airborne-inf-disease..
Contents
1. Pressure should be checked daily when occupied or monthly when unoccupied AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 23 Capacity anteroom Temporary Negative controls infectious disease Pressure Isolation management 37 16 13 5 3 2 1 C HVAC System Maintenance Schedule Sample Preventive Maintenance Schedule for HVAC Systems For each item place a X in the appropriate box Y indicates Yes Fan is in compliance N indicates No Fan does not comply FAN ID LOCATION INSPECTION DATE TASK YES Inspect and clean exhaust grilles to prevent blockage amp airflow retardation2. Visually inspect filter housing for holes and proper filter seal Clear outside air intake of debris Check return exhaust dampers move freely Check filters for proper installation spacers Check pressure Set points Check steam CW lines have no leaks Check return exhaust belts are tight Check fan bearings sheaves are lubricated Check humidifier controls are in working order Check fan lights are in working order PS Check fan cleanliness FOLLOW UP DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE COMMENTS AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 24 Capacity anteroom Temporary Negative controls infectious disease Pressure Isolation management 37 16 13 5 a 2 1 Using a Pressure Gauge to Measure Relative Pressurization Between Two Spaces Airflow management requires monitoring of the Steps for Using a Pressure ventilation system Airborne infectious disease environments Gauge to Measure Relative require airflow cont
3. Pressure in this application is used to induce airflow from adjacent spaces into the isolation room A AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI l Environmental Principles of airborne Introduction 4 oes an a a ene me Dilation ventilation 37 20 16 13 5 Filtration 2 1 Dilution ventilation Filtration When used correctly portable HEPA filters prove to be an effective method eae d For the purposes of this guide for achieving an airborne isolation SAMENE raan Ese filtration refers to the process of environment When properly installed to acg me SENARREN passing air through a filter Hospital and maintained filters for clinical The time required for removing buildings have some of the highest spaces should be able to remove at a given percentage of airborne filtration requirements Without filtration least 90 of particles 0 5 microns particles from a room or space particle concentrations accumulate in in size and larger from outside and depends on the number of indoor environments This can cause Tees toxic effects even in healthy people ae e Nanges PEN NOUTKACHI For evaluation of hospital HVAC systems location of the ventilation Filtration reduces the risk for and HEPA filters refer to Appendix G inlet and outlet and the physical transmitting airborne infectious agents Using a Particle Counter to Assess configuration of the room or space D
4. 2006 AIA Criteria 2006 American Institute of Architects AIA Guidelines for Design and Construction of Hospital and Health Care Facilities The following AIIR criteria are specified in the 2006 American Institute of Architects AIA Guidelines for Design and Construction of Hospital and Health Care Facilities Hospital AlIRs are required to meet criteria that was in place at the time of construction for new construction and major renovation However upgrading AllRs to meet the criteria in the 2006 guidelines will better prepare hospitals to isolate patients with airborne infectious diseases These criteria are consistent with CDC Guidelines for Preventing the Transmission of Mycobactenum tuberculosis in Health Care Settings 2005 Differential pressure shall be a minimum of 0 01 in w g 2 5 Pascals lf alarms are installed allowances shall be made to prevent nuisance alarms of monitoring devices AIA Table 2 1 2 Provide ventilation to ensure 12 air changes hour ACH AIA Table 2 1 2 Rooms with reversible airflow provisions for the purpose of switching between protective environment and AIIR functions are not acceptable AIA Table 10 2 2 1 3 Airborne infection isolation room perimeter walls ceilings and floors including penetrations shall be sealed tightly so that air does not infiltrate the environment from the outside or from other spaces AIA 3 2 2 4 2a Airborne infection isolation room s sha
5. Portable HEPA filter machines are used to provide temporary pressure management dilution ventilation and filtration the three environmental controls required for airborne infection isolation The ventilation systems that serve standard rooms are designed to provide dilution ventilation and filtration For these two parameters the HEPA filter acts as an enhancement Because standard rooms are not designed to be negatively pressurized the HEPA filter serves as the primary control for pressure management As a result the primary motivation for using a HEPA filter for TNP I is pressure and airflow direction management Secondary to pressure management are dilution ventilation and filtration The recommended air exchange rate for AllIRs is 12 air changes per hour ACH As designed most rooms provide some amount of air changes through mechanical ventilation This is most likely less than the amount recommended for AllRs Although the primary purpose for HEPA filter usage is negative pressure the HEPA filter output required to achieve 12 ACH can be determined by following the steps presented here Principles of airborne Introduction 26 infectious disease management 2 Steps to Determine and Achieve Necessary Airflow You are not required to follow these steps They are given to simply provide an example of the required steps for achieving a given air exchange rate 1 2 Calculate room volume Calculate necessary HEPA out
6. Additional Notes for Discharging Air to Return Air System e You must be careful when exhausting additional large volumes of air through the return air system e When no longer needed the HEPA filter and flex duct should be wiped down with a hospital approved disinfectant HEPA filters can also be used to enhance dilution ventilation Refer to Appendix E Using a HEPA Filter for Dilution Ventilation on page 26 for a discussion and example of dilution ventilation A References Appendix Surge capacity 37 20 16 Curtain TNPI Curtain TNPI does not provide negative pressure for the entire room but induces airflow into the enclosed space from Surrounding areas and discharges HEPA filtered air from the enclosure to the surrounding space AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Portable TNPI Environmental Principles of airborne Introduction 10 anteroom controls infectious disease Temporary management Negative 13 Pressure 3 Isolation Curtain TNPI The TNPI methods 1 Discharging Air to the Outside and 2 Discharging TNPI Installations Air to Retum Air System are Must Observe ferred 3 Curtain TNPI aes Ee ee nates Building amp Fire Codes In this method a HEPA filter is used to provide a type of relative negative pressure around a patient FIGURE 12 e This method should be used for non ambulatory patients As stated earlier
7. TEMPLATE RETURN AIR ADJ ACENT SPACE FIGURE 22 Engineered System shown with three different options References Appendix 37 Appendix Surge capacity 16 AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Portable TNPI Environmental Principles of airborne Introduction anteroom Temporary Negative controls infectious disease Pressure Isolation management 13 5 3 2 1 A 2006 AIA Criteria B AIIR Maintenance Schedule C HVAC System Maintenance Schedule D Using a Pressure Gauge to Measure Relative Pressurzation Between Two Spaces Using a Pressure Gauge E Using a HEPA Filter for Dilution Ventilation F Microorganisms Associated with Airborne Transmission G Using a Particle Counter to Assess Indoor Air Quality and Filter Efficiency Portable HEPA Filters Testing Efficiency of Building Filtration System Building Filtration System Inside Outside the Building Building Filtration System Before After the Filter H Data Interpretation l Sample Log for Measuring Particle Counts 21 22 23 24 25 26 28 29 30 31 32 33 34 36 20 AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 21 Capacity anteroom Temporary Negative controls infectious disease Pressure Isolation management 37 16 Is 5 3 2 iL
