Transcript Air Quality in our Hospitals

Cynthia McMaster-McCoy MPH Student
Walden University
PUBH-6165-2 Environmental Health
Instructor: Rebecca Heick
Richard Hermans, P.E., ASHRAE certified healthcare facility design professional
(HFDP) Stated in presentation to an ASHRAE chapter.
 “Air-transmitted
pathogens can be found
everywhere in poorly ventilated health care facilities.”
 “Because these organisms are found in higher
concentrations in hospitals and because patients are
susceptible to them, additional care should be taken in the
design of ventilation systems.”
(New Ventilation Design Requirements for Health Care Facilities Available from ASHRAE,
2008)
THE HISTORY OF THE LONDON HOMOEOPATHIC
HOSPITAL


The West Wards are 29 1/2 ft. long, 28
ft. wide, and 13 ft. high, and contain
eight beds, and open into the large
wards of the New Wing to be
described later. The East Wards are 50
1/2 ft. long, 28 ft. wide, and 13 ft. high,
and contain 14 beds. Each bed is
separated from the next by a window,
and each patient has about 100 Square
feet of floor space, and about 1,400
cubic feet of air. Each ward is
supplied with a kitchen with gas range,
and necessary cleansing and other
arrangements on the latest approved
model. Everything possible has been
done throughout to prevent lodgment
of dust and dirt and to facilitate easy
cleaning and ensure sanitary
conditions.
The sanitary blocks, containing the
necessary accommodation for the
wards, being placed in a separate tower
from the main building, ensure a
thorough means of ventilation.
MECHANICAL VENTILATION ON THE DOWNDRAUGHT
PRINCIPLE, BY IMPULSION, OR THE 'PLENUM' SYSTEM,
APPLIED TO A HOSPITAL WARD.}} |Source=Natural & Artificial
Methods of Ventilation |Author=Robert Boyle & Sons |Date=1899
|
Airborne transmission:
 In this type of transmission, infective agents are spread as aerosols, and
usually enter a person through the respiratory tract.
 Aerosols are tiny particles, consisting in part or completely of the
infectious agent itself, that become suspended in the air.
 When a person breathes in these particles, they become infected with
the agent—especially in the alveoli of the lungs.
 These particles may remain suspended in the air for long periods of
time, and some retain their ability to cause disease, while others
degenerate due to the effects of sunlight and dryness
 (National Center for Infectious Diseases, 2004)
Air quality issues resulting in lawsuits
Unfortunately, almost every facility has contaminants
generated from within the space (i.e. molds, fungus, offgassing of materials, etc,).
Therefore methods that lag occupancy (such as CO2 DCV)
should be carefully considered prior to implementation.
For example, studies have shown that gases such as
formaldehyde, which are present in many common office
materials, may not be adequately diluted under CO2 DCV
strategies without an extensive pre-purge cycle prior to
occupancy.
(Ventilation for Acceptable Indoor Air Quality , 2003)
How do infectious aerosols
get into the air?
Small particles of many different sizes contaminated with
the infective agent may rise up from soil, clothes, bedding
or floors when these are moved, cleaned or blown by wind.
These dust particles may be fungal spores—infective
agents themselves—tiny bits of infected feces, or tiny
particles of dirt or soil that have been contaminated with
the agent.
(National Center for Infectious Diseases, 2004)
What is the ventilation quality in our hospital?
 Without high-quality ventilation in health care facilities,
patients, health care workers and visitors can become infected by
simply breathing.

“Air-transmitted pathogens can be found everywhere in poorly
ventilated health care facilities,” Richard Hermans, P.E.,
ASHRAE certified healthcare facility design professional
(HFDP), chair of the committee that wrote the standard, said.
“Because these organisms are found in higher concentrations in
hospitals and because patients are susceptible to them,
additional care should be taken in the design of ventilation
systems.”

(New Ventilation Design Requirements for Health Care Facilities Available from ASHRAE, 2008)
Can you tell what the original hospital was?
What has happened to the ventilation systems?
JCAHO EC Standards
EC.7.10 The organization manages its utility risks.
EC.8.30 The organization manages the design and building of the
environment when it is renovated, altered, or newly created
AIA Guidelines: 5.3 Commissioning “Acceptance criteria for
mechanical systems shall be specified. Crucial ventilation
specifications for air balance and filtration shall be verified
before owner acceptance. …”
CDC Guidelines: C.II.G, “Commission the HVAC system for newly
constructed health-care facilities and renovated spaces before
occupancy and use, with emphasis on ensuring proper ventilation
for
operating rooms, AII rooms, and PE areas. Category IC (AIA: 5.1;
ASHRAE: 1-1996)
2007 Guideline for Isolation Precautions: Preventing
Transmission of Infectious Agents in Healthcare Settings

