1. Temperature
68-73
2. Humidity
20-60%
3. Air Exchange/Hour
4
4. Pressure to Outside
Positive
Sterile Processing Area:
1. Temperature
68-73
2. Humidity
20-60
3. Air Exchange/Hour
10
4. Pressure to Outside
Positive
Decontamination Area
1. Temperature
65-73
2. Humidity
20-60
3. Air Exchange/Hour
6-10
4. Pressure to Outside
Negative