HOSPITAL ISOLATION ROOMS AIR CONDITIONING

GENERAL:
As a result of the great importance of hospital isolation rooms, this study has been prepared to help A/C execution and maintenance Engineers in understanding and proper executing/maintaining of this type of rooms. As an example of the great importance of hospital isolation rooms, A survey of 763 U.S. hospitals in 1992 concluded that 88% had admitted TB patients. According to the survey, 70% of the hospitals had isolation rooms that met criteria set forth by the Center for Disease Control (CDC). Where isolation rooms were present, 45% of the facilities kept doors open some or most of the time with patients in these rooms, and only 47% of the facilities routinely checked for negative air pressure. TB had been transmitted to workers at 13% of the 763 (i.e. 99 hospitals!!). As a conclusion, properly designed, executed & maintained isolation room is one of the most important factors in stopping spread of infectious diseases.

ORGANIZATIONS:
Several organization have guidelines for designing, executing and maintaining isolation rooms, such as ASHRAE (American Society of Heating Refrigerating and Air conditioning Engineers), CDC (Center for Disease Control and Prevention, USA), OSHA (Occupational Safety and Health Administration, USA), AIA (American Institute of Architects), JCAHO (Joint Commission on Accreditation of Healthcare Organizations), HICPAC (Healthcare Infection Control Practices Advisory Committee), etc.

DEFINATION :
Isolation room is an in-patient room with special environment control as to prevent infection from patient to others (negative pressurization) or from others to patient (positive pressurization).

TYPES OF ISOLATION ROOMS:

Airborne Infection Isolation (AII) room:
Also called Negative pressure isolation room, this type of rooms is designed to isolate patients who is suffering from airborne infectious diseases such as : Chicken pox, Measles, severe Influenza, Tuberculosis (TB), Severe Acute respiratory Syndrome (SARS),etc. Negative pressure inside the room prevents air to flow from inside to outside the room and accordingly prevent spreading of airborne infectious agents in the hospital environment, to protect health care workers in addition to other patients in the hospital against infection. This room function is to PROTECT HOSPITAL ENVIRONMENT AGAINST INFECTION FROM ISOLATED PATIENT.

Protective Environment (PE) isolation rooms :

Also called Positive pressure isolation rooms, this type is designed to isolate patients who are especially vulnerable to airborne infectious agents, such as : AIDS, Bone-Marrow and solid organ transplant recipients, Burns, patients undergoing Cancer treatment, Patients whose immunity is compromised by interventions such as surgery, etc. Positive pressure inside the room prevents air to flow from outside to inside the room and accordingly prevent transmission of airborne infectious agents to the room to protect patient against infection This room function is to PROTECT ISOLATED PATIENT AGAINST INFECTION FROM HOSPITAL ENVIRONMENT.

Note:
Indoor condition (DBT & RH) is not the subject of this study, where its similar to inpatient room (i.e. DBT<=75 F & RH =50 %) for both types of isolation rooms.

 Airborne Infection Isolation (AII) Rooms:

This room should be kept under negative pressure, which can be achieved by extracting more air than supplied to the room as to create a negative pressure inside the room related to the surrounding.

1.1. Executing a new room :

CHECK PROJECT CONTRACT DOCUMENTS FOR THE FOLLOWING :

1.1.1. Architectural considerations :

Some Architectural notes should be considered, these notes will help in getting proper performance of the isolation room : The location of the proposed isolation room should be selected as far as possible from strong drafts (strong air streams), such as those near elevators or doorways. Room should not be oversized. Room should have a separate bathroom. Its recommended that isolation room should have an anteroom (fig.1)

Anteroom : A small room leading from a corridor into an isolation room this room can act as an airlock, preventing the escape of contaminants from the isolation room into the corridor. Note that the 2 doors should be aligned together to allow easy movements for trolleys, beds, equipments,etc. or provision of a second locked and gasketed (sealed) door for entry and exit of equipments and similar (fig.2). A view window can be provided in the door to the isolation room, this will be useful in reducing number of door opening & closing. Room door should be opened in the direction of lower pressure, i.e. in case of negative pressure room, door will be opened toward the room and NOT toward the corridor, this is to avoid contaminants transmission through air draft caused by door opening & closing. 4

Fig.1

Fig.2

Door should be provided with gasket at the sides and top of the door. Generally room should be sealed except door undercut (maximum). All openings should be sealed by gasketting or proper sealant (around windows, Pipe & A/C duct penetration through walls, Medical gasses outlets, Electric conduit entry to sockets, switches and lights, etc. Doors should be provided with self closing devices (door closer). Windows should have no handle and can be opened only by use of tools or keys to avoid opening by patient or unauthorized person (just the window is opened, room negative pressure is lost). False ceiling is not recommended in isolation rooms and should be avoided whenever possible. If false ceiling has to be done, the following should be considered : o Ceiling & walls above false ceiling should plastered and finished according to concerned regulations. o Use non-porous vinyl tiles and apply gasketing at tile connection to ceiling grid. o Light fixtures should be of exposed type (surface mounted).

Transfer grills and/or door grills are not allowed to avoid pressurization loss.

1.1.2. Ventilation air flow rate :

Old regulations require 6 ACH (Air Changes per Hour) for isolation rooms. For new constructions (January 2003), it is recommended that isolation room has 12 ACH ( higher values are preferable ) , and 10 ACH for anteroom and bathroom.

