Air Pressure Relationships

Q: We have operating rooms with two doors, one that is adjoining to the sterile corridor and one to the common corridor in the Surgery department. We monitor the common corridor continuously through our building automation system (BAS). We do not monitor the sterile corridor. Is there a requirement to monitor the sterile corridor continuously or daily?

A: The standards on monitoring and logging are weak on ventilation requirements and not well defined in many cases. But the expectation is your organization will be monitoring and logging certain environmental parameters regarding operating rooms, such as:

  • Air-pressure relationship to surrounding areas;
  • Humidity levels;
  • Temperature levels

For new construction, CMS and the accreditation organizations recommend compliance with industry standards such as FGI Guidelines, AORN, CDC, and the like when other state or local regulations are silent. For existing conditions, most accreditation organizations have standards that require you to maintain ‘appropriate’ pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity, based on the edition of the design standards used at the time of design… if you know when that was, and what document was used for the design.

Many organizations don’t have that information available to them. When that is not known, most surveyors will lean on what is currently required for temperature, humidity, and air-pressure relationships. The FGI Guidelines require a positive air-pressure relationship to surrounding areas for operating rooms. That would include all areas, including the sterile OR corridor. I believe CMS and the accreditation organizations would expect you to monitor the air-pressure relationship between the operating room and all other areas, including the sterile corridor. There is no requirement to monitor this on a continuous basis, but should be conducted prior to every case.

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.