I.B.3.c. Airborne transmission Airborne transmission occurs by dissemination of either airborne
droplet nuclei or small particles in the respirable size range containing infectious agents that remain
infective over time and distance (e.g., spores of Aspergillus spp, and Mycobacterium tuberculosis).
Microorganisms carried in this manner may be dispersed over long distances by air currents and may
be inhaled by susceptible individuals who have not had face-to-face contact with (or been in the same
room with) the infectious individual

Preventing the spread of pathogens that are transmitted by the airborne route requires the use of
special air handling and ventilation systems (e.g., AIIRs) to contain and then safely remove the
infectious agent. Infectious agents to which this applies include Mycobacterium tuberculosis , rubeola
virus (measles), and varicella-zoster virus (chickenpox).



In addition, published data suggest the possibility that variola virus (smallpox) may be transmitted
over long distances through the air under unusual circumstances and AIIRs are recommended for this
agent as well; however, droplet and contact routes are the more frequent routes of transmission for
smallpox .
(2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007)
Currently policy is being reviewed for hospitals.
– As a move toward a single consensus-based
standard of care, a ventilation standard from
ASHRAE and ASHE has been incorporated into
the Guidelines for Design and Construction of
Health Care Facilities, copyrighted by the
Facility Guidelines Institute and published by
the American Society for Healthcare
Engineering (ASHE), (IAQ 2010 Examines
Impact of HVAC on Airborne Infectious Disease,
2009).
New Ventilation Design Requirements for
Health Care Facilities
 Without high-quality ventilation in health care facilities,
patients, health care workers and visitors can become
infected by simply breathing.
 The first standard in the nation to specifically address
ventilation in health care facilities is being developed by
ASHRAE.
 ASHRAE/ASHE Standard 170, Ventilation of
Health Care Facilities,
 (New Ventilation Design Requirements for Health Care Facilities Available from ASHRAE,
2008)
Continued increase in the incidence of HAIs
caused by multidrug-resistant organisms
(MDROs) in all healthcare settings and the
expanded body of knowledge concerning
prevention of transmission of MDROs created a
need for more specific recommendations for
surveillance and control of these pathogens that
would be practical and effective in various types
of healthcare settings
(2007 Guideline for Isolation Precautions: Preventing
Transmission of Infectious Agents in Healthcare Settings,
2007)
ASHRAE Standard 62
 ASHRAE Standard 62 prescribes ventilation rates for acceptable indoor air quality.
Whether or not it explicitly requires airflow measuring devices or not is irrelevant. It
should be clear to the design professional that the dynamic nature of mechanical
ventilation requires dynamic control. Being a rate based standard, continuous airflow
measurement should be a central component of any effective control strategy to
assure acceptable indoor air quality.
Existing supply fans and ductwork in hospitals may not be
able to produce the static pressure required to overcome
the filter grill resistance of HEPA filters. Increasing the
output of existing air handling system supplying
pharmacies will increase operational cost and may not
even be possible depending on current fan loading and/or
the gauge of the ductwork.
Hospitals will need additional engineering design work to
install in-line booster fans to create the required static
pressure to overcome the filter grill resistance and
maintain a positive pressure of the buffer zone relative to
the ante zone relative to the adjacent areas.
(Comments on Summary of Proposed Revisions to <797>,
2005)
Not requiring airflow measurement is
analogous to ignoring the requirement for
temperature measuring devices to maintain
automatic temperature control.
(Ventilation for Acceptable Indoor Air
Quality , 2003)
When antibiotics are becoming resistant, why do we
forget previous studies which could help answer some
of the problems?
 An editorial about the study suggested that prophylactic antimicrobials are at
least as effective as ultraclean air and exhaust ventilated suits in reducing
deep sepsis and that cheaper alternatives such as prophylactic
antimicrobials "should be exhausted" before any of the substantially more
expensive provisions, such as ultraclean air and exhaust ventilated suits, are
considered.
 A follow-up report from the multicenter study that examined the cost
implications for the British National Health Service of ultraclean air and other
infection control measures for total joint replacement suggested that
antimicrobial prophylaxis was more cost effective than an ultraclean air
system.
Ventilation Systems
 Florida Hospital of Orlando did try adding UV light to their ventilation
systems a few years ago and had an excellent experience.
 They found that UV device resulted in clean coils and drain pans areas
in a very humid and hot environment most of the year.
 This resulted in double the air velocity over the coils, from 230 fpm to
520 fpm = no more visible evidence of mold or organic buildup. The
wetbulb temp of the AHU decreased significantly. All of this translated
into increased capacity of Btuh or air conditioning ability.
 The dollar figures were calculated were $0.07 the current electric rate,
to translate into $4,867.00 in savings for this one unit. The cost of the
unit was $2,000.00. After all the facilities own by Florida Hospital in
Orlando, the final saving was estimated yearly savings well into the
six figures.