(AIA 2001 Guidelines for Design and Construction of Hospital and

Healthcare Facilities (Partial List) Adopted by JCAHO and will be in effect as of January 1, 2003.) The purpose is to reduce the concentration of contaminants in the air by removing contaminated air and replacing it with fresh air. To calculate the air flow rate, assume that isolation room dimensions are

4 x 4 x 3 ms. (height is measured from floor to ceiling and NOT to false ceiling). 12 air changes = 12 x (4 x 4 x 3) = 576 cubic meters = 20342 cubic ft. So, Supply air flow rate = 20342 CFH = 20342/60 = 340 CFM

1.1.3. Pressure difference :

Different recommendations according to organization ranging from (-0.001 )WC (inch of water) to (-0.05) WC, or if expressed in air flow difference between .extracted and supplied air will be from 50 CFM to 150 CFM extra extract As a conclusion, difference between extracted air and supplied air should be not .less than 100 CFM, or 10 % of supply air In fact, the actual flow difference depends upon room air tightness, i.e. a room with so many cracks and holes may need 300 CFM more extract to have a pressure difference of - 0.01 WC, while the same room may need only 100 CFM more extract to have the same pressure (-0.01) if its properly sealed. Considering the above mentioned example, for a 4 x 4 x 3 ms room : Supply air = 340 CFM Extract air = Supply air + 100 = 340 + 100 = 440 CFM NOTE : The air flow difference (100 CFM) should not include bathroom extract, i.e. if bathroom extract is 50 CFM , the total extract of isolation room + bathroom = 440 + 50 = 490 CFM

1.1.4. Recirculation or Exhaust :

Air recirculation is NOT RECOMMENDED in an airborne infection isolation room. Room should have 100 % fresh air supply with all air exhausted to atmosphere, which is the preferred way to ensure pure air inside the isolation room. Air should be cleaned through HEPA filter (High Efficiency Particulate Air filter Capable of trapping 99.97% of all particles greater than 0.3m in diameter) before exhausting to atmosphere. Air can be exhausted to the atmosphere with no filtration under the condition that exhaust outlet should be far from building ( windows, doors, fresh air intakes, 7

etc.) with a distance of not less 25 feet, but this is NOT the best selection where, some times, its difficult to have 25 feet far from building and considering hospital future extensions, or any new adjacent building, also consider that exhausted air is cooler than the atmosphere (i.e. density is higher than atmosphere which may direct part of the exhausted air down near windows & similar) so, Its recommended to clean the air before exhausting to atmosphere through HEPA filter in all cases. Some codes accept Recirculated air under the condition that return air should filtered through HEPA filter (or a combination of HEPA filter and duct mounted Ultraviolet Germicidal Irradiation (UVGI) to prevent or limit the growth of vegetative bacteria and fungi) and to provide fresh air of minimum 2 ACH (air changes/hour). This is for economical reasons only (to save energy of fresh air cooling), but its not the most preferred way. In conclusion, isolation room should have 100% fresh air with all air exhausted to atmosphere after cleaning with HEPA filter

1.1.5. Air Equipments :

Its preferred that isolation room is not connected to central air systems (i.e. room should have a separate fresh air handler & a separate extract fan).

Isolation room can be served from central system under certain conditions as will be explained later. Temperature sensed VAV (Variable Air Volume) system is NOT accepted in an isolation room to avoid air flow change according to temperature which will affect room pressurization. If the hospital building is served by VAV, the VAV box serve the isolation room should be adjusted to give constant flow.

1.1.6. Air distribution :

Air distribution system should be designed as to :

Maximize air mixing.

Protect health care workers (doctors, nurses, housekeeping team, etc.), this can be obtained through directing supply air from supply terminal to health care worker then to patient then to extract terminal.

Prevent stagnation : (Stagnation occurs when part of the room does not benefit from the clean supply air. Infectious particles in a stagnant spot are not being diluted or removed.

Prevent short circuiting : (Short-circuiting occurs when the exhaust is located too close to the supply; the clean air is removed from the room before it can effectively mix with and dilute contaminants in the room air.

Supply air terminal should be located where airflow is not obstructed by items such as surface-mounted light fixtures or a suspended television set,etc.

Several arrangements for supply & exhaust terminal locations. The best arrangement to get the above mentioned points, is to supply air at the ceiling above the foot of the bed, and to exhaust air on the wall near the floor (around 15 cms above floor level) at the head of the bed (i.e. patients head). See fig.3 (room plan & section S-S).

Fig.3 (Air distribution plan & section ss)

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1.1.7. Filtration :
As previously mentioned, air should be cleaned or sterilized through HEPA filter before exhausting to atmosphere, here are some notes which should be considered : HEPA filter should be located as to collect all room extracts (i.e. bathroom, anteroom & isolation room extract. A pre filter (disposable type) may be provided before HEPA filter. This will increase the life of HEPA filter by approximately 25%. If desired, carbon filter can be added to remove smells. Filter should be checked periodically (minimum semi-annually)to discover any gaps or cracks. A warning should be provided to indicate that filter is dirty & has to be changed (see control section). Dealing with contaminated filter should be done by expert technician (see labeling section). When filter has to be changed, it should be disinfected before replacement. The duct assembly should be opened and the filter should be sprayed with a disinfectant, such as Phenol Para-formaldehyde. The filter should be allowed to soak for approximately one hour, to allow for thorough disinfecting. The filter is then pulled from the housing. The used filter should be bagged for disposal. A new filter is then placed into the duct housing. If old filter is not disinfected, it should be bagged tightly and treated as dangerous medical waste (if possible, should be incinerated). Its recommended to have a mobile (or portable) recirculating HEPA filter unit for emergency cases (when extract fan is stopped). See fig.4 This device is available also in stationary models either floor, wall or ceiling mounted. Consists of an electric fan, pre-filter, HEPA filter, 3 speed fan switch (better to change fan speed only by technician, to avoid

