In his October 25th ASHE-sponsored webinar, TJC Director of Engineering George Mills emphasized the importance of maintaining proper pressure relationships for infection prevention where rooms are required to be positive or negative with respect to adjacent rooms or spaces. Mr. Mills reiterated previous statements regarding how TJC surveyors will test for required pressure relationships – surveyors will use the tissue test very early to assess the adequacy of pressure relationships at the doorways of rooms subject to those requirements. The tissue test is often performed by holding a thin tissue at the bottom door gap of a closed door. The tissue will typically bend or flutter in the direction of air flow, which will be from a more positive to a less positive (or from a less negative to a more negative) space. As a rule of thumb, the “more clean” areas need to be positive pressure with respect to the “less clean” areas. If the tissue flutters from the “more clean” areas to the “less clean” areas – no problem. If the tissue flutters in the opposite direction however – big problem. This is likely to result in a Requirement for Improvement (RFI) against Standard EC.02.05.01, Element of Performance (EP) #6, which states the requirements for areas designed to control airborne contaminants along with the concomitant need for appropriate pressure relationships, air-exchange rates, and filtration efficiencies.
Mr. Mills stated that this RFI will result in a Condition Level Deficiency reported to CMS, which of course requires a re-survey within 45 days. Mr. Mills also stated that if the hospital is able to correct the process that led to the improper air flow (and it sounded as if simply adjusting some dampers would not be sufficient) the Life Safety surveyor may review the finding, and can contact TJC to discuss the possibility of reducing the Condition Level Deficiency to a Standard Level Deficiency. Mr. Mills cautioned that this lesser outcome was not guaranteed. Regardless of the Condition Level Deficiency outcome, the RFI will remain. He stated his hope that very rapid correction of such findings will result in a safer environment for the hospital’s patients.
Besides being a direct impact requirement, EC.02.05.01 EP6 is also an identified risk (R icon) EP and is scoring category A. Scoring category A means that a single instance of noncompliance will result in an RFI. As an identified risk EP, EP6 would also be addressed annually by TJC-accredited organizations during the annual Focused Standards Assessment.
It has been previously indicated that a TJC surveyor may initiate an environment of care tracer upon discovery of an improper pressure relationship in order to arrive at the cause of the problem. TJC surveyors may request details on previous inspection, testing and monitoring (ITM) activities relative to both those areas and the equipment that create the pressure relationships. Follow-up questions could also address the adequacy of maintenance processes, training, and competencies. Reports from the field during 2013 indicate that multiple RFIs may result from these types of EC tracers since they often probe utility infection control operating components, ITM activities, ITM frequencies, follow-up and corrective actions on problems found, and the like.
We recommend that organizations have a current inventory of all areas designed to control air flow (both positive and negative); the required air exchange rates, air handling unit filter efficiencies, along with a maintenance activities matrix for this equipment. ASHE recently developed a spreadsheet template for such testing and inspection activities and made it available to ASHE members. Mr. Mills included a graphic of that template, entitled VENTILATION SYSTEM PARAMETERS,” in his presentation.
This issue is not just an engineering issue – it is an environment of care issue. Because some rooms will have the required pressure relationships only with doors closed, it is important that users (clinical, environmental services, central sterilization personnel and others) understand both the operational behavioral requirements and the importance of compliance.
This is one of those cases where meeting a compliance requirement can coincide with doing the right things for the right reasons. We recommend that facility managers educate all affected users about this issue, the spaces with their requirements, and the behavioral issues that can drive a hospital out of compliance. Although some facilities have permanently installed monitoring equipment for those rooms, not all facilities have such equipment. We also recommend that facility managers in hospitals that do not have permanent monitoring use their inventories and conduct their own regular testing using either the tissue testing method or the smoke tube testing method. This more frequent monitoring would be in addition to the scheduled verification of the overall system air balance.
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