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.

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.

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, 9.2.1.5). 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, 9.2.1.5). 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.