Q: During our mock inspection this week at our hospital, they are asking for temp and humidity checks in the surgery hallways. We do monitor the surgery rooms and center core room, along with sterile storage and clean rooms. Is there a regulation or code to monitor the hallway in any part of a hospital?
A: While there are no direct and specific standards that require the monitoring of temperature and humidity in a surgery hallway, it could be an issue that the mock surveyor is concerned about. If you’re Joint Commission accredited, they do have a couple of standards that address this issue:
EC.02.06.01, EP 13
This standard requires the hospital to maintain proper ventilation, temperature and humidity levels suitable for the care, treatment, and services provided. If the mock surveyor believed the temperature or humidity levels in the surgery hallway were not suitable then that would be a legitimate finding. But, this standard does not require the hospital to maintain logs that they are constantly monitoring the temperature or humidity levels.
EC.02.05.01, EP 15
This standard requires the hospital to ensure the ventilation system provides the appropriate air-pressure relationships, air-exchange rates, and filtration efficiencies in areas designed to control airborne contaminants. A note underneath this standard explains that areas designed for the control of airborne contaminants include operating rooms, special procedure rooms, delivery rooms, etc. It does not specially include surgery hallways as an area designed for the control of airborne contaminants, but it would fall under the provisions of air-pressure relationships to the ORs and clean or dirty utility rooms.
It all falls back on what the mock surveyor saw, and why they cited it. If there was a serious deficiency with temperature or humidity in the surgery hallway then the finding appears to be legitimate. However, if the mock surveyor’s opinion is you should be monitoring and logging the temperature and humidity in the surgery hallway just because the mock surveyor thinks it is a good idea, then that does not seem to be a legitimate finding. I suggest you appeal this finding.