8. on page 26 for a discussion and example of dilution ventilation A References Appendix Surge capacity 37 20 16 Discharging air to return air system yyy gt L e E 3JATIVELY 5SURIZED HAA Creates negative pressure room airflow into patient room from the corridor or anteroom EXHAUST RETURN H ABELIN ae FIGURE 8 Discharging air to return air system AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Environmenta controls Portable TNPI anteroom Temporary Negative 13 Pressure 3 Isolation Discharging air to return air system Steps for discharging air to return air system 2 Attach flex duct adapter to desired return grille 3 Set up HEPA filter machine and flex duct Pere ereecerseerceesereesseeeeErseseeesereeEeeEseEeeEeeseeErereeEeeesereeEeeEeeLeeeSe 5 Turn on HEPA filter machine and adjust flow Attach flex duct adapter to desired return grille Principles of airborne Introduction 8 infectious disease management 2 1 This option is one of the two preferred methods for achieving TNPI In this method a HEPA filter machine is used to discharge room air into the return air system FIGURE 8 e You must be careful when exhausting additional large volumes of air through the return air system e Because the air is HEPA filtered it is okay to exhaust it through the return air system If air was being exhausted b
9. 13 5 3 2 1 H The numbers in Table A and Table B are an approximate reduction These numbers If you don t see this type of reduction will vary considerably from second to second as the environment is less controlled you should check the filters for due to variations in ambient particle generation both indoors and outdoors leakage worn out gaskets worn Because of this the important reduction is in the order of magnitude reduction out or broken clips and proper and not necessarily in the integer installation of the spacers A For example with a 90 efficient filter and an outside particle count of 100000 itis expected that the particle count after the filter would be approximately 10000 one tenth of the outdoor concentration Because of the vanability in conditions an indoor particle of higher or lower than 10000 could be expected e g 15000 or 5000 respectively References 37 AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Appendix Surge Portable TNPI Environmental Principles of airborne Introduction Capacity anteroom Temporary Negative controls infectious disease Pressure Isolation management 16 13 5 a 2 1 Sample Log for Measuring Particle Counts This log can be used for testing portable HEPA filters as well as whole building air filters PC INITIAL and PC FINAL refer to the initial and final particle counts respectively For testing a HEPA filter PC INITIAL refers
10. AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Environmental Principles of airborne controls infectious disease management Introduction 30 3 2 il Step 4 Log both measurements and note conditions at the time of the reading These measurements should be recorded on a log similar to Appendix Sample Log for Measuring Particle Counts on page 36 It is important to note that this isn t a scientific or laboratory test of the HEPA filter but is useful in determining that the HEPA filter is working properly Also the test is only as accurate as the particle counter Users should look to see a reduction of particles near the expected reduction for the machine Examples for data interpretation when using either optical or condensation particle counters can be found in Appendix H Data Interpretation on page 34 A AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 31 capacity anteroom Temporary Negative controls infectious disease Pressure Isolation management 37 16 16 5 3 2 Il Testing Efficiency of Building Filtration System There are two options for using a Steps for Using a Particle Counter particle counter to test the efficiency of to Test the Efficiency of a Building Filtration System a building filtration system Checking the efficac
11. EEE EHO EEHH EEO EHH EHH EHH EHEEH HEHEHE LE ESEEELELEELOEL DONE 3 Set up portable HEPA filter machine 4 Attach remaining surfaces with strong tape Portable TNPI anteroom Ls AIRBORNE INFECTIOUS DISEASE MANAGEMENT Environmental trol Temporary pane Negative Pressure Isolation 3 Curtain TNPI Select a room all Hu v If the patient is already in a hospital room the room can be adapted for the Curtain TNPI method Due to the proximity of the machine to the patient noise considerations and patient comfort must be addressed FIGURE 13 As with the health care workers caring for the patient the health care workers setting up Curtain TNPI must also wear PPE Standard patient room Health care workers setting up Curtain TNP must wear PPE Principles of airborne PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Introduction 11 infectious disease management 2 Attach fire rated plastic to ceiling le BU an It is important to note that the plastic must be able to fit nearly all the way around the bed FIGURE 14 Also the height should be at least six inches taller than the ceiling which allows for the plastic to be taped to the floor For accessibility to the patient the plastic should be at least three feet from the bed on all sides Most patient care rooms have curtain tracks installed around the bed on the ceiling These can be adapted for use wit
12. THE MINNESOTA DEPARTMENT OF HEALTH Portable TNPI Environmental Temporary Negative controls anteroom Pressure Isolation 5 3 Portable anterooms can be purchased with portable filters to create a space at the entrance to a standard room for TNPI FIGURE 18 The advantage of a portable anteroom is the relatively easy conversion of regular rooms to AllRs without manipulation of the existing room ventilation Portable anterooms are easy to set up and convenient to use because any chosen room can be converted quickly A disadvantage of a portable anteroom is the inability to move beds through the door Another disadvantage is that they do not depressurize the room unless the room door is open Principles of airborne Introduction 13 infectious disease management Steps for using a Portable Anteroom 1 Set up anteroom to manufacturer s recommendations POC SO OHSS EEE E ETOH EESOEHOEEOESO SEE ETOO SEES OOHEEOEESEEEEESEEHEEEOSEEEESESEEEOES 3 Open the doors while HEPA machine is on 4 Close the doors after the patient and or caregiver enters or leaves the room 5 Both doors should never be open at the same time 6 Clean and disinfect the portable anteroom cover COC OOH OHSS EEE ELE E HEHE EEOE HEE OEE HEEHE HEE EHEH HET EEEHE TEESE HE SEEHEELEEEHERDOS PORTABLE ANTEROOM BATHROOM anteroom HEPA filter compatible HEPA FIGURE IB es smite compatible DiS Antero Attach the portable HEPA filter The anteroom
13. an anteroom is present between the AllR and the corridor the AIIR may be negatively or positively pressurized to the anteroom However if the AIIR is positively pressurized to the anteroom the anteroom must be negatively pressurized to the corridor PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Principles of airborne infectious disease management Introduction 3 2 1 o A difference in pressure Causes movement of air from areas at higher pressure to those at lower pressure The greater the pressure difference the greater the resulting air velocity The movement of air is used to help provide containment of infectious particles by providing clean to dirty airflow Refer to Appendix D Using a Pressure Gauge to Measure Relative Pressunization Between Two Spaces on page 24 for instructions on using a pressure gauge to determine differential pressure e The differential pressure or pressure offset is established by mechanically adjusting the supply and exhaust air For a negative pressure room the sum of the mechanically exhausted air must exceed the sum of the mechanically supplied air This offset forces air to enter the room under the door and through other leakages and prevents infectious particles from escaping e In order to maintain consistent offset airflow the difference between exhaust and supply should create a pressure differential of about 0 01 inch water gauge in w g or 2 5 Pascals Pa
