Frequency of Ventilation Checks

Q: Is there a code or standard that states how frequent the test intervals must be for air-exchange rates and air-pressure relationships in operating rooms, soiled utility rooms, and central sterile supply clean rooms must be conducted? We check air-pressure relationships periodically, but typically we only check air-exchange rates if we suspect or know of a problem.

A: Depending on the particular authority having jurisdiction (AHJ), they may have specific standards that addresses the frequency of air-pressure checks and air-exchange rates, but generally speaking, there is no specific code or standard that addresses this on a national level, that I am aware of. A quick check of the FGI Guidelines (2010 edition) did not identify anything specific on the frequencies of these checks. NFPA, CMS, Joint Commission, HFAP and DNV do not have specific standards that address the frequency of ventilation checks.

When the standards do not specifically state a specific action, then it is up to the AHJ to make an interpretation on this issue. Where the AHJ has not made an interpretation, then it is up to the institution to make an interpretation. But be aware, that most AHJs have their own interpretation and/or rules on the frequency of air-pressure checks and air-exchange rates, whether they publish those interpretations or not. Many of them usually want to see daily checks on basic requirements like air-pressure relationships to surrounding areas. This can be done with a tissue held at the bottom of the door to confirm air-flow in or out of the room; or you can invest into some air-pressure gauges that are mounted on the wall. The air-exchange rates are more difficult to confirm, so this may be done less frequent, such as semi-annual or annual. Check with your operating room nurse manager. I believe their professional organization, the Association of periOperative Registered Nurses (AORN), has published recommendations of daily checks for air-pressure relationship requirements for operating rooms. Make sure all checks are documented.

My best advice for you is to contact all of your AHJs and ask them directly how frequent they expect you to test these ventilation requirements.