Humidity and Temperature Logs
Q: Can you advise on the accreditation standards in regards to keeping logs on OR rooms that are only used two days a month for cataract surgeries. No equipment is stored in these rooms when not in use or sterile instruments. The day prior to the cases the room is terminally cleaned and the temperature and humidity readings are checked to make sure it is in range. The morning of the cases the equipment is brought in by an outside vendor and cleaned and the instruments are all sterilized in the autoclave. The room is checked for condensation on floors and lights and the temperature and humidity is checked to make sure again it is in range. After the cases all of the equipment is taken out by the vendor and the instruments. The room is terminally cleaned and locked until the next month. Is there a standard that says the rooms humidity and temperature has to be checked every day and logged when only used one time a month?
A: No. As far as I can tell, there is not a standard from NFPA, CMS, or the accreditation organizations that specifies how often (or how frequent) the temperature and humidity needs to be checked and logged. However, there may be other standards that recommends or suggests hourly/daily checks and logs, such as AORN, CDC, FGI, etc.
The accreditation organizations may expect frequent checks and logs of temperature and humidity to ensure your rooms are within range. After all, if you don’t check it frequently, then how do you know it is within range? But how frequent is often enough? Since the standards do not say (subject to review of AORN, CDC and FGI guidelines) how frequent, then you get to decide.
In your case, it seems logical on what you are doing. I suggest you conduct a risk assessment to evaluate the potential risks for checking the temperature and humidity as infrequent as you do, based on 1 day’s use per month. Then contact your accreditation organization and run your process past them to see if they approve. If they do, then get it in writing (email response is fine), and if challenged by a surveyor during a survey you can show them you’ve done your due-diligence and got their approval and the surveyor should accept that.