14. area of the enclosure and provide stronger airflow and containment The curtain near the HEPA filter must be taped to the head wall This will also help to minimize the leakage area of the enclosure Plastic curtain taped to wall Principles of airborne Introduction 12 infectious disease management 2 1 1G Tum on portable Ve HEPA filter uN The last step is to turn on the HEPA filter If set up correctly the sides of the plastic will pull in as if under a vacuum This will indicate that the enclosure is under negative pressure Additional Notes for Curtain TNPI e This method is not the preferred method for isolating a patient Health care workers will not be able to move the patient to another area in the building without completely disassembling the Curtain TNPI setup In addition the set up process can be time consuming and the majority of the set up takes place while the patient is within the enclosure which could increase transmission risk e When no longer needed the plastic curtain and HEPA filter should be wiped down with a hospital approved disinfectant HEPA filters can also be used to enhance dilution ventilation Refer to Appendix E Using a HEPA Filter for Dilution Ventilation on page 26 for a discussion and example of dilution ventilation A References Appendix Surge Capacity 87 20 16 Portable anteroom AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY
15. the HEPA filter intensity until the desired differential pressure was reached When determining the airflow needed for dilution ventilation the HEPA filter will already be operating at the minimum intensity required to induce the desired pressure differential A flow hood is used to measure airflow Following the user manual for the flow hood measure the airflow Q in cfm of the HEPA filter In order to provide 12 ACH in a room with a volume of 960 cubic feet the required airflow is 192 cfm ACH Air changes per hour Airflow Mechanically exhausted airflow rate in cubic feet per minute cfm Volume Room air volume length x width x height in cubic feet ft ACH x Volume 60 Airflow Step 4 Adjust intensity control on HEPA filter Step 5 Mark intensity level on machine Once the airflow output has been determined the intensity control on the HEPA filter can be adjusted and re measured if the airflow is below the desired airflow If the airflow is above that required for dilution ventilation do not change the intensity of the HEPA filter Mark the intensity level on the HEPA filter required to obtain 12 ACH It is important to note that this airflow will only be constant for rooms of the same volume A MEDIUM jn erie 9 et g Tia inii PEHLA MI ELEY SPEED CONTROL Ankankers piira SPEED CONTRC ip AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY
16. the room and turned on without attached ductwork This is known as room recirculation and is not a preferred method for isolation There are three types of temporary isolation The two most effective methods of achieving temporary Isolation are i 1 AD Discharging air Discharging to the outside alr to retum air system One less effective methods of achieving temporary isolation is Curtain TNPI LA HEPA Filter Maintenance If the HEPA filter is in place for an extended period of time the pre filter should be changed when lint buildup becomes visible FIGURE 3 It is important to completely follow the manufacturer s directions for operation and maintenance of portable HEPA filter machines Pre filter at inlet side of HEPA machine is shown AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 6 capacity anteroom controls infectious disease Temporary management Negative Sy 20 16 13 Pressure 3 2 1 Isolation Discharging air to the outside Steps for This option is one of the two preferred discharging air methods for achieving TNPI Discharging air a to the outside to the outside In this method a HEPA filter is used 1 Select a room to exhaust room air outside through S the window Clearly a window is lt 2 Set up pre constructed required for this metho
17. the screen the room is under negative pressure There will Next connect flexible To measure the be no sign displayed on the screen if the room is rubber tubing to relative pressure positively pressurized Record the sign of the the DPG of a room from the reading on a log corridor connect the There is a set of rubber tubing to the connections on the input pressure Step 6 DPG One connection connection on the Record the value and date is for input pressure DPG The reference connection is left open to corridor air and the other Is for the reference pressure The final step in the process is to note the value on the screen and record the value and date The DPG as shown in the log in the graphic has two sets of connections With the door closed place the tube at least four inches under the door You should consult the pressure gauge user manual to change measurement units in w g or Pa and to set the time interval over which the pressure will be averaged A common time average interval is 1 5 or 10 seconds Measurements should be recorded on a form similar to the AlIIR Maintenance Schedule Shown in Appendix B on page 22 References Appendix AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Surge Portable TNPI Environmental capacity anteroom Temporary Negative controls Pressure Isolation 16 13 5 3 Using a HEPA Filter for Dilution Ventilation
18. 19 should be created between the IDZ and the rest of the hospital A portable HEPA filter is used to pressurize the anteroom This also provides clean air in the anteroom Different models of HEPA filters have different configurations of the air intake Regardless of the model the air intake should be drawing air into the HEPA filter from the IDZ The filtered exhaust should be discharged into the anteroom An airtight seal should be made for all connections The anteroom should be large enough to accommodate function for example change clothes hang PPE dispose of waste etc A References Appendix Surge Capacity Smoke Zones AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Portable TNPI Environmental Principles of airborne Introduction 17 anteroom Temporary Negative controls infectious disease Pressure Isolation management is 5 3 2 1 Smoke Zones Hospitals have smoke zones that are designed to evacuate the smoke if a fire occurs The zone has smoke stopped barriers to prevent smoke movement between zones These airtight barriers would allow for potential isolation of several hospital beds The patient rooms themselves may not be capable of being depressurized by the existing ventilation system The smoke zone however is designed with fire rated doors that close as well as entire zone exhaust capability Zone exhaust capability effectively isolates the wing suite or s
19. Airborne Infectious Disease Management Methods for lemporary Negative Pressure Isolation gt Minnesota Department of Health Office of Emergency Preparedness Healthcare Systems Preparedness Program Airborne Infectious Disease Management Methods for Temporary Negative Pressure Isolation Office of Emergency Preparedness Healthcare Systems Preparedness Program Airborne Infectious Disease Management Methods for Temporary Negative Pressure Isolation For further Information please contact Office of Emergency Preparedness Minnesota Department of Health 625 Robert Street North P O Box 64975 St Paul MN 55164 0975 Phone 651 201 5701 Fax 651 201 5720 This user guide is available on the Minnesota Department of Health Web site htto www health state mn us oep training bhpp isolation html Acknowledgements This user guide has been written by the Minnesota Department of Health in Conjunction with the University of Minnesota to assist hospital personnel in the management of airborne infection isolation AUTHORS J eanne Anderson Infection Control Practitioner Office of Emergency Preparedness Minnesota Department of Health Andrew Geeslin Engineering Infection Control Intern University of Minnesota Andrew Streifel Hospital Environmental Health Specialist Environmental Health and Safety University of Minnesota Minnesota Department of Health does not endorse particular brand
