Design Considerations for Pressurized Spaces

1. Design Considerations for Pressurized Spaces General Hospitals

2. Why are Pressurized Spaces Required? • Infection Control • Patient, Community and Staff Safety • Prevention • Specialized Procedures • TJC – EC .02.02.01.6 (2012) • CMS

3. Contagious Disease History • “No lepers, lunatics or persons having the following sickness… or other contagious diseases are to be admitted, and if any such be admitted by mistake, they are to be expelled as soon as possible.” • — Bishop Joscelin of Bath – 1219 A.D. • Listed in the hospital’s initial statutes

4. Today’s Plight of Infectious Diseases Headline: Los Angles Times “Los Angeles Tuberculosis Outbreak Generates Federal Gov’t Help” Date: February 21, 2013 4,500 people possibly infected Multi-Drug Resistant- TB (MDR-TB) Extensively Drug Resistant- TB (XDR-TB)

5. Drug Resistant Infections on the Rise • FRONTLINE- “Hunting the Nightmare Bacteria.” (Oct 22, 2013) • Gram Negative Bacteria (Pan Resistant) • 23K die/yr; 2M infected/yr • No known Antibiotic • Major Drug Companies- No R&D

6. Types of Rooms/Areas Requiring PressurizationIn (I-2) Facilities • Airborne Infectious Isolation (AII) • Protective Environment (PE) • Operating (Class A, B & C) • Procedure Rooms (Bronchoscopy, Endoscopy, etc.) • Laboratories/Pharmacies • Sterilizing/Surgical Processing • Central Medical and Surgical Supply • Service (Laundry, Food Prep, Housekeeping) • Support Space (Workrooms, HazMat’l Storage)

7. Planning • Standards/Guidelines • FGI-AIA/ASHE (2010) • CDC • USP 797 • ASHRAE/ANSI/ASHE Standard 170 w/Addenda (2008) • UL • NRC • Regulatory Codes • NFPA 99 (1999), 101 (2000) • Building Codes • CMS • JCAHO • State Health Codes • ADA

8. Planning Participants • End- Users/Clinicians • Facilities Engineering staff • Internal Designers/Planners • Infection Control personnel • Architect/Engineer • Support Departments (Housekeeping, Food Service) • Other Personnel deemed appropriate

9. Design Considerations • Physical Design • Adopt a holistic view to counter emerging infectious diseases • New designs are Open, public spaces, hard to control spread of infectious diseases • Ease of travel allow people to cross borders that harbor, carry or catch infectious diseases. • During the Severe Acute Respiratory Syndrome (SARS) outbreak, issues with multiple public entrances. • Consider Negative pressure wards, designated areas in ED and ICU • New designs should incorporate only single patient rooms—easily convertible to Isolation rooms if an outbreak occurs • When renovating or new construction, plan for at least two methods of infection control: Isolation and ventilation.

10. Area Design • Emergency Departments • Typically designed with patient flow and satisfaction rather than healthcare worker safety and protection • Waiting areas to be negative with respect to staff locations • Manage fever and higher risk patients separately from others • Provide febrile areas (screening) and provide higher ACH for ventilation • During design, look for turbulent ventilation across patient access areas • Possibly provide a separate entrance for persons who know they have a fever • Increased Ventilation systems can help dilute droplets nuclei discharged by patients and is the single most important engineering control in prevention of transmission of airborne infections • Fever areas and rooms with negative pressure directed outdoors post HEPA filtered (no recirc) • Febrile patients who are non-ambulatory, manage in a critical care area. Construct rooms to accommodate portable x-ray and isolate • Signage and restricted entry points need to properly identified and enforced

11. Area Design • Airborne Infection Isolation (AII) • For the purpose of Isolating known patients who have a communicable infectious disease, (e.g., TB, measles, varicella) • Pressure differential to be negative to corridor. If Anteroom is provided, the room differential pressure still required to be negative to corridor and also the Anteroom. • When determining location of Isolation Room(s), try and stay away from stair towers, elevator shafts or large building shafts. They will play havoc in maintaining proper differential pressure. • Min (2) Outdoor ACH, (12) total, min ≥ -0.01” w.c. • If possible, provide an Anteroom. Dilution rates are higher. • Design for only one person • Windows should be non-operable, Door seals at top and sides with adjustable door sweep. • Construction of walls should go from floor to deck above. Sealed at all seams. Seal all outlets, med gas openings, IT openings, etc…

12. Area Design- (AII) con’t • If Anteroom can be constructed, door from patient room should swing into Anteroom. Capture velocity will be maintained at door edge. (Haltage 1998) • Must provide self-closing device on patient room door • Two different design approaches for maintaining minimum negative pressure: • Differential Air-Flow (Provide at least 10%.) • Differential Pressure • Must provide continuous monitor in the corridor for staff observe pressure with alarm. If permanent monitor provided, specify BACnet connection for BMS monitoring. • Suggest monthly testing of air-flow direction (Manometer, ball in tube, smoke test, flitter patch, etc…) • Commission all systems via 3rd party verifier • Train all personnel on the proper operation of pressure monitors, room occupancy and ventilation system and function.

15. Area Design – Protective Environment (PE) Rooms • Protective Environment Rooms • Intended to protect immunocompromised patients from contracting infectious diseases by aerosol transmission • Pressure differential to be positive to corridor or to suite. If Anteroom is provided, room differential pressure required to be positive to the Anteroom. • When determining location of PE Room(s), try and stay away from stair towers, elevator shafts or large building shafts. They will play havoc in maintaining proper differential pressure. Elevator vestibules must be in air-locks if opening into a Suite. • Min (2) Outdoor ACH, (12) total, min ≥+0.01” w.c.. Supply air must pass through HEPA filtration prior to entering room. • If possible, provide an Anteroom. Dilution rates are higher. • Design for only one person • Windows should be non-operable, Door seals at top and sides with adjustable door sweep. • Construction of walls should go from floor to deck above. Sealed at all seams. Seal all outlets, med gas openings, IT openings, etc…

16. PE Rooms – con’t • Construction of ceilings shall me monolithic (hardpan) • Walls shall be smooth and impervious to cleaners and disinfectants • Flooring shall be smooth with sealed seams (MedTech) • Patient room door should swing IN to room and must have self closing device • Two different design approaches for maintaining positive pressure • Differential Air Flow (Min 10%) • Differential Pressure • Must provide continuous monitor in the corridor for staff to observe pressure with alarm. If permanent monitor provided, specify BACnet connection for BMS monitoring. • Suggest monthly testing of air-flow direction (Manometer, ball in tube, smoke test, flitter patch, etc…) • Commission all systems via 3rd party verifier • Train all personnel on the proper operation of pressure monitors, room occupancy and ventilation system and function

20. Combination AII/PE Rooms • Combo AII/PE Rooms • For patients who are immunosuppressed(HiV) and have an airborne infectious disease • FGI (2010)- Hospitals with PE rooms shall have at least (1) AII/PE room. • It must have an Anteroom • Anteroom is positive to the corridor and to the patient room • Patient room shall be negative • Same internal design as a PE room • Patient room ACH remain the same and pressure must be a min ≥ -0.01” w.c. Note: This is not a variable pressure room, i.e., change from negative to positive and back again. AIA Guidelines for Design and Construction of Hospital and Health Care Facilities (2006) prohibits this type of operation for any pressurized room.

21. Questions and Answers