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unauthorized changing which may affect ventilation rate & room pressurization in case of exhaust to outdoor) , dirty filter warning,etc. Available in different capacities. Unit should be selected according to actual requirements of the room as to give air flow rate of 12 ACH of room volume. Unit should be selected at low speed (i.e. air flow rate at low speed) or if the manufacturer catalogue list one air flow its better to select a unit with 25% more air flow than required, this is to compensate for decreased air flow rate when filter is dirty. As an example, if room volume is 1500 ft , then the required flow = 12 ACH = 18000 ft /hr = 300 CFM, add 25%,

Fig.4 (Mobile or portable HEPA filter unit) then the required HEPA filter unit will be selected for 300 x 1.25 = 375 CFM

1.1.8. Controls & monitoring :

Clogged filter warning should be provided to indicate filter change (depends on pressure drop through filter).

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Its recommended to provide a permanent pressure monitor to ensure that the room remains under negative pressure. The monitor is continuously displaying room pressure with respect to corridor or anteroom. There are several type with different mechanisms, one type is simply translate air flow velocity (from outside to inside the room )into a pressure reading which compare the pressure inside the room with pressure in corridor (see fig.5 & 6). In case of room pressure exceeds certain limit, a signal lamp (flasher) and a sound alarm will be activated to warn the nurse staff that room lost negative pressure. Monitor should be fixed in a clear position outside the room as to be seen by nurse staff or in nurse station.

Fig.5 (Pressure monitor)

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Fig.6 (Monitor location) Fluctuations in pressure are to be expected once a door is opened. monitor shall be equipped with a time-delay feature to activate when the door to the room is opened, so that the alarm is not sounded. The delay must include time for the ventilation system to reestablish the correct pressure differential after the door is closed; otherwise repeated alarms will be a problem.

Fig.7 (Portable monitor)

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Variable Air Volume : Variable Air Volume (VAV) system can be used for isolation rooms. In this case the pressure sensor will be utilized to control a modulating air damper fixed on exhaust duct. If the pressure difference between room & corridor is changed (toward positive), then the sensor will modulate the damper (through controller) to increase the exhaust and viseversa, so as to keep room at constant negative pressure. Notes : Temperature sensor will NOT be utilized to control modulating air damper, but it will control either chilled water modulating valve or refrigeration compressor (in case of DX system). Fan & extract duct should be oversized to allow for higher demand by VAV.

If permanent monitor is not available, then the room pressure should be measured daily (especially if room is occupied with a TB patient) and monthly if room is not in use. Pressure can be measured by a portable monitor (see fig.7).

Fresh air supply handler should be electrically interlocked with extract fan (i.e. in case of extract fan is stopped, the fresh air handler should be also stopped), this is to avoid positive pressure inside the room which may spread the contaminants to the surrounding.

In case of central supply air system and central extract system, supply & extract ducts to isolation room should be provided with motorized damper. Both damper should be electrically interlocked as to close both dampers in case of extract fan is stopped. supply damper advantage is to stop fresh air supply, while extract damper advantage is to prevent transmission of air from room to other areas served by same duct (although a HEPA filter is exist but its more safe to close extract duct during fan stopping because of possibility of cracked HEPA filter in addition that duct pressure becomes neutral with all served rooms).

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Fresh air handler & Extract fan should be electrically supplied from emergency networks (hospital stand-by diesel generator and UPS system). In addition, pressure monitor, room lighting and one electric socket (with enough power to operate a mobile HEPA filter unit), should be supplied from emergency networks.

1.1.9. Labeling :
One of the most important factors which should not be ignored or considered as a minor item. Labels should be provided in ENGLISH & ARABIC LANGUAGES in the following locations : 1.1.9.1. Outside room (anteroom door & room door) signs should be fixed to warn for the following : This is an infection isolation room, check nurse before entering. Gloves are required. Respiratory protection is required (surgical mask is not a protection, use N95 or similar respirator) Keep THE doors closed & do not open both doors at the same time. Do NOT open the windows. Throw gloves & respirator in the basket beside room door after leaving the room. Wash your hands after leaving the room. Vulnerable or Non-immune personnel should not enter this room NOTE : N95 respirators collected >95% of particles with diameters ranging from 0.1 - 0.3 m and achieved filtering efficiencies of >99.5% with particles of 0.75 m diameter. 1.1.9.2. At all points of extract air ducts, dampers, outlets, fans,etc. before air is treated with HEPA filter, The following words should be written on duct (by stencil), at intervals of not more than 3 meters apart & at all wall and ceiling penetrations, and wherever seems to be required, labels should warn for the following. respiratory