20. FIGURE 21 In this method the infectious disease zone IDZ is depressurized using an exhaust diversion system taking air from the IDZ and exhausting it to the outside 25 feet away from public access and air intakes Damper Manipulation and Changes to the Ventilation System This method will require damper manipulation and changes to the ventilation system that must be preformed by the facility s management The exact steps required will vary from hospital to hospital For example some hospitals will need to change the settings on their Building Automation System BAS Others may be designed with pre existing controls in the area that allow for this scenario PPE should be worn inside the IDZ The doors to the IDZ must be kept closed except when entering or exiting FIGURE 21 Engineered System AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 19 anteroom Temporary Negative controls infectious disease capacity Pressure Isolation management 37 20 13 5 3 2 il Temporary Surge Area Temporary Surge Area Discharging through a window Using HEPA Filter This method can be used to create a temporary surge area using a HEPA filter The three options for creating a temporary Surge area using a HEPA filter are listed below FIGURE 22 They are similar to Types 1 and 2 of TNPI for a
21. MINNESOTA DEPARTMENT OF HEALTH Portable TNPI Environmental anteroom Temporary Negative controls Pressure Isolation 13 5 3 airborne infectious disease management Principles Introduction 2 of airborne infectious disease management 1 Airborne infection isolation is based on the following hierarchy of control measures These measures are intended to reduce the risk for exposure to airborne infectious disease agents by uninfected persons AIlRs and hospital systems in general must be monitored to provide continual protective measures Refer to Appendixes B and C AIIR and HVAC System Maintenance Schedules on pages 22 and 23 Administrative work practice controls E Managerial measures that reduce the risk for exposure to persons who might have an airborne infectious disease M Work practice controls include using infection control precautions while performing aerosol generating procedures closing doors to AIIRs hand hygiene and signage cmon EXAMPLES Too written policies and 2 protocols to ensure ES the rapid identification isolation diagnostic evaluation and treatment of persons likely to have an airbome infectious disease Environmental controls Mm Physical or mechanical measures as opposed to administrative control measures used to reduce the risk for transmission of airborne infectious diseases E EXAMPLES ventilation ss filtration ultraviolet germicidal irradiat
22. OUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental capacity anteroom Temporary controls Negative 37 20 16 13 Pressure Isolation Temporary Negative Pressure Isolation TNPI All of the TNPI installations must observe state building and fire codes and National Fire Protection Association NFPA 101 Life Safety Code Being able to set up a TNPI requires planning and early contact with the authority that has jurisdiction your State Health Department to establish and verify compliance with applicable codes In Minnesota you can contact Fernando Nacionales P E Engineering Services section at 651 201 3712 or Fernando Nacionales state mn us Principles of airborne Introduction 5 infectious disease management 2 1 TNPI is considered when airborne infection isolation is needed and there are no available or insufficient AlIRs such as can happen when there is an outbreak of an airborne infectious disease with large numbers of communicable patients Temporary isolation is designed to protect patients and staff from contracting or transmitting highly infectious diseases Portable HEPA filters have been used in the past to Isolate patients These filters can also be used as an air scrubber When used in this fashion the filter simply cleans the air It does not provide pressure management for appropriate airflow direction The filter is placed in
23. THE MINNESOTA DEPARTMENT OF HEALTH i a 5 37 16 13 5 3 2 1 F Microorganisms Associated with Airborne Transmission CDC Guidelines for Environmental Infection Control in Health Care Facilities 2003 FUNGUS BACTERIA VIRUS Numerous reports in health care facilities Atypical occasional reports Airborne in nature airborne transmission in health Care settings not described Under investigation Aspergillus spp Mucorales Rhizopus spp Acremonium spp Fusarium spp Pseudoallescheria boydii Scedosporium spp Sporothnx cyanescens Coccidioides immitis Cryptococcus spp Histoplasma capsulatum Pneumocystis carinii Refer to the text for references for these disease agents Airborne transmission of smallpox is infrequent Potential for airborne transmission increases with patients who are effective disseminators present in facilities with low relative humidity in the air and faulty ventilation Documentation of pseudoepidemic during construction Mycobacterium tuberculosis Acinetobacter spp Bacillus spp 4 Brucella spp Staphylococcus aureus Group A Streptococcus Coxiella burnetii Q fever This list excludes microorganisms transmitted from aerosols derived from water Airborne transmission documented in the laboratory but not in patient care areas Measles rubeola virus Varicella zoster virus Smallpox virus variola Influenza viruses Respiratory syncytial virus Adenovi
24. Temporary Negative e The area around the bed can be me sealed off by attaching fire rated plastic sheeting to the curtain isolation is needed and there is no track along with duct tape to attach available or insufficient AIIRs This the plastic to the floor considered when airborne infection could happen when the number of infectious patients exceeds the number of available rooms PLASTIC CURTAIN HEAD WALL FIGURE 12 All of the TNPI installations must Cece reece rreerrcreecesreesereeeernerersereseeEeereeeeeserEereeeereeeEEeeeoe Curtain TNPI observe state building and fire codes and National Fire Protection Association NFPA 101 Life Safety The area around the bed can be sealed Code Being able to set up a TNPI off by attaching tire rated plastic sheeting requires planning and early contact with the authority that has jurisdiction your State Health Department to RE E T A aes hoes ees establish and verify compliance with The intake must be within the plastic enclosure and the output must be outside the plastic enclosure you can contact Fernando Nacionales PE applicable codes In Minnesota Engineering Services Section at 651 201 3712 or Fernando Nacionales state mn us References Appendix Surge Capacity I gt l Steps for H a setting up AW Curtain TNPI POCO SEES EEE EEO EEEEEEEEOHEEESOSE SES OEEEE OS ESOT EE ETOOH EES OEH EEE SESEEESESEEEEES EONS POCO E HEHEHE EEE EE
25. are Settings 2005 MMWR Dec 30 2005 54 RR17 http www cdc gov mmwr preview mmwrhtml rr5417al htm Streifel AJ Design and maintenance of hospital ventilation systems and the prevention of airborne nosocomial infections In Mayhall CG editor Hospital epidemiology and infection control Philadelphia Lippincott Williams amp Wilkins 2004 p 1577 1589 Rutala W J ones S Worthington J Reist P Weber D Efficacy of portable filtration units in reducing aerosolized particles in the size range of mycobacterium tuberculosis Infect Control Hosp Epidemiol J uly 1995 16 7 391 398 Mead K J ohnson D An evaluation of portable high efficiency particulate air filtration for expedient patient isolation in epidemic and emergency response Annals of Emergency Medicine Dec 2004 44 6 635 645 Minnesota Department of Health Office of Emergency Preparedness Healthcare Systems Preparedness Program Pe LL TL bi Ba Phone 651 201 5701 TTY 651 201 5797 IC 141 1783 02 07 PRINTED ON RECYCLED PAPER
