Environment of Care Establishing a Protective Environment

1. Environment of CareEstablishing a Protective Environment October 25, 2013 Larry Rubin, CPE, CHFM, CHSP, CEM Senior Director, Facilities Management

2. Introduction • CMS/TJC Compliance for Pressure Differential Rooms • Operating Rooms • Isolation Rooms • Sterile Processing • Monitoring

3. In a Hospital……………. “Which way does the wind blow?” Always clean, not dirty!

4. What’s the Risk? According to the CDC every year hospital acquired infections; • Sicken 9.8 billion • Kill over 99,000 • Almost 5000 deaths per year from construction related hazards • Adds more than $28 billion to health care costs John Q. Patient Killed by ACME Hospital

5. What’s the Risk? “The Centers for Medicare & Medicaid Services are no longer reimbursing for the extra costs of treating patients for some hospital-acquired infections that reasonably could have been prevented. Private insurers are sure to follow.”

6. Establishing a Protective Environment What does The Joint Commission say? • EC.02.05.01 EP6 • In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust) the ventilation system provides appropriate pressure relationships air exchange rates, and filtration efficiencies

7. Establishing a Protective Environment What does The Joint Commission say? • EC.02.05.01 EP6 • Note- Areas designed for control of airborne contaminants include spaces such as: • Operating rooms • Special procedure rooms • Delivery rooms for patients diagnosed with or suspected of having airborne communicable diseases (such as- pulmonary or laryngeal tuberculosis) • Patients in “protective environment” rooms (such as- those receiving bones marrow transplants) • Laboratories • Pharmacies & Sterile supply rooms

8. What Pressurization is Required by FGI-2010?

12. What’s the Risk? • Think 3-dimensional, who’s above, below adjacent? • Proximity to “at risk” patients?

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

16. Negative Pressure FGI Guidelines • Differential pressure shall be a minimum of 0.01” water gauge (2.5 Pa) • Table 7-1 note n : The verification of airflow direction can include a simple visual method such as; • Smoke trail • Ball-in-tube • Flutterstrip

17. Measuring Pressure Smoke Trail

18. Toilet Paper Test Measuring Pressure Flutter Strip

19. Measuring Pressure Ball in Tube

20. Measuring Pressure Ball in Tube

21. Measuring Pressure Portable Monitor

22. Operating Rooms

23. Establishing a Protective Environment • EC.02.05.01 OR Rooms • The ventilation system provide appropriate pressure relationships, air exchange rates and filtration efficiencies (and relative humidity between 20% and 60%).

24. Establishing a Protective Environment

25. References- OR • There is no period for the OR testing implied • Many hospitals just set up their building automation systems (BAS) to trend the systems. They also set up alarms in the BAS if the parameters go out of bounds.  • The OR staff should be trained to recognize conditions that are not consistent with the normal environmental parameters. • Even though there is not a "D" by the EP, Surveyors still ask for documentation during a survey, but cannot write the finding unless there is no program at all • The hospital should have a policy that is approved by Facilities Management and Infection Control and has been fully implemented. • Leo Gehring, CHFM, CHC, FASHE (25 OCT 11)Gehring Health Facility Resources

26. References- OR • Because there is no specific frequency we survey to the organization policy • Generally twice a year (may be reduced to annual based on trending) • If the organization has a Building Automation System (BAS) that monitors (and alarms when out of range) they might test annually (calibration of the BAS).  It really depends on the organization policy George Mills, MBA, FASHE, CEM, CHFM, CHSP (25 OCT 11) Senior Engineer Standards Interpretation Group The Joint Commission

27. Sterile Processing

31. Establishing a Protective Environment DISINFECT CLEAN STORAGE DECON

32. Establishing a Protective Environment Any Hospital, USA

33. Establishing a Protective Environment FGI

34. Monitoring

35. Measuring Pressure Iso-Tek Space Monitor What is that key switch for? Does it effect the operation or readout of the monitor? -0.01

36. Measuring Pressure Iso-Tek Space Monitor • Differential Pressure shall be a minimumof 0.01” water gauge • If alarms are installed, allowances shall be made to prevent nuisance alarms of monitoring devices • The health of people may depend on the proper installation, setup, and maintenance of this device -0.01

37. Measuring Pressure Iso-Tek Space Monitor -0.01

40. EC.02.05.01 EP 6 • Ventilation system is unable to provide appropriate pressure relationships, air-exchange rates and filtration efficiencies • Specific areas lack • negative or positive pressures in relationship to adjacent areas • i.e. Endoscopy Processing Room should be negative to the egress corridor • the correct number of air changes per hour • Improper filtration • MERV = minimum efficiency reporting value

41. SCREENING • Tissue test: only to be used as a pre-screening tool to evaluate if further investigation needs to occur • To perform the flutter test take a tissue and let it hang just off the floor near the bottom edge of a door • If the tissue indicates incorrect air flow, stabilize the area by closing doors and windows, wait a few minutes and retest • If the organization presents a Testing & Balancing report the following questions should be asked • when was the balancing done (seasonal issues) • are any specific requirements (such as keeping a door closed) needed to achieve satisfactory results

42. SURVEY PROCESS • EC.02.05.01 EP 6 will generate a CLD • If the organization can repair the process that led to non-compliance the LSCS may review • Following LSCS review, the LSCS may contact the Central Office to discuss the possibility of reducing the CLD to SLD, with no change to the finding • Resolution should include the area affected by the equipment identified as non-compliant, not just the identified room/area • I.e. ensure zone is balanced • Is there an ongoing process to assess

43. References- OR • Guidelines for Design and Construction of Health Care Facilities, 2010 Edition, administered by the Federal Guidelines Institute (FGI) and published by ASHE • The Joint Commission, Environment of Care standard EC.02.05.01, EP 6 • CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Facilities, 1994" on October 28, 1994

44. Pressure Differential Rooms Wrap-up • Operating Rooms • Isolation Rooms • Sterile Processing • Monitoring

45. Questions, Comments?