In part III of my blogpost series regarding the CMS report on fines issued to hospitals for having too many patients return within a month for additional treatments .  I’ve focused my recent posts on Indoor Air Quality (IAQ) and ventilation systems as a primary driver in preventing HAI’s and will present challenges and opportunities to assist healthcare executives in addressing this key component now! (Blogseries Intro, Part I-Hand Hygiene, Part II-PPE, Part IIIa-Ventilation)

What are the challenges we face in addressing ventilation issues and HAIs?

IAQ complaints are typically driven by staff/patients/visitors with complaints of temperature issues, odors, or particulate release. Launching an IAQ investigation is a difficult task for non-Industrial Hygiene professionals. From what I’ve encountered, ventilation system design is often a primary culprit as fresh air intakes are usually located in various locations such as near a loading dock, on rooftops where birds can nest, or in the vicinity of vehicle traffic patterns, kitchen exhaust or laboratory ventilation systems where than can pull in and disseminate contaminants like vapors, gases, mists, microbial particulates and odors. I’ve also witnessed make up air pulled from areas where odors can be present and distributed throughout a facility. In addition, most of these systems are concealed in ceiling grid systems, wall cavity’s, crawl spaces, and mechanical rooms. Unless they are air tight, which most aren’t, they can pull in a multitude of contaminants from any portion of the system and distribute throughout the spaces they serve.

Ventilation/HVAC system maintenance is a huge challenge for any healthcare facility engineer/manager to confront. Especially, when facilities change functions of spaces during relocation of departments, and with construction and renovation activities. When the function of a space is changed and/or altered, very little attention is paid to ventilation impact on the space that it is intended to serve, and impact of adjacent spaces and their functions. As one C-Suite executive told me, out of site out of mind! One major influence for sure.

Construction of a new building for clinical care is normally straight forward with ventilation design being state of the art.

It’s not always as clear cut as we’d like to think though! I was confronted with a unique challenge during one investigation. In a newly constructed high rise clinical center after occupation, I received a complaint from a Nurse Manager who was complaining of skin and respiratory irritation. It was discovered during the investigation that an adjacent floor above the occupied space, the contractors staged their equipment and took lunch breaks, the floor was not sealed to the outside elements and breaches observed between the slab and deck. Low and behold, we found bird droppings everywhere in that staging area that impacted the adjacent occupied spaces including the ventilation system through the analyses of airborne and surface sampling results. Thorough IAQ investigations will reveal flaws and oversights, especially in construction and renovation projects.

Complications can arise in older, existing healthcare facilities. IAQ was not revealed as a universal health concern when these facilities were built so design considerations were typically suited to construction type and not occupant and operational demand. Most H/C facilities are utilizing Building Automation Systems (BAS) to manage indoor air quality. This enables the facility pro’s to control the function of an HVAC system in real time from a computer regulating fresh/recirculated air, air flows, air exchange rates, pressure relationships, temperature and relative humidity with the click of a mouse. It’s been my experience that these systems are not deployed for all areas of a facility that require this level of technological control and management. Although most H/C facilities utilize this technology, not all have this luxury so they must depend on their HVAC technicians/contractors to manually verify the parameters described above via balometers, anemometers, velometers and other air measurement devices. For those who utilize BAS, how many times are those parameters manually field verified? Not many, if any at all unless the facility has it listed as a preventative maintenance measure in their work order system.

Another major influence on ventilation system impact is construction and renovation which occurs all of the time in healthcare facilities. I have published many articles and blogposts on this topic so will not get too detailed. All construction/renovation projects must be completely isolated, sealed, and independently ventilated from hospital operations, especially adjacent occupied clinical spaces that may or may not share the same ventilation or elevators and corridors utilized to transport patients. A common occurrence in all healthcare facilities is to see an electrical, telecommunication contractor or maintenance/IT staff running wires with no protection. These activities expose all patients, visitors, and staff to highly contaminated interstitial spaces such as ceiling plenums, wall cavities, crawl spaces, basements, mechanical rooms, etc, and their activities disrupt and disperse contaminants in ways that can harm those in the immediate and adjacent area(s).