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CONTAMINATED AIR RESPIRATORY PROTECTION AND GLOVES ARE REQUIRED Do NOT repair or reuse any part of this system (grilles, dampers, sensors,etc.) before disinfecting check nurse for disinfectant. 1.1.9.3. Beside pre-filter and HEPA filter housing (label or sign) : change filter, follow the following : Contaminated filter, gloves and respiratory protection is required (surgical mask is not a respiratory protection). Put the filter in a sealed bag just after removal. Add the new filter. Filter, gloves and respirator should be incinerated or treated as dangerous medical waste. Or To change filter, follow the following : Contaminated filter, gloves and respiratory protection is required (surgical mask is not a respiratory protection). Disinfect filter before removal by Phenol Para-formaldehyde or similar for one hour. Remove disinfected filter and bag it. Add the new filter. Filter, gloves and respirator should be treated as dangerous medical waste. 1.1.9.4. Beside Exhaust fan and fan electric isolator :

To

Air may be contaminated gloves & respiratory protection is required This fan exhausts air from infection isolation room Do NOT stop the fan for any reason while room is occupied-check nurse.

NOTES :

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Above mentioned are suggestions, any similar words and additional warnings can be used. For labeling directed to technicians, its preferred to be in ARABIC, ENGLISH & AURDO. Signs & Labels should be metal engraved plates or written by stencil with permanent paint. Preferred to add any warning sign such as the shown below.

Fig.8 (Warning logos)

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1.2. Changing an ordinary in-patient room to a negative pressure isolation room :

Check your contract documents to cover all points mentioned under (1.1Executing a new room), considering the following notes : Room should have a complete separate ventilation & air conditioning systems (i.e. separate air handling unit (fresh air), separate exhaust fan, etc.) If its not possible to execute a separate fresh air handler & a separate exhaust fan for the room, the central systems can be utilized with proper controls, filtration,etc. as mentioned under (1.1). Portable or mobile HEPA filter unit can be used either to clean & recirculate air inside the room or to clean & create a negative pressure inside room through exhausting air to outside as shown in fig.9. Portable unit can be used in addition to central exhaust, if this exhaust is not enough to give the required number of room air changes per hour. For example if exhaust system is giving 4 ACH, the portable unit can be selected as to give the remaining 8 ACH, so the room will have a total of 12 ACH as recommended.

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Fig.9 (Wall mounted HEPA filter unit with direct exhaust to outside)

1.3. Related hospital areas :

Airborne infectious disease patients are expected to be present in some other hospital rooms such as : Waiting area : The following requirements apply to waiting areas found in hospital emergency rooms, pulmonary clinics, and acute care clinics, where infectious patients (especially TB patients) may be present : Where possible, sectional waiting areas with partitions should be used to separate suspected TB patients. Waiting areas shall be under negative pressure. Ventilation shall provide a minimum 10% negative pressure (i.e. if supply air is 1500 CFM, then extract air will be 1650 CFM taking into consideration that difference should be not less than 50 CFM). Waiting areas for infectious patients shall be directly exhausted to the outside in new facilities. If its not possible to exhaust all air, Ventilation in waiting areas for infectious patients shall provide a minimum 15 ACH with a minimum of 2 ACH of outdoor air shall be provided as part of the required 15 ACH. Return & exhaust air shall be filtered with HEPA filter. The same can be applied for existing old hospitals.

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In areas where ventilation may be a questionable, infectious patients may be segregated from the general waiting area by using negative-pressure enclosures, such as tents or booths. Negative-pressure enclosures should be located in concealed areas, as to not make a patient feel segregated in a high-traffic area such as a waiting room. Examination & treatment rooms : Treatment, examination, Bronchoscopy & dental treatment rooms for infectious patients shall be designed in a similar way to the isolation room as previously mentioned, considering the following points : Treatment room can be executed with or without anteroom. Treatment room should be kept under negative pressure similar to isolation room. Preferred to be provided with a separate bathroom/toilet. Treatment room is not required to have an outside window. Switchability of HVAC systems in treatment areas from negative to positive pressure, and vice versa is NOT ACCEPTED. Air should be distributed to give the same functions as for isolation room. One example of such a design involves placing the supply register at the side of the room opposite of the patient, typically near the patient room door, the exhaust register is then located near the head end of the exam table. Preferred to exhaust all air (with HEPA filtering before exhausting). If its not possible air can be recirculated with minimum 6 ACH (recommended 12 ACH) of 2 ACH of fresh air, and HEPA filtering for extract & return air.

Operating rooms : Operating rooms construction should consider that surgical procedures may be performed on an infectious patient (especially TB patient). Since operating rooms are designed to be under positive air pressure, the

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following precautions should be considered to minimize the possibility of infection spread : Operating Rooms should include one operating room equipped with an anterooms. Anteroom & scrub room shall be kept under negative pressure (minimum 10 %) to prevent air from entering the corridor. (I think its better to keep both anteroom & scrub room under a higher negative pressure as to extract all air exfiltrated from operating room in addition for some air from corridor as an example : If an operating room has extract air = 1500 CFM & supply air = 1650 CFM, and anteroom has supply air = 90 CFM, then anteroom extract should be = 90+100 = 190 CFM- and if Scrub room has supply air = 80 CFM, then scrub room extract = 80+100= 180 CFM. So, the residual extract will be 100+100 = 200 CFM, which is enough to extract all exfiltrated air from operating room (150 CFM) in addition to 50 CFM more extract (25 CFM for each room), as to keep both rooms (anteroom & scrub room) under negative pressure related to corridor). Exhaust system in the operating room shall be functioning properly at all times. Operating room is preferred to have 100% fresh air with HEPA filter in supply & exhaust air ducts. If the operating room has recirculating A/C system, HEPA filters should be provided in supply, exhaust & return air ducts.

