Annual Testing & Balance of HVAC Systems

Q: Do you know if the ambulatory health care facilities are required to do an annual Test and Balance of the HVAC system?

A: No… I am not aware of that requirement. As far as I know, there is no standard for ambulatory healthcare occupancies (ASC) and healthcare occupancies (hospitals) to conduct annual TAB for their HVAC systems.

Now, having said that, the accreditation organizations and the CMS certification agencies do require you to demonstrate compliance with certain ASHRAE ventilation requirements in critical areas, such as operating rooms. But there is no actual standard that says you have to conduct annual TAB on the HVAC systems.

I suspect your accreditation organization and state agency who surveys on behalf of CMS will expect you to have documentation that your HVAC systems in your critical areas of the ambulatory healthcare occupancy is in compliance. An annual TAB report should be sufficient for that purpose.

Air Pressure Requirements

Q: This question concerns isolation room negative pressure parameters. Our ICU isolation rooms have two sensors for air pressure; one located inside the room and the other located outside the room, of course. Could you tell me what the maximum and minimum negative pressure standard is supposed to be? Is there even such a standard? The CDC website says that if a room is negative then it’s fine. That seems too ambiguous for me. I’d like to see something more specific if possible. I want to be sure that our negative pressure monitors are configured correctly.

A: The ASHRAE standard 170-2013, which is incorporated into the 2014 FGI Guidelines, calls for 0.01 inches of water column (wc) of air pressure, when the air pressure relationship to surrounding areas is required to be positive or negative. This number is referenced in many sections inside ASHRAE 170-2013, such as: 7.2.1(e), 7.2.1(f), 7.2.2(a), 7.4.1, 7.5.1(c), 7.5.2(a). This seems to be the standard value for positive/negative air pressure. But I suggest you check with your state and local authorities to determine if they have additional requirements.

Strange Observations – Sprinkler Pipe Supported From Ductwork

Continuing in a series of strange things that I have seen while consulting at hospitals…

This is another picture of sprinkler pipe supported from HVAC ductwork, similar to last week’s Strange Observations.

I include it here to emphasize that sprinkler pipe cannot be supported from anything except the building structure itself.

I suspect I see this problem in 75% of the hospital where I consult… but then, I’m looking for it.

There is one exception to that rule… Sprinkler pipe may be suspended from a hanger that also supports ductwork, provided the hanger is designed to support the weight of the duct, the pipe, the water in the pipe, and an additional 250 lbs. (see NFPA 13-2010, If you ever see sprinkler pipe suspended from the same hanger that supports ductwork, ask the installer to provide documentation that the hanger can support that weight.

Probe Cleaning Room

Q: We have two small processing rooms in a hospital where they clean and reprocess vaginal probes, using the chemical RESERT. Should these rooms be held to the same standard as an Endoscope cleaning room (negative pressure, 10 ACH and exhausted directly to the outdoors, per FGI Guidelines)?

A: I would think so… The Life Safety Code does not comment on this, so it ends up being an issue that the Infection Control people should be consulted. Also, since it is a design issue, please check with your state and local authorities to see if they have a comment.

Strange Observations – Sprinkler Pipe Suspended From Ductwork

Continuing in a series of strange things that I have seen while consulting at hospitals…

Some organizations fail to install sprinklers underneath the ductwork that is 48-inches wide or wider. This facility did not forget, but the sprinkler-fitter who installed this pipe for the sprinkler head attached it to the ductwork, which is not permitted.

The sprinkler pipe can only be suspended from the building itself (i.e. structural beams, joists, etc.), and not from anything else.

There is one exception to that rule… Sprinkler pipe may be suspended from a hanger that also supports ductwork, provided the hanger is designed to support the weight of the duct, the pipe, the water in the pipe, and an additional 250 lbs. (see NFPA 13-2010, If you ever see sprinkler pipe suspended from the same hanger that supports ductwork, ask the installer to provide documentation that the hanger can support that weight.

Air Pressure Requirements for OR Suite

Q: I have a small 28 bed hospital with one OR suite. Within the OR suite are sterile rooms, a soiled room, and of course the Operating Room, etc. We are rebalancing the air flows for the entire floor which is all health care occupancy. I am aware that the rooms mentioned above, all have air pressure relationship requirements to adjacent areas per the Guidelines for Design & Construction of Hospitals and ASHRAE 170. However, some are questioning the need to have a positive air pressure relationship between the OR suite and other areas. That is, they measure the pressure from the OR suite door to other side which is the in-patient corridor. Is there any pressure relationship requirement in this location?

A: ASHRAE Standard 170: Ventilation of Health Care Facilities section 7.1.a.1 states that design of the ventilation system shall provide air movement that is generally from clean to less clean areas. Since surgery departments may or may not be suites, the ASHRAE 170 ventilation Table 7-1 in the FGI Guidelines does not address that. You are correct that the actual operating room has to have a positive air pressure relationship to its surrounding areas. But in addition,  sterile storage areas should have a positive pressure relationship to all adjacent areas except ORs and restricted areas within a surgery suite should have a positive pressure relationship to all adjacent areas except ORs and sterile storage areas.

Strange Observations – Part 39

Continuing in a series of strange things that I have seen while consulting at hospitals…

Okay… this was not taken at a hospital. This AC condensing unit was suspended from 2x4s for a restaurant in a small town in Iowa.

Ugh. Being a former HVAC guy, this makes my skin crawl.

Forward this picture to your HVAC contractor and let him have a good laugh today.

If you know where this was at, send my an email.

Fully Ducted HVAC System

Q: I have never been able to understand what a fully ducted heating system is and when a damper is not required. Can you explain this matter to me?