The ventilation system within a project envelope shall be completely shut down and sealed off from not only the construction activities, but from adjacent spaces too.   The registers should be protected from dust producing activities via filter media and negative pressure in the space continually functioning and monitored/documented. Too often, I see renovation & construction projects taking place in an occupied healthcare facility with minimal protection, never mind isolation. How often is air and surface sampling prescribed in healthcare to assess and determine operational and environmental impact? Do you have a baseline of data to evaluate dirty v. clean? I’ve developed these baselines with follow up, tracked & trended to prevent IAQ issues from presenting a problem.   A proactive IAQ program can positively impact your staff and patient care experience and reduce, rule out ventilation systems and their impact on HAI’s in a profound way.

The following proactive measure should be implemented by all healthcare facilities to eliminate and rule out the role of ventilation system(s) impact on HAI’s:

Key Elements of a Proactive IAQ Management Program

Environment of Care Evaluation – Conduct a risk assessment of the physical environment bu a qualified safety/risk management consultant. Hire a qualified Industrial Hygienist for the establishment of an aggressive sampling protocol to assess air and surface contaminants in your critical care areas, then expand to the remainder of non-critical clinical care areas in your facility.  The ventilation system should be evaluated and included in your IH sampling protocol and risk assessment. After the initial assessment is completed, address identified issues immediately to establish a baseline database and conduct follow up to expand your database. This is a proactive process that can identify problems and solutions before they become a full blown crisis.

Ventilation System Assessment – Hire a qualified, NADCA certified air conveyance system cleaning contractor to conduct a thorough mechanical hygiene assessment to evaluate the condition of your entire HVAC/Ventilation systems to determine extent of contamination and clean/sanitize all systems that are heavily impacted. They should deliver a written report with photo’s of before and after conditions with visual observations noted. This is your baseline. This should be a part of all healthcare work order/preventative maintenance programs and should be done annually in all clinical areas of your facility. Your facilities department should have a boroscope on hand to conduct periodic inspections of your ventilation systems to identify areas that may need to be cleaned/sanitized at more frequent intervals. A qualified Mechanical Contractor should also be hired after this assessment is complete to address any balancing, filtration or pressure differential situations that need to be addressed to comply with code requirements. *All areas that have been renovated need to have their ventilation systems cleaned/sanitized prior to occupancy even if the system has been isolated and protected. *Maintenance staff should not be cleaning any component of a ventilation system unless they are NADCA certified. 

Ventilation System Alterations – Review all HVAC/Ventilation systems that are not code compliant with a qualified Mechanical Engineer to upgrade any systems that do not meet code and implement their recommendations. The engineer should also evaluate air intakes, make up air locations, and supplemental systems to assess impact and provide recommendations for improvements.

Ventilation System Management – Evaluate all spaces that require specified air exchange rates, and positive/negative pressure differentials by an independent, third party consultant and address deficiencies immediately. Install digital manometers at entry points to all O.R.’s, Special Procedure Rooms, Isolation Rooms, Laboratories so the staff can verify after you’ve trained them that those spaces are ventilated properly, and are safe for patients and staff to utilize.   Non irritant smoke should be utilized to periodically and continuously document positive/negative air pressure differentials. *Please remove ping pong balls in walls and discontinue the use of tissue paper to evaluate air pressure relationships. Those methods are inadequate, antiquated and unreliable.

In closing, I can envision an Indoor Air Quality Environment similar to what we see in the semi- conductor industry in the near future as C-Suite executives become more aware of how this impacts HAI’s. I mean, why wouldn’t we protect patients, staff, and visitors in the same fashion that we protect micro-processing chips? Hmmmm????