Autopsy : Autopsy should be kept under negative pressure similar to isolation room. Ventilation rate of 12 ACH. & 2 ACH of fresh air can be used but 100% Fresh air is preferred. 22

Direct exhaust to outside (with HEPA filtering). Ultraviolet Germicidal Irradiation (UVGI) and in-room HEPA filtration units may be used as supplemental engineering controls to reduce the risk of exposure to infectious particulates.

Non refrigerated body holding room : This room should be kept under negative pressure similar to isolation room. Ventilation rate of 10 ACH. Direct exhaust to outside (with HEPA filtering). 100% Fresh air is preferred.

2. Protective Environment (PE) isolation rooms :

This room should be kept under positive pressure, which can be achieved by extracting less air than supplied to the room as to create a positive pressure inside the room related to the surrounding.

2.1. Executing a new room :

CHECK PROJECT CONTRACT DOCUMENTS FOR THE FOLLOWING :

2.1.1. Architectural considerations :

The same architectural considerations as negative pressure isolation rooms (see 1.1.1), except that : Room door should be opened in the direction of lower pressure, i.e. in case of positive pressure room, door will be opened toward the

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corridor and NOT toward the room, this is to avoid contaminants transmission through air draft caused by door opening & closing. See fig.10

Fig.10 (Protective Environment isolation room)

2.1.2. Ventilation air flow rate :

Similar to negative pressure room, 12 ACH is recommended ( higher values are preferable ) , and 10 ACH for anteroom and bathroom. The purpose is to reduce the concentration of contaminants in the air by removing contaminated air and replacing it with fresh air.

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To calculate the air flow rate, assume that isolation room dimensions are 4 x 4 x 3 ms. (height is measured from floor to ceiling and NOT to false ceiling). 12 air changes = 12 x (4 x 4 x 3) = 576 cubic meters = 20342 cubic ft. So, Extract air flow rate = 20342 CFH = 20342/60 = 340 CFM

2.1.3. Pressure difference :

Similar to negative pressure room, different recommendations according to organization ranging from (0.001 )WC (inch of water) to (0.05) WC, or if expressed in air flow difference between supplied and extracted air will be from .50 CFM to 150 CFM extra extract As a conclusion, difference between supplied air and extracted air should be not .less than 100 CFM, or 10 % of supply air In fact, the actual flow difference depends upon room air tightness, i.e. a room with so many cracks and holes may need 300 CFM more supply air to have a pressure difference of 0.01 WC, while the same room may need only 100 CFM more supply to have the same pressure (0.01) if its properly sealed. Considering the above mentioned example, for a 4 x 4 x 3 ms room : Extract air = 340 CFM Supply air = Extract air + 100 = 340 + 100 = 440 CFM NOTE : The air flow difference (100 CFM) should not include bathroom extract, i.e. if bathroom extract is 50 CFM , the total extract of isolation room + bathroom = 340 + 50 = 390 CFM

2.1.4. Recirculation & Exhaust :

The air recirculation is NOT RECOMMENDED in positive pressure isolation room. Room should have 100 % fresh air supply with all air exhausted to

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atmosphere, which is the preferred way to ensure pure air inside the isolation room. Supply air should be cleaned through HEPA filter (High Efficiency Particulate Air filter Capable of trapping 99.97% of all particles greater than 0.3m in diameter) before being supplied to the room. Optionally a duct mounted Ultraviolet Germicidal Irradiation (UVGI) can be used in addition to HEPA filter

2.1.5. Air Equipments :

Similar to negative pressure room (see 1.1.5)

2.1.6. Air distribution :

Air distribution system should be designed as to :

Protect patient, this can be obtained through directing supply air from supply terminal to patient then to healthcare workers then to extract terminal.

Prevent stagnation : (Stagnation occurs when part of the room does not benefit from the clean supply air. Infectious particles in a stagnant spot are not being diluted or removed.

Prevent short circuiting : (Short-circuiting occurs when the exhaust is located too close to the supply; the clean air is removed from the room before it can effectively mix with and dilute contaminants in the room air.

Supply air terminal should be located where airflow is not obstructed by items such as surface-mounted light fixtures or a suspended television set,etc.

Several arrangements for supply & exhaust terminal locations, but in all arrangements clean, filtered air should enter from one side of the room, flow

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across the patient's bed, and exit from the opposite side of the room. One of the arrangements to get the above mentioned performance, is to supply air at the ceiling near head of the patient, and to exhaust air on the wall near the floor (around 15 cms above floor level) at the other side of the room (i.e. beside room door). See fig.11 (room plan & section S-S).

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Fig.11 (Air distribution plan & section s-s) Some physicians prefer an isolated laminar airflow unit to protect the patient (similar to operating room), others are of the opinion that the conditions of the laminar cell have a psychologically harmful effect on the patient and prefer flushing out the room and reducing contaminants in the air. Generally laminar flow system is not recommended in a PE room, studies attempting to demonstrate patient benefit from laminar airflow in a PE setting are equivocal In fact the best way is to use radial flow diffusers to supply air. One of the arrangements is to place 2 diffusers in the ceiling above the patient's bed, one to the left and one to the right (as shown in fig.12).

