Policy and Procedure Manual

HOSPITAL NAME CRITICAL PRESSURE SENSITIVE ROOMS POLICY NUMBER: XXXX

1. 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.

2. LOCATION/SITUATION – ISOLATION ROOMS

Recommended Pressure Minimum Differential Building Floor Room Description Direction ACH Pressurization Requirements 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 3. TESTING PROCEDURES FOR NEGATIVE PRESSURE ROOMS

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.

4. 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.

5. 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 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.

6. 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.

7. RESPONSE TO INCORRECT PRESSURE PROCEDURES

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.

4 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:______Date:______Director of Infection Control