Air Changes in the Morgue

Q: We are presently undergoing our 3-year licensure inspection by the Dept. of Health. One of the inspectors asked to see our air change records for the morgue. We have never completed air changes for the morgue. We use outside air and make sure the exhaust fan is working properly. So, should we be doing air change testing in the morgue? Also, do we need to do air change testing in all clean and soiled utility rooms in the hospital?

A: When your facility was designed and constructed, the HVAC system had to be designed to certain Air Changes per Hour (ACH). Depending when the facility was designed, the designer would use the AIA Guidelines (or as they are now called, the FGI Guidelines), or other state or local regulations as appropriate. You need to find out what those design ACH were at the time the facility was designed/constructed, or last renovated in that area.

It is important to understand that you do not have to meet the latest edition of FGI Guidelines; you just have to meet the edition at the time your facility was designed, or last renovated. It is important to also understand that you must comply with state and local regulations at all times.

So, let’s say the morgue was required to have 6 ACH at the time it was designed. You must maintain that 6 ACH for the life of the building, or until you renovate; then you would have to comply with new construction ACH for a morgue. The state inspector’s request is valid: How do you know you are maintaining 6 ACH if you don’t measure it from time to time? How often should you measure the ACH? The codes and standards do not say, so do a risk assessment and determine what is a valid number. Usually once per year is sufficient as long as you have historical data that shows the ACH rate was always in compliance.

You need to start measuring ACH rates in all areas where there was a design requirement for ACH.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.