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Fig.12 (Protective isolation room with radial supply diffusers)

Radial flow diffuser (see fig.13) is a special type of diffusers which have a radial flow pattern. Air flows from the diffuser displacing large volumes of air out and away from the diffuser. This forced displacement of air prevents entrainment (Entrainment: The induced flow of room air by the primary air from an outlet, creating a mixed air path, commonly called secondary air motion) of room air which may be contaminated with pollutants.

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Radial flow diffuser Fig.13

Radial flow pattern

2.1.7. Filtration :
As previously mentioned, air should be cleaned or sterilized through HEPA filter before supplied to the room, here are some notes which should be considered : A pre filter may be provided before HEPA filter. This will increase the life of HEPA filter by approximately 25%. Optionally, a HEPA filter can be provided in extract duct as to prevent back draft. Filter should be checked periodically (minimum semi-annually)to discover any gaps or cracks. A warning should be provided to indicate that filter is dirty & has to be changed (see control section). Similar to negative pressure room, its recommended to have a mobile (or portable) recirculating HEPA filter unit for emergency cases (when supply air is stopped). See fig.4 This device is available also in stationary models either floor, wall or ceiling mounted. Consists of an electric fan, pre-filter, HEPA filter, 3 speed fan switch (better to change fan speed only by technician, to avoid unauthorized changing which may affect ventilation rate & room

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pressurization in case of exhaust to outdoor), dirty filter warning,etc. Available in different capacities. Unit should be selected according to actual requirements of the room as to give air flow rate of 12 ACH of room volume. Unit should be selected at low speed (i.e. air flow rate at low speed) or if the manufacturer catalogue list one air flow, its better to select a unit with 25% more air flow than required, this is to compensate for decreased air flow rate when filter is dirty. As an example, if room volume is 1500 ft , then the required flow = 12 ACH = 18000 ft /hr = 300 CFM, add 25%, then the required HEPA filter unit will be selected for 300 x 1.25 = 375 CFM. NOTE : Do NOT use mobile recirculating HEPA filter unit which is previously used in an airborne infection isolation room to serve in a protective isolation room (unless properly sterilized).

2.1.8. Controls & monitoring :

Similar to negative pressure rooms (see section 1.1.8) for : clogged filter warning, permanent pressure monitor (positive pressurization)& alarms, periodical checking of positive pressurization, emergency electric power supply,...etc. In addition : Fresh air supply handler should be electrically interlocked with extract fan (i.e. in case of fresh air handler is stopped, the extract fan should be also stopped), this is to avoid negative pressurization inside the room which may transfer the contaminants to the isolated patient. In case of central supply air system and central extract system, supply & extract ducts to isolation room should be provided with motorized damper. Both damper should be electrically interlocked as to close both dampers in case of fresh air supply is stopped. Extract damper advantage is to stop extract air, while supply damper advantage is to prevent transmission of air from other areas served by same duct to the 31

room (although a HEPA filter is exist but its more safe to close supply duct during supply air stopping because of possibility of cracked HEPA filter in addition that duct pressure becomes neutral with all served rooms). Variable Air Volume : Variable Air Volume (VAV) system can be used for isolation rooms. In this case the pressure sensor will be utilized to control a modulating air damper fixed on exhaust duct. If the pressure difference between room & corridor is changed (toward negative), then the sensor will modulate the damper (through controller) to decrease the exhaust and vise-versa, so as to keep room at constant positive pressure. Notes : Temperature sensor will NOT be utilized to control modulating air damper, but it will control either chilled water modulating valve or refrigeration compressor (in case of DX system). Fan & extract duct should be oversized to allow for higher demand by VAV.

2.1.9. Labeling :
Similar to negative pressure room (see section 1.1.9), this is one of the most important factors which should not be ignored or considered as a minor item, taking into consideration that labeling here is mainly to protect the isolated patient. Labels should be provided in ENGLISH & ARABIC LANGUAGES in the following locations : 2.1.9.1. Outside room (anteroom door & room door) signs should be fixed to warn for the following : This is a Protective Environment isolation room, check nurse before entering. Wash your hands before entering the room. Gloves & Gown are required. Respiratory protection is required (surgical mask is not a protection, use N95 or similar respirator) Keep THE doors closed & do not open both doors at the same time. respiratory

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Do NOT open the windows. NOTE : N95 respirators collects >95% of particles with diameters ranging from 0.1 - 0.3 m and achieved filtering efficiencies of >99.5% with particles of 0.75 m diameter. This respirator is to protect patient against infection transfer from personnel entering the room. At all points of supply air ducts, the following words should be written on duct (by stencil), at intervals of not more than 3 meters apart & at all wall and ceiling penetrations, and wherever seems to be required, labels should warn for the following: Do NOT open branches or reduce air flow on this duct. 2.1.9.3. Beside pre-filter and HEPA filter housing (label or sign) : Replace the filter when room is not occupied, check nurse firstly. 2.1.9.4. Beside Fresh air handler, Exhaust fan and their electric isolators :

Do NOT stop the air handling unit or the exhaust fan for any reason while room is occupied-check nurse firstly.

NOTES : Above mentioned are suggestions, any similar words and/or additional warnings can be used. For labeling directed to technicians, its preferred to be in ARABIC, ENGLISH & AURDO. Signs & Labels should be metal engraved plates or written by stencil with permanent paint.

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Preferred to add any warning sign such as the shown in fig.8.