26. culosis Audience for this Guide The intended audience for this guideline includes health care WE facility engineering and maintenance WE infection control M environmental health and safety E management personnel Purpose of this Guide E Provide guidance on environmental controls for airborne infectious disease management M Provide a general guide for temporary setup installation and operation of portable HEPA machines when used to create negative pressure in a hospital room area M Provide instruction on the use of Pressure gauges Particle counters E Outline of preventative maintenance schedule for HVAC equipment related to AIIR Goal of this Guide A timely response is crucial for identification and containment of potentially infectious patients The goal is for facilities to develop a 12 hour response to implement containment measures Temporary negative pressure isolation methods are a Safe alternative for hospitals that lack engineered AlIRs These can be utilized in facilities to meet increased surge capacity for patient isolation TNPI should also be used during hospital construction projects to reduce risks associated with airborne infectious diseases These temporary measures should be incorporated into the facility s infection control and emergency response plans A References Appendix Surge capacity 37 20 16 Principles of AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE
27. d FIGURE 4 we window adapter SURIZED lt BASSO SOOO OOOO COSCO OOO OCO OOO OO OOOO OOOO C COSCO SOOO OOO OOO OO OOOOOO OOS OO SOO oo ooooor The two main purposes of the 3 Set up HEPA machine and HEPA machine in this application 4 4 4 flex duct are to clean contaminated air Teee negative DOODO O0O OOOHOO 0O00 00000000H terete tetera O0 HGO 000000 0H0 00000000A 0000000000 0000000000005 and induce negative pressure 4 Seal return air grille in the room pressure room airflow into patient room from the corridor or anteroom 5 Turn on HEPA machine Because the discharged and adjust flow air is HEPA filtered no extra cecosecooooocooosococoossccososooooosooooosocooosocooococooocococosocooosoocsoosooo consideration for air discharge location is required To prevent pulling air from return air system the exhaust return grilles should be sealed aaa with tape EXHAUST RETURN SUPPLY eee ie Sot up HEPA machine and flex duct N I inaunda adan is A UN See Gs WN CLEANED AR lt MULS KIIA HEPA MACHINE negative pressure HEPA filter FIGURE 4 HEPA fan exhausting clean air outside through the window better prepare A References Appendix Surge capacity 37 20 16 Select a room I Hu v You should choose a room to set up TNPI The HEPA machine should be set up in advance to placing the patient with a suspected airborne infectious disease
28. eal remaining air grilles A ld v To prevent pulling air from return air system additional exhaust return grilles should be sealed with tape FIGURE 11 Most rooms have only one supply a return grille and one bathroom exhaust 100 of bathroom discharge is exhausted outside so no extra consideration is required If there is more than one return grille which is uncommon the additional grille s should be sealed A sheet of plastic or cardboard can be used provided that the edges are completely sealed with tape FIGURE 9 cocoscoococoooocococoocooooooooo A return grille adapter A return grille adapter with flex duct attached ae FIGURE 11 Ca This return Tit duct must be sealed to prevent pulling alr from return air system Principles of airborne infectious disease management Introduction g 2 1 Tum HEPA machine on and adjust flow 1G BU Once the flex duct is connected to the window template and the HEPA machine the machine should be turned on Adjust the flow on the output until the desired pressure differential of negative 2 5 Pa pressure in corridor is greater than pressure in patient room is reached Increasing the flow will increase the pressure differential and decreasing the flow will decrease the pressure differential The pressure differential should be measured with a hand held digital pressure gauge The pressure should be monitored daily
29. ecorded on a form similar to Appendix I Sample Log for Measuring Particle Counts on page 36 References Appendix Surge Portable Capacity anteroom 16 iS AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH TNPI Temporary Negative Pressure Isolation 5 Environmental Principles of airborne infectious disease management Introduction 33 2 iL Building Filtration System Step 1 Turn on the particle counter The first step is to turn on the particle counter Step 2 Measure the particle count before the final filter Measure the particle count before the final filter If you have access to the air before and after the final filter the filter efficiency can be checked Large hospitals have mechanical spaces with fans and filter banks and the particle count can be tested before and after the final filter Hospitals with smaller air handling units can also test their filters in a similar manner Step 3 Measure the particle count after the final filter Measure the particle count after the final filter If you have access to the air before and after the final filter the filter efficiency can be checked Accuracy can be increased by taking a series of measurements and finding the average Step 4 Record both measurements and note conditions at the time of the reading The final step is to record both measurements and note cond
30. epending upon their size particles Indoor Air Quality and Filter Efficiency FIGURE 2 may be deposited in the upper ERE respiratory tract or the lower respiratory pag tract of h Particl nal i i i Refer to Appendix E Using a ake artic eee be For information on filter selection HEPA Filter for Dilut SPOS eae a CUNNY and performance see Appendix H a Iter ror Orudon dressing changes or invasive Seay ee ae Data Interpretation on page 34 Ventilation on page 26 A procedures See Appendix F See Appendix I Sample Log for Microorganisms Associated with Measuring Particle Counts on page 36 4 Airbome Transmission on page 28 FIGURE 2 ACH AND TIME REQUIRED FOR REMOVAL EFFICIENCIES AcH 90 99 99 9 EFFICIENCY EFFICIENCY EFFICIENCY 2 69 138 VA a O ver 199 EFFICIENCY w TE O i n E a ba 199 9 EFFICIENCY 8 Vi 35 52 5 m A B E 100 ET E ee ee ee 10 14 28 4 5 90 80 12 12 23 35 a 15 9 18 28 50 40 20 14 21 a 50 5 6 8 10 Modified from Table B 1 CDC Guidelines for 4 Environmental Infection Control in Health Care Facilities AIR CHANGES PER HOUR ACH 2003 Perfect mixing of air is assumed For rooms with stagnant air spaces the time required may be much longer than shown This is intended only as an approximation and is for ideal ventilation configurations AIRBORNE INFECTI
31. ety of Heating Refrigeration and Air conditioning Engineers whether it is a condensation particle counter or an optical particle counter If you re using a condensation particle counter the size range should be 0 02 to LO um The optical particle counter TABLE B OPTICAL PARTICLE COUNTER size range should be 0 5 pm Some PARTICLES REPORTED PER CU FT RANGE gt 0 5 pm particle counters have data logging capabilities and directions for use vary HOSPITAL FILTER RATING OUTSIDE AIR PARTICLES AFTER FILTER PC PERCENT REDUCTION from model to model 80 120000 24000 80 90 120000 12000 90 99 9 120000 36 99 97 Condensation particle counts are reported as particles per cubic centimeter ranging from 0 02 to 1 0 um PC particle counts Note Percent reduction of particles is determined by subtracting the reading after the filter from the reading before Optical particle counts are reported as particles per cubic foot ranging 0 5 um the filter outside air particles dividing PC particle counts by the reading before the filter outside air particles and multiplying by 100 ASHRAE American Society of Heating Refrigeration and Air conditioning Engineers AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 35 Capacity anteroom Temporary Negative controls infectious disease Pressure Isolation management 37 16
