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Design
Considerations
for Pressurized
Spaces
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General Hospitals
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Why
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Infection Control
Patient, Community and Staff Safety
Prevention
Specialized Procedures
TJC – EC .02.02.01.6 (2012)
CMS
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Disease History
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“No lepers, lunatics or persons having the
following sickness… or other contagious diseases
are to be admitted, and if any such be admitted by
mistake, they are to be expelled as soon as
possible.”
— Bishop Joscelin of Bath – 1219 A.D.
Listed in the hospital’s initial statutes
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Today’s
Infectioustitle
Diseases
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Headline: Los Angles Times
“Los Angeles Tuberculosis Outbreak Generates
Federal Gov’t Help”
Date: February 21, 2013
4,500 people possibly infected
Multi-Drug Resistant- TB (MDR-TB)
Extensively Drug Resistant- TB (XDR-TB)
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Drug Resistant
the Rise
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• FRONTLINE- “Hunting the Nightmare
Bacteria.” (Oct 22, 2013)
• Gram Negative Bacteria (Pan Resistant)
• 23K die/yr; 2M infected/yr
• No known Antibiotic
• Major Drug Companies- No R&D
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Types of Rooms/Areas Requiring Pressurization
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In (I-2) Facilities
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Airborne Infectious Isolation (AII)
Protective Environment (PE)
Operating (Class A, B & C)
Procedure Rooms (Bronchoscopy, Endoscopy,
etc.)
Laboratories/Pharmacies
Sterilizing/Surgical Processing
Central Medical and Surgical Supply
Service (Laundry, Food Prep, Housekeeping)
Support Space (Workrooms, Haz Mat’l Storage)
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• Standards/Guidelines
• Regulatory Codes
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FGI-AIA/ASHE (2010)
CDC
USP 797
ASHRAE/ANSI/ASHE Standard 170
w/Addenda (2008)
• UL
• NRC
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NFPA 99 (1999), 101 (2000)
Building Codes
CMS
JCAHO
State Health Codes
ADA
Participants
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End- Users/Clinicians
Facilities Engineering staff
Internal Designers/Planners
Infection Control personnel
Architect/Engineer
Support Departments (Housekeeping, Food
Service)
• Other Personnel deemed appropriate
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Design
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• Physical Design
– Adopt a holistic view to counter emerging infectious diseases
– New designs are Open, public spaces, hard to control spread of
infectious diseases
– Ease of travel allow people to cross borders that harbor, carry or
catch infectious diseases.
– During the Severe Acute Respiratory Syndrome (SARS) outbreak,
issues with multiple public entrances.
– Consider Negative pressure wards, designated areas in ED and ICU
– New designs should incorporate only single patient rooms—easily
convertible to Isolation rooms if an outbreak occurs
– When renovating or new construction, plan for at least two
methods of infection control: Isolation and ventilation.
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• Emergency Departments
– Typically designed with patient flow and satisfaction rather than healthcare
worker safety and protection
– Waiting areas to be negative with respect to staff locations
– Manage fever and higher risk patients separately from others
– Provide febrile areas (screening) and provide higher ACH for ventilation
– During design, look for turbulent ventilation across patient access areas
– Possibly provide a separate entrance for persons who know they have a fever
– Increased Ventilation systems can help dilute droplets nuclei discharged by
patients and is the single most important engineering control in prevention of
transmission of airborne infections
– Fever areas and rooms with negative pressure directed outdoors post HEPA
filtered (no recirc)
– Febrile patients who are non-ambulatory, manage in a critical care area.
Construct rooms to accommodate portable x-ray and isolate
– Signage and restricted entry points need to properly identified and enforced
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• Airborne Infection Isolation (AII)
– For the purpose of Isolating known patients who have a
communicable infectious disease, (e.g., TB, measles, varicella)
– Pressure differential to be negative to corridor. If Anteroom is
provided, the room differential pressure still required to be negative
to corridor and also the Anteroom.
– When determining location of Isolation Room(s), try and stay away
from stair towers, elevator shafts or large building shafts. They will
play havoc in maintaining proper differential pressure.
– Min (2) Outdoor ACH, (12) total, min ≥ -0.01” w.c.
– If possible, provide an Anteroom. Dilution rates are higher.
– Design for only one person
– Windows should be non-operable, Door seals at top and sides with
adjustable door sweep.
– Construction of walls should go from floor to deck above. Sealed at
all seams. Seal all outlets, med gas openings, IT openings, etc…
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If Anteroom can be constructed, door from patient room should
swing into Anteroom. Capture velocity will be maintained at door
edge. (Haltage 1998)
Must provide self-closing device on patient room door
Two different design approaches for maintaining minimum negative
pressure:
• Differential Air-Flow (Provide at least 10%.)
• Differential Pressure
Must provide continuous monitor in the corridor for staff observe
pressure with alarm. If permanent monitor provided, specify BACnet
connection for BMS monitoring.
Suggest monthly testing of air-flow direction (Manometer, ball in
tube, smoke test, flitter patch, etc…)
Commission all systems via 3rd party verifier
Train all personnel on the proper operation of pressure monitors,
room occupancy and ventilation system and function.
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Area Design – Protective Environment (PE)
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• Protective Environment Rooms
– Intended to protect immunocompromised patients from contracting
infectious diseases by aerosol transmission
– Pressure differential to be positive to corridor or to suite. If Anteroom is
provided, room differential pressure required to be positive to the Anteroom.
– When determining location of PE Room(s), try and stay away from stair
towers, elevator shafts or large building shafts. They will play havoc in
maintaining proper differential pressure. Elevator vestibules must be in airlocks if opening into a Suite.
– Min (2) Outdoor ACH, (12) total, min ≥+0.01” w.c.. Supply air must pass
through HEPA filtration prior to entering room.
– If possible, provide an Anteroom. Dilution rates are higher.
– Design for only one person
– Windows should be non-operable, Door seals at top and sides with
adjustable door sweep.
– Construction of walls should go from floor to deck above. Sealed at all seams.
Seal all outlets, med gas openings, IT openings, etc…
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Rooms
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Construction of ceilings shall me monolithic (hardpan)
Walls shall be smooth and impervious to cleaners and disinfectants
Flooring shall be smooth with sealed seams (MedTech)
Patient room door should swing IN to room and must have self closing device
Two different design approaches for maintaining positive pressure
• Differential Air Flow (Min 10%)
• Differential Pressure
Must provide continuous monitor in the corridor for staff to observe pressure
with alarm. If permanent monitor provided, specify BACnet connection for
BMS monitoring.
Suggest monthly testing of air-flow direction (Manometer, ball in tube, smoke
test, flitter patch, etc…)
Commission all systems via 3rd party verifier
Train all personnel on the proper operation of pressure monitors, room
occupancy and ventilation system and function
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established
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AII/PE Rooms
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• Combo AII/PE Rooms
– For patients who are immunosuppressed (HiV) and have an airborne infectious
disease
– FGI (2010)- Hospitals with PE rooms shall have at least (1) AII/PE room.
– It must have an Anteroom
– Anteroom is positive to the corridor and to the patient room
– Patient room shall be negative
– Same internal design as a PE room
– Patient room ACH remain the same and pressure must be a min ≥ -0.01” w.c.
Note: This is not a variable pressure room, i.e., change from negative to positive and
back again. AIA Guidelines for Design and Construction of Hospital and Health
Care Facilities (2006) prohibits this type of operation for any pressurized room.
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Questions
and Answers
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