http://www.steril-aire.com/images/cs_floridahospital.pdf
IAQ 2010 Examines Impact of HVAC
on Airborne Infectious Disease
 The building industry is increasingly faced with the challenge of providing a healthy
indoor environment,” Dr. Chandra Sekhar, conference chair, said. “The SARS episode,
the current H1N1 pandemic and fears of avian flu have transformed the built
environment landscape, raising not only significant public health concerns but also
economic implications on a global scale. Airborne infection and its control in the built
environment have tremendous impact in the design, operation and maintenance of
buildings and other enclosed environments. IAQ 2010 will review the state of
knowledge about airborne infection and help define future directions.”
 (IAQ 2010 Examines Impact of HVAC on Airborne Infectious Disease, 2010)
Change
From this 1800’s hospital
To this state of the art
hospital
The next slide shows a diagram of how one patient
infected several patients in a hospital setting. You can
view the entire document at the below web site.
http://emergency.cdc.gov/agent/smallpox/training/overview/pdf/eradicationhistory.pdf
Airborne
Spread of
Smallpox in
the
Mesched
Hospital
http://www.bt.cdc.g
ov/agent/smallpox/t
raining/overview/pd
f/isolationquarantin
e.pdf
Air quality issues are a necessary component of every
hospital. The actual status or condition of our hospitals air
handlers justify adequate monitoring and inspections.
New standards are coming and either we can wait for
them, or we can be proactive and start taking
necessary measures to prevent patient exposures and
assure efficient ventilation management is in place to
allow for the maximum cost savings possible by
elimination of a over-worked and poorly functioning
air handler system.
Clean Air Act, EPA , http://www.epa.gov/air/airtrends/
Missouri air quality standards can be found at http://www.epa.gov/airtrends/factbook.html
American Society of Heating, Refrigerating and Air-Conditioning Engineers, can be found at
http://www.ashrae.org/
AIA Academy of Architecture for Health (AAH) http://www.ashe.org/ashe/codes/aia/index.html
Infection Control in Healthcare Settings http://www.cdc.gov/ncidod/dhqp/
Joint Commission accreditation http://www.jointcommission.org/
References:
Comments on Summary of Proposed Revisions to <797>. (2005). Retrieved Jan 2010, from ASHE:
http://www.ashe.org/ashe/codes/advisories/pdfs/comment090905_usp797rev3.pdf
Dooley, B. (May 12, 2004). Infection Control & HVAC. Pudget Sound: ICRA Design Consultants LLC
Health Hazard Evaluations:. (2001, Jan). Retrieved Jan 17, 2010, from NIOSH: http://www.cdc.gov/niosh/docs/2001116/default.html#health
IAQ 2010 Examines Impact of HVAC on Airborne Infectious Disease. (2009, Dec 17). Retrieved Jan 16, 2010, from
ASHRAE: http://www.ashrae.org/pressroom/detail/17385
Isolation and Quarantine Measures in Response to a Smallpox Emergency . (n.d.). Retrieved Jan 16, 2010, from CDC:
http://www.bt.cdc.gov/agent/smallpox/training/overview/pdf/isolationquarantine.pdf
Keikavousi, F. (2007). Florida Hospital puts HVAC Maintance under A New Light. Retrieved Jan 12, 2010, from Sterile Air Inc.:
http://www.steril-aire.com/images/cs_floridahospital.pdf
National Center for Infectious Diseases. (2004, Aug 8). Retrieved Jan 17, 2010, from CDC:
http://www.cdc.gov/ncidod/diseases/hanta/hps/noframes/glossary.htm
New Ventilation Design Requirements for Health Care Facilities Available from ASHRAE. (2008, Sept). Retrieved Jan 15, 2010,
from ASHRAE: http://www.ashrae.org/pressroom/detail/16900
Ventilation for Acceptable Indoor Air Quality . (2003, Jan). Retrieved Jan 16, 2010, from ASHRAE Standard 62-2001:
http://www.automatedbuildings.com/news/jan03/articles/ebtron/ebt.htm