A: ‘Fully ducted’ HVAC systems are those in which the air in the HVAC system travels from the air handler to the room diffuser in ducts. The alternative is open return-air plenum ceilings or open supply-air plenum ceilings. Those types involve the open space above the ceiling for the movement of air, and there is no HVAC duct in that area. The return-air plenum ceilings are much more common than supply-air plenum ceilings, and would have an opening at the smoke compartment barrier (above the ceiling) to allow the movement of ventilation air without being inside ducts. What the Life Safety Code is saying is if you have ‘fully ducted’ HVAC system from the air handler all the way to the room diffuser on both the supply and return sides, and it penetrates a smoke compartment barrier, then the LSC does not require that you have a smoke damper in this barrier if the smoke compartments on both sides of the barrier are protected with sprinklers. While this is a huge benefit for facility managers, if you are required to comply with the International Building Code (IBC), they do not allow this exception, and you would have to have smoke dampers at the barrier.

Ventilation Requirements for Endoscopy Procedure Rooms

I was asked recently if the ventilation requirements for Endoscopy procedure rooms have changed recently, and the answer is yes. But the changes only apply to new construction, meaning you are not required to go back and retroactively update the ventilation design of the Endoscopy rooms.

The following editions of the Guidelines for Design and Construction of Healthcare Facilities have the following air pressure relationship requirements:



  • (AIA) 1996-1997 edition                 Neutral                 6 ACH                    2 ACH (outdoor air)
  • (AIA) 2001 edition                           Negative               6 ACH                    2 ACH (outdoor air)
  • (FGI) 2006 edition                           Neutral                 6 ACH                    2 ACH (outdoor air)
  • (FGI) 2010 edition                           Positive               15 ACH                     2 ACH (outdoor air)

So, from 1996 to 2010, the air pressure relationship for the endoscopy procedure room, went from being neutral, to negative, back to neutral, then to positive, and the air changes per hour (ACH) went from 6 to 15.

These are guidelines, and are not standards, meaning these are meant to be followed at the time of new construction, unless there are other reasons not to follow them (such as state requirements). The good thing is, as long as you have documented what edition of the guidelines you designed your Endoscopy procedure room to, you are not required to go back and update the room to meet the newer edition of the guidelines.

Typically, most states have firm requirements on ventilation requirements in hospitals that frequently follow along with the guidelines, so in those situations the hospital would have to follow the state’s requirements. Joint Commission has currently adopted the 2010 FGI guidelines (see EC.02.05.01, EP 6) which applies to new construction, and is not enforceable to older designs (many surveyors are not fully aware of this). Again, the guidelines are just guidelines, not standards. In lieu of any other reason, TJC would expect compliance with the guidelines that apply at the time the Endoscopy room was constructed.

CMS has not adopted any specific edition of the Guidelines…. See §482.41(c)(4) [A-0726], which requires ‘proper ventilation’. The CMS interpretative guidelines for this standard just says acceptable standards from AIA should be incorporated. This is not a specific requirement to use the AIA (or FGI) Guidelines. [NOTE: AIA used to write the Guidelines for Design and Construction, but in 2006 they turned it over to FGI.]

Portable Space Heaters

As I write this posting, it is very cold in Northern Illinois. Keeping a healthcare facility warm and cozy for staff is always a challenge in cold weather, but one of the biggest challenges is herding all those portable space heaters that seem to pop up without warning.

Portable space heaters are often found in the strangest places in hospitals and nursing homes, even though the major accreditors for healthcare organizations do not permit them in patient care or treatment areas of healthcare occupancies.

Portable space-heating devices are prohibited in healthcare care occupancies (such as hospitals, nursing homes, limited care facilities and hospice centers with more than 12 beds), with the exception of those portable heaters whose heating elements do not exceed 212 degrees F which are only permitted in smoke compartments which do not contain sleeping rooms, or patient care or treatment. [LSC 19.7.8]

However, in free standing medical offices which are classified as business occupancies, then the Life Safety Code has no restrictions on the use of portable space heaters.

But you need to be careful about using portable heaters in areas that are not traditional patient care or treatment areas. For example: The administrative offices of a healthcare occupancy (such as a hospital, nursing home, limited care facility or a hospice center with more than 12 beds) may be part of a smoke compartment that includes patient care or treatment areas.

The bigger picture is: If staff needs to use a portable space heater, then what does that say about the facility’s HVAC system? Even if an approved portable heater is used in an approved non-patient care or treatment area, it becomes a ‘red flag’ for a surveyor. Once it is noticed, a tracer may begin on why it is in use. If a surveyor determines the facility’s HVAC is not adequate to maintain staff’s comfort, it can be scored as a deficiency under EC.02.05.05 for a Joint Commission survey, or under section 482.41(c) [A-0722] for a CMS survey.

If you already have an approved Fire Safety Evaluation System (FSES) equivalency, or are considering one, then portable space heaters are not permitted in your organization at all. Question ‘D’ on worksheet 4.7.10 prohibit portable electric space heaters anywhere in your facility, if you are granted an approved FSES equivalency.

The bottom line… portable space heaters are trouble. Without the knowledge of the facility manager, staff tends to bring in  portable heaters from home without understanding what kind/style is permitted, and will use them in areas where they are not allowed. Heaters with orange glowing elements exceed the 212 degree F maximum allowed by the Life Safety Code. They add a load onto the electrical distribution system, which may not be designed to handle the extra current. The wrong type of heater may even start a fire if combustible products come into contact with them.

A good life safety code surveyor should be very skeptical of any portable space heater that they observe.