32. h the plastic sheeting In addition clips can be purchased that will allow the plastic sheeting to be attached to the ceiling grid assuming the room has a suspended ceiling FIGURE 15 FIGURE 15 Plastic can be attached to ceiling tile grid or curtain track with clips References Appendix Surge capacity 37 20 16 f Set up portable 7 HEPA filter machine The HEPA filter should be inserted into the plastic sheeting FIGURE 16 The plastic needs to be cut so that the HEPA filter can be fit into the space The intake must be within the plastic enclosure and the output must be outside the plastic enclosure This will draw the air from the enclosure filter it and exhaust it to the rest of the room This will provide an airflow that will help to isolate the patient Pta a FIGURE 16 n Portable HEPA filter machine installed in plastic sheeting The plastic Should be taped around the HEPA machine to provide a seal AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Portable TNPI Environmental anteroom Temporary controls Negative 13 Pressure 3 Isolation Curtain TNPI af Attach remaining HU surfaces with n strong tape Once the HEPA filter is installed and sealed with tape the remaining surfaces need to be sealed with tape FIGURE 17 The hanging plastic curtain should be taped to the floor This will help to minimize the leakage
33. in the room If possible select a room without transfer grilles If no such room exists completely seal the grilles to promote negative pressure 2 Hu Set up pre constructed window adapter When using this option to establish TNPI a window adapter must be constructed This is used to provide a connection to the flex duct FIGURE 5 The template should be constructed out of wood to fit into a standard window in your hospital s patient care rooms and should provide an airtight fit A piece of sheet metal a flange of the same diameter as the flex duct should be fixed to the circular hole in the wood to serve as an adapter between the wood template and the flex duct The use of a window template flex duct and fan is Common in hospital construction FIGURE 5 Window adapter with flex duct attached AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Environmental controls Portable TNPI anteroom Temporary Negative 13 Pressure 3 Isolation Discharging air to the outside Set up HEPA machine and flex duct 3 i V Connect the flex duct to window adapter and HEPA machine FIGURE 6 Seal return air grille A an v To prevent pulling air from return air system the return grilles should be sealed with tape A sheet of plastic or cardboard can be used provided that the edges are completely sealed with tape Flex duct connected t
34. ion AllRs local exhaust ventilation devices Personal protective equipment PPE M Equipment worn by health care workers and others to reduce exposure to communicable diseases EXAMPLES es i gowns F N gloves aA f masks Perr respirators eye protection References Appendix Surge capacity 37 20 16 Environmental controls AIRBORNE INFECTIOUS DISEASE MANAGEMENT Portable TNPI Environmental anteroom Temporary Negative controls Pressure Isolation 13 5 This user guide will focus on the environmental controls necessary for airborne infection isolation The ventilation parameters essential for airborne infection Isolation rooms areas include E Pressure management for appropriate airflow direction E Room air changes for dilution ventilation and E Filtration to remove infectious particles NEGATIVELY PRESSURIZED lt I H posmnvey gt l PRESSURIZED gt y FIGURE 1 Illustrations used to identify Negatively top and Positively bottom pressurized air space Pressure management For the purposes of this guide pressure refers to the differential pressure between two spaces FIGURE 1 In health care settings the two spaces are typically the isolation room and the corridor For AllR the room should be negatively pressurized in relation to the corridor This helps to prevent infectious particles from escaping the room envelope If
35. itions at the time of the reading This option provides a method to test the filters installed in the air handling units Although this isn t a scientific test it is a reliable way to assess the performance of the filters A Sample Log for Measuring Particle Counts Is Shown in Appendix on page 36 A AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 34 Capacity anteroom Temporary Negative controls infectious disease Pressure Isolation management 37 16 13 5 3 2 Il Data Interpretation Filters are rated by industry standards Examples of data interpretation on their ability to remove particulate for particle reduction in various filter efficiencies matter from an airstream Various rating systems exist Efficiency can be measured by determining the concentration of material upstream and TABLE A CONDENSATION PC PARTICLES REPORTED PER CC RANGE 0 02 TO 1 0pm downstream of the filter Particles HOSPITAL FILTER RATING OUTSIDE AIR PARTICLES AFTER FILTER PC PERCENT REDUCTION should be reduced by the percentage 80 55000 11000 80 efficiency of respective filtration 90 55000 5500 90 systems a a 99 9 55000 17 99 97 You should consult the user manual of the particle counter for instructions on how to use it Refer to the user manual for your particle counter to determine ASHRAE American Soci
36. ll have self closing devices on all room exit doors AIA 3 2 2 4 2b Rooms shall have a permanently installed visual mechanism to constantly monitor the pressure status of the room when occupied by patients with an airborne infectious disease The mechanism shall continuously monitor the direction of the airflow AIA 3 2 2 4 4 All areas for inpatient care treatment and diagnosis and those areas providing direct service or clean supplies such as sterile and clean processing etc Shall have filter efficiency of 90 based on average dust spot efficiency per American Society of Heating Refrigeration and Air conditioning Engineers ASHRAE 52 1 1992 AIA Table 2 1 3 A AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 22 Capacity anteroom Temporary Negative controls infectious disease Pressure Isolation management 37 16 13 5 a 2 Il B AIIR Maintenance Schedule Sample Preventive Maintenance Schedule for AIIRS For each item place a X in the appropriate box Y indicates Yes Room is in compliance N indicates No Room does not comply NA indicates Not Applicable to this room DATE ROOM WINDOWS DOORS ALARMS MECHANICAL PRESSURE READING COMMENTS CLOSED SEALED SELF CLOSING ELECTRONICS DEVICE ZEROS OPERATIONAL FUNCTIONING WHEN DOOR OPENS ELECTRONIC
37. o window template The other end of the flex duct should be connected to the HEPA machine HIGH MEDIUM LOW SPEED CONTROL FIGURE 7 The flow rate on this machine is adjusted with the dial on the right hand side Principles of airborne Introduction 7 infectious disease management 2 1 Tum on HEPA machine and adjust flow al ale v Once the flex duct is connected to the window template and the HEPA machine the machine should be turned on FIGURE 7 Adjust the flow on the output until the desired pressure differential of negative 2 5 Pa pressure in corridor is greater than pressure in patient room is reached Increasing the flow will increase the pressure differential and decreasing the flow will decrease the pressure differential The pressure differential should be measured with a hand held digital pressure gauge The pressure should be monitored daily Additional Notes for Discharging Air to the Outside In locations with seasonal cold below freezing weather it may be necessary to install a damper or louver on the outside of the window template This will help to prevent airflow restnction due to condensation or ice Snow buildup e When no longer needed the HEPA filter and flex duct should be wiped down with a hospital approved disinfectant e HEPA filters can also be used to enhance dilution ventilation Refer to Appendix E Using a HEPA Filter for Dilution Ventilation