2.2. Changing an ordinary in-patient room to a positive pressure isolation room :

Similar to negative pressure room, check your contract documents to cover all points mentioned under (2.1- Executing a new room), considering the same notes under (1.2) for ventilation and air conditioning systems but for a positive room.

2.3. Related hospital areas :

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Its recommended to have a positive pressure treatment room (in a similar way to PE room), which will be used for the treatment of PE isolated patients (see also 1.3).

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USEFUL NOTES :
Over time, dust and lint can collect at exhaust grilles and in exhaust ducts. Seals at duct joints also break down and leak. These two effects result in diminished exhaust airflow from the isolation room. To compensate, exhaust ducts should be oversized. Isolation room exhaust ducts and fan systems should be sized for the expected airflow plus an extra 50%. AIA guidelines prohibit United States hospitals and surgical centers from shutting down their HVAC systems for purposes other than required maintenance, filter changes, and construction. While working on the HVAC system, remove bird roosts and nests near air intakes to prevent mites and fungal spores from entering the ventilation system. In addition registers and ductwork should be observed for dust and other contaminants. Facilities should consider a complete cleaning of all HVAC systems. Currently, there are no industry standards for the timeframe of cleaning ductwork. It is at the discretion of the facility to determine when a system needs to be cleaned (one suggestion to be once every 10 years or less according to practical observation). Old healthcare facilities may have variable pressure rooms (i.e., rooms in which the ventilation can be manually switched between positive- and negative pressure). These rooms are NO LONGER PERMITTED in the construction of new facilities, and their use in existing facilities is discouraged because of difficulties in assuring the proper pressure differential, especially for the negative pressure setting, and the potential for error associated with switching the pressure differentials for the room. Avoid placing decorative fountains and fish tanks in patient-care areas; ensure disinfection and fountain maintenance if decorative fountains are used in public areas of the health-care facility. 36

Areas contaminated by body fluids from the suspect case (e.g. vomit) should not be vacuumed unless a HEPA filter vacuum is available (vacuum cleaner with HEPA filter ). Wet mopping with a disinfectant cleaner (hard surfaces) or steam cleaning (carpets) is recommended. Positive pressure and HEPA filters may be preferred in some rooms in intensive care units (ICUs) caring for large numbers of immunocompromised patients. Its preferred to provide isolation rooms with electronic water mixers (i.e. without handles, operated with electronic cell detects hands near the mixer and automatically open the mixer), either in bathroom or in anteroom, to avoid crosscontamination.

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References :
ASHRAE APPLICATIONS HANDBOOK 1999 ASHRAE JOURNAL FEB./2003 ASHRAE JOURNAL june/2001 AMERICAN INSTITUTE OF ARCHITECTS (AIA) : www.aia.org THE NEW ZEALAND INSTITUTE OF HEALTH ESTATE & ENGINEERING MANAGEMENT : www.nziheem.org.nz USA CENTER FOR DISEASE CONTROL AND PREVENTION (CDC) :
www.cdc.gov

OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA) :

www.osha.gov

CHAPTER IV GENERAL HOSPITAL (http://www.cdphe.state.co.us/op/regs/healthfacilities/10110104generalhosp itals.pdf) - COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT GUIDELINES FOR PREVENTION OF NOSOCOMIAL PNEUMONIA CDC MMWR 1997, www.cdc.gov/mmwr/index/html AIA Ventilation Requirements for Patient Care in Hospitals - "2001 Guidelines for Design and Construction of Hospital and Healthcare Facilities" (Partial List), (Adopted by JCAHO and will be in effect as of January 1, 2003.)

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Guidelines for Environmental Infection Control in Health-Care Facilities Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) CDC MMWR JUNE 2003 ,

www.cdc.gov/mmwr/index/html
Guidelines for the Classification and Design of Isolation Rooms in Health Care Facilities, www.dhs.vic.gov.au/phd/9906058a/index.htm Technical Design Guidelines for Health Care Facilities, Alberta Infrastructure - Technical Resources and Standards Division Property Development

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Glossary of Terms
AIA - American Institute of Architects. AIDS - Acquired Immune Deficiency Syndrome, caused by HIV. AII room - airborne infection isolation room. Airborne transmission - a means of spreading infection when airborne droplet nuclei (small particle residue of evaporated droplets < 5 m in size containing microorganisms that remain suspended in air for long periods of time) are inhaled by the susceptible host. Ambient air - the air surrounding an object. Anteroom - A small room leading from a corridor to an isolation room. This room can act as an airlock, preventing the escape of contaminants from the isolation room into the corridor or from corridor to isolation room. ASHRAE - American Society of Heating, Refrigerating, and Air Conditioning Engineers. Bronchoscopy - A procedure for examining the respiratory tract. An instrument (a bronchoscope) is inserted through the mouth or nose and into the trachea. The procedure can be used to obtain diagnostic specimens. CDC - Center for Disease Control and Prevention, USA

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Contaminant - an unwanted airborne constituent that may reduce acceptability of the air. DBT Dry bulb temperature Differential pressure gauge - A pressure gauge with two ports that will display the difference in pressure between one port on the gauge and the other. It is normally placed to measure the difference in pressure between two rooms. Diffuser - the grille plate which disperses the air stream coming into the conditioned air space. Dilution (by ventilation) - an engineering control technique to dilute and remove airborne contaminants by the flow of air into and out of an area. Air that contains droplet nuclei is removed and replaced by contaminant-free air. If the flow is sufficient, droplet nuclei become dispersed, and their concentration in the air is diminished. Displacement diffuser - Air outlet that creates displacement diffusion Displacement diffusion - A directional airflow pattern that provides a singlepass air stream. The air flows from the source, over the designed target area, to exhaust, with the least mixing, therefore creating as little turbulence as possible. Droplet nuclei - Microscopic particles (15 m in diameter) produced when a person coughs, sneezes, shouts or sings. An infectious tuberculosis patient can produce droplet nuclei that carry tubercle bacilli and remain suspended in the air for prolonged periods (being carried on normal air currents in the room). Dust - an air suspension of particles (aerosol) of any solid material, usually with particle sizes < 100 m in diameter. Exhaust air - air removed from a space and not reused therein.