38. orary Negative controls Pressure Isolation 13 5 3 Isolation surge capacity is the ability to manage high volumes of specialized patients Under extraordinary circumstances where the quantity of engineered airborne infection isolation rooms is insufficient to meet surge demand for patient isolation hospitals can take various measures to protect patients and staff This section describes different methods of Isolating large numbers of patients including Smoke Zones Engineered System Temporary Surge Area Principles of airborne Introduction 16 infectious disease management 2 1 The Goal of Isolation Surge Capacity Housing large numbers of patients with airborne infectious diseases Is challenging The goal of surge Capacity is to provide areas with Safeguards to protect you and other patients from exposure to airborne infectious agents FIGURE 19 An infectious disease zone IDZ is a space used to Isolate large numbers of patients NON IDZ lt lt FIGURE 19 e SAFE AREA lt iea NURSES STATION escesooccsocoocoocoococoocoocoocooeoooocoocoococooccocoocooooococoocoocoooocoocoocooocococsocoocoocoosocoocoocecococoocooccocosoocoocoocoococococoocesocooccocoosocooooococoocoooooo An infectious disease zone IDZ is a space used to isolate large numbers of patients A temporary constructed anteroom safe area for surge area is shown Safe Areas A safe area or anteroom FIGURE
39. other public health emergencies such as emerging airborne infectious diseases requires strategic planning to ensure that all components of respiratory protection programs including environmental controls are in place for airborne infection isolation rooms AIIRs Hospitals have insufficient facilities to provide airborne infection isolation for large numbers of patients with airbome infectious diseases presenting in a short time period However AllRs have been increased recently due to requirements of National Bioterrorism Hospital Preparedness Program Without adequate environmental controls patients with airborne infectious diseases will pose a risk Principles of airborne infectious disease management Introduction 1 2 to other patients and health care workers Heating ventilation and air conditioning HVAC expertise is essential for proper environmental management when planning control of airborne infectious disease outbreaks natural or intentional Design manuals and guidelines provide direction for infectious disease management Refer to Appendix A 2006 AIA Criteria on page 21 This guide will assist health care facility plant maintenance and engineering Staff in coordination with infection control professionals to prepare for a natural or terroristic event involving an infectious agent transmitted by airoorne droplet nuclei Examples of such agents include measles varicella and tuber
40. pace from other areas of the health care facility These zones are routinely tested for fire management Smoke Zones as Perimeter of IDZ The smoke zones can be used as the perimeter of an infectious disease zone IDZ FiGuRE 20 This area can also be negatively pressurized in a method similar to TNPI 1 and 2 That is air can be discharged through the window into the return air system or discharged to an adjacent space using a portable HEPA filter machine As always when discharging to the return air system users must be cautious with the volume of air being discharged A Hi CORRIDOR WALL M2 HOUR FIRE WALL T SMOKE BARRIER FIGURE 20 eccccocooooocoocococcooocoocooceoocooooooooo secocoococooocoocoocoocoocoooooosoceocoocoocoocoocooocoocoosoceocoocoocoocoocooocococooceocoocoocoocoocoocococoosoceocoocoooooooooooooooo Example of the hospital smoke zones that could be considered for potential isolation areas AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 18 anteroom Temporary Negative controls infectious disease capacity Pressure Isolation management 57 20 13 5 a 2 1 Engineered System Engineered System Ducted to the Outside If the suite or wing is exclusively served by a single air handling unit the facility engineer may be able to provide 100 exhaust from the area
41. patient room Each of these options should be used in conjunction with a safe area anteroom Discharging through a window Discharging to an adjacent space Discharging to a return air system These three options may be used in combination to achieve desired pressure differential Some considerations to keep in mind when discharging air through a window are A window template can be created to exhaust a suite of rooms through a flexible duct hookup from the HEPA filter to the window Large exhaust fans placed in the window can be used instead of HEPA filters if the air is exhausted 25 feet away from public access and air intakes More than one machine may be needed to establish appropriate pressure differential Discharging to an adjacent space Some considerations to keep in mind when discharging air to an adjacent space are The air must be HEPA filtered The air in the IDZ can be discharged to an adjacent area outside the IDZ within the building Discharging to a return air system BUILDING EXTERIOR Some considerations to keep in mind when discharging air to a return air system are e The air must be HEPA filtered A return air grille adapter is used to connect a flex duct from the HEPA filter to the return air grille e As always when discharging to the return air system users must be cautious with the volume of air being discharged A WINDOW
42. put airflow Measure airflow from HEPA filter with flow hood Adjust intensity control on HEPA filter Mark intensity level on machine AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Portable TNPI anteroom Temporary Negative Pressure Isolation Environmental controls References Principles of airborne infectious disease management Rppendix Surge Introduction 27 Capacity BY 16 iL 5 3 2 1 Step 1 Calculate room volume Determine the room volume by measuring the length width and height of the room Example calculation given a room with the following dimensions The floor area may be calculated by counting ceiling tiles most are 2ft x 2ft or 2ft x 4ft or floor tiles many are 1 ft Note A typical room has an 8 ft ceiling Floor Area 10 feet by 12 feet 10 x 12 120 square feet Ceiling Height 8 feet Volume Floor Area x Ceiling Height 120 sq ft x 8 ft 960 cu ft Step 2 Calculate necessary HEPA output airflow The recommended air change rate is 12 ACH Using the volume and the recommended air change rate calculate the necessary HEPA output airflow using the formula to the right Step 3 Measure airflow from HEPA filter with flow hood As previously mentioned the primary purpose for using a HEPA filter is pressure management The minimum airflow required to achieve a pressure differential of negative 2 5 Pa was found by varying
43. rol to avoid potential infection Although the Pressurization Between airflow can be checked with a smoke stick for direction it is Two Spaces important to know the magnitude of the flow A pressure gauge is a quantitative method to measure the relative 1 Turn on the digital pressure pressurization of two spaces gauge DPG 2 Close the door of the area to be pressure tested 3 Connect flexible rubber tubing to the DPG 4 Place the tubing under the closed door 5 Note the airflow direction 6 Record the value and date References Appendix Step 1 Turn on the Digital Pressure Gauge DPG The first step is to turn on the Digital Pressure Gauge DPG The display Should read zero when both hose connections are reading the same air pressure Note the Sensitivity of the machine tapping one of the connections will Cause a reading Step 2 Close the door of the area to be pressure tested Make sure the door IS closed AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Surge Portable TNPI Environmental Principles of airborne Introduction 25 Capacity anteroom Temporary Negative controls infectious disease Pressure Isolation management 16 16 5 3 2 IL Using a Pressure Gauge Step 3 Step 4 Step 5 Connect flexible Place the flexible Note the airflow direction rubber tubing to rubber tubing the DPG under the door If a negative sign is displayed on