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HEPA filter - High Efficiency Particulate Air filters capable of removing 99.97% of particles > 0.3 m in diameter and may assist in controlling the transmission of airborne disease agents. These filters may be used in ventilation systems to remove particles from the air or in personal respirators to filter air before it is inhaled by the person wearing the respirator. The optimal HEPA filter allows only three particles to pass through for every 10,000 particles that are fed to the filter. HICPAC - Healthcare Infection Control Practices Advisory Committee High efficiency filter - a filter with a particle-removal efficiency of 90% - 95%. HIV - Human immunodeficiency virus, the virus that causes AIDS. A person can be infected with HIV and not yet have full blown AIDS. Housekeeping surfaces - environmental surfaces (e.g., floors, walls, ceilings, tabletops,etc.) HVAC - Heating, Ventilation, Air Conditioning. Immuno-compromised - Severe cellular immunosuppression resulting from HIV infection or immunosuppressive therapy. Immunosuppressed - Those having a damaged or non-functioning immune system including patients with AIDS, leukemia, cancer undergoing certain chemotherapies, certain other medical conditions. Infection - The condition in which organisms capable of causing disease (for example, M. tuberculosis) Infectious - Capable of transmitting infection. JCAHO - Joint Commission on Accreditation of Healthcare Organizations.

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Laminar flow - HEPA filtered air that is blown into a room in an unidirectional pattern with parallel streamlines, characterized by little or no mixing of air. Low efficiency filter - the prefilter with a particle-removal efficiency of approximately 30% through which incoming air first passes. See also Prefilter Makeup air - outdoor air supplied to replace exhausted air. Natural ventilation - the movement of outdoor air into a space through intentionally provided openings (i.e., windows, doors, nonpowered ventilators). Negative pressure - air pressure differential between two adjacent airspaces such that airflow is directed into the room relative to the corridor ventilation (i.e., room air is prevented from flowing out of the room and into adjacent areas). Nosocomial infection - A hospital-acquired infection. OSHA - Occupational Safety and Health Administration, USA Outdoor air - air taken from the external atmosphere and, therefore, not previously circulated through the system. Portable room-air HEPA recirculation units - free-standing portable devices that remove airborne contaminants by recirculating air through a HEPA filter. Positive pressure - air pressure differential between two adjacent air spaces such that airflow is directed from the room relative to the corridor ventilation (i.e., air from corridors, adjacent areas is prevented from entering the room). PPE - Personal Protective Equipment ppm - parts per million.

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Prefilter - the first filter for incoming fresh air in a HVAC system that is approximately 30% efficient in removing particles from the air. See also lowefficiency filter. Re-circulation - Ventilation in which all or most of the air that is exhausted from an area is returned to the same area or other areas of the facility. RH Relative humidity. SARS - Severe Acute respiratory Syndrome Short-circuiting - occurs when the exhaust is located too close to the supply; the clean air is removed from the room before it can effectively mix with and dilute contaminants in the room air. Stagnation - occurs when part of the room does not benefit from the clean supply air. Infectious particles in a stagnant spot are not being diluted or removed. Sterilization - the use of a physical or chemical procedure to destroy microbial life. Supply air - that air delivered to the conditioned space and used for ventilation, heating, cooling, humidification, or dehumidification. Transmission - The spread of an infectious agent from one person to another. The likelihood of transmission is directly related to the duration and intensity of exposure to the pathogen. Ultraviolet germicidal irradiation lamps - lamps that kill or inactivate microorganisms by emitting ultraviolet germicidal radiation, predominantly at a wavelength of 254 nm. UVGI lamps can be used in ceiling or wall fixtures or within air ducts of ventilation systems.

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Ventilation - the process of supplying and removing air by natural or mechanical means to and from any space. Such air may or may not be conditioned. Ventilation, local exhaust - ventilation used to capture and removed airborne contaminants by enclosing the contaminant source (i.e., the patient) or by placing an exhaust hood close to the contaminant source.

ARABIC TRANSLATIONS

acquire acute AIDS Bone-Marrow recipients Bronchoscope Chicken pox dilution diminish disperse droplet nuclei equivocal germicidal host Immunosuppressed infection infectious inhale Leukemia likelihood Measles nosocomial infection = hospital acquired infection pathogen pulmonary

- - - - ) ) ) ) ) )
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respiratory tract SARS segregate solid organ transplant recipients specimens sterilization suspected TB patient TB (Tuberculosis) vulnerable vomit Health-care

- ) )

- .

Warning
This study is prepared for training purposes of Department of Municipalities & Agriculture Engineers. Copying is allowed for non commercial use. Publishing, copying or any type of commercial use is not allowed. Author has the right of a legal question of any responsible for commercial use of this study.

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