44. rticle count outside the The first step is to building turn on the particle counter Measure the particle count outside the building Accuracy can be increased by taking multiple readings outdoors and indoors Step 3 Measure the particle count inside the building Then measure the particle count inside the building away from main doors Accuracy can be increased by taking multiple readings outdoors and indoors Step 4 Record both measurements and note conditions at the time of the reading Since conditions can vary greatly from day to day and especially from season to season it is important to record any abnormal readings and take notes on conditions at the time of the reading For example it would be important to note ff it is raining if construction activities are going on inside or outside if a medical nebulizer or housekeeping chemical is being used in the area or if there are any other activities present that could possibly Cause an abnormal reading Testing the building filtration system in this way can lead to unexpected results For example the outdoor particle count may be abnormally high due to vehicles nearby Also the indoor particle count may be abnormally high due to treatments or cleaning as described above While this method is useful because it provides an overall view of the building a more accurate test can be done to test the filters in particular Measurements should be r
45. ruses Norwalk like virus Hantaviruses Lassa virus Marburg virus Ebola virus Crimean Congo virus References Appendix AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Surge Portable TNPI Environmental Capacity anteroom Temporary Negative controls Pressure Isolation 16 Is 5 3 Principles of airborne Introduction 29 infectious disease management 2 iL Using a Particle Counter to Assess Indoor Air Quality and Filter Efficiency Particle counters measure the quantity of small particulate matter in the air Particle counters can also be used to determine the efficacy of HEPA filters This can be done by comparing the particle count at the inlet to the HEPA filter with the particle count at the output of the HEPA filter when the HEPA filter is running The efficacy of building filtration systems can be monitored using a particle counter This can be done by measuring the particle count before and after the final filters of the fans that serve those rooms Filtration can also be monitored by measuning the particle count outside the building and companing tt with the indoor particle count Condensation and optical particle counters are two particle counters Both types are acceptable to use when evaluating indoor air quality and filter efficiency Directions for usage and examples of data interpretation are provided here Condensation particle counts are reported as particles per c
46. s Health Resources and Services Administration Health Care Systems Bureau National Bioterrorism Hospital Preparedness Program Cooperative Agreement Continuation Guidance Federal Fiscal Year 2003 2004 2005 http www hrsa gov bioterrorism Nicas M Sprinson J E Royce SE Harrison RJ Macher M Isolation rooms for tuberculosis control Infect Control Hosp Epidemiol Nov 1993 14 11 619 622 CDC Guidelines for Environmental Infection Control in Health Care Facilities Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee HICPAC MMWR Recomm Rep J un 6 2003 52 RR 10 1 42 http www cdc gov mmwr preview mmwrhtml rr5210al htm Guidelines for the classification and design of isolation rooms in health care facilities Victoria Department of Human Services Standing Committee on Infection Control 1999 http www health vic gov au ideas regulations isolation htm Isolation Rooms Including Mechanically Ventilated Rooms Best Practice Standards for Capital Planning Belfast Department of Health Social Services and Public Safety Regional Advisory Committee on Communicable Disease Control 2003 http www dhsspsni gov uk hssmd41 04 pdf ASHRAE HVAC Design Manual for Hospitals and Clinics 2003 27 45 47 60 87 113 129 141 AIA Guidelines for the Construction of Hospitals and Health Care Facilities 2006 CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health C
47. s among competing products Examples shown in these materials are for illustration only All material in this document ts in the public domain and may be used and reprinted without special permission The authors gratefully acknowledge the Minnesota Emergency Readiness Education and Training MERET at the University of Minnesota Centers for Public Health Education and Outreach and the following individuals for their participation assistance and support of this project Keith Carlson Director of Facilities Management Mercy Hospital and Health Care Center Moose Lake MN Gary Davis Plant Engineer LakeWood Health Center Baudette MN Pete Swanson Facility Services Manager Pipestone County Medical Center Pipestone MN The following individuals are gratefully acknowledged for their invaluable Suggestions J udene Bartley Vice President Epidemiology Consulting Services Inc Beverly Hills MI Rick Hermans Senior Project Manager Center for Energy and Environment Minneapolis MN Curtain TNP I photographs courtesy of Ken Meade Research Mechanical Engineer NIOSH CDC USPHS MERET photos provided by Paul Bernhardt References Appendix Surge capacity 37 20 16 Introduction AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Portable TNPI Environmental anteroom Temporary Negative controls Pressure Isolation iS 5 3 Hospital preparedness for bioterronsm and
48. same time UNSS If individual health care workers or visitors enter the room one door Should be closed before the other is opened Both doors should never be open at the same time This prevents short circuiting of air through an open doorway 1G Clean portable i7 anteroom cover When no longer needed the portable anteroom cover should be cleaned and disinfected with a hospital approved disinfectant i Portable TNPI anteroom AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Environmental Temporary Negative controls Pressure Isolation 5 3 Principles of airborne Introduction 15 infectious disease management 2 iL Additional Notes for Portable Anterooms The door on the portable anteroom and patient room should be closed except for entry and egress In addition only one door should be opened at one time e There are no standards on the magnitude of anteroom pressure Therefore there is no suggestion on airflow output or pressure differential for portable anterooms It is only suggested that the airflow is strong enough to pull in the sides of the anteroom while not so strong that it produces excess noise A IN are designed anterooms A References Appendix Surge Surge Capacity capacity AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Portable TNPI Environmental anteroom Temp
49. should be placed door frame A to the appropriate sized portal in front of the patient room door on the side of the portable and taped to the wall to secure anteroom and cover the seams When turned on the HEPA machine should cause the sides of the portable anteroom to pull inward AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 14 capacity nteroom Temporary Negative controls infectious disease anteroo Pressure Isolation management 37 20 16 5 3 2 1 Set up anteroom aa Ve The anteroom should be set up according to manufacturer s recommendations The anteroom should be placed in front of the patient room door and taped to the wall to secure and cover the seams Attach the HEPA machine al Aa Attach the portable HEPA filter to the appropriate sized portal on the side of the portable anteroom When turned on the HEPA machine should cause the sides of the portable anteroom to pull inward indicating suction ED Open 4l Close VE the doors the doors US UN The door to the patient room and portable anteroom After the patient and or caregiver enters or leaves the room are opened for patient transport while the HEPA the room door and portable anteroom door should be closed machine is on References Appendix Surge Capacity 37 20 16 1G Both doors not open s at
50. to the particle count at the air intake and PC FINAL refers to the particle count at the air output of the HEPA filter When testing a whole building air filtration system PC INITIAL can refer to either the particle count outside or before the filter and PC FINAL can refer to the particle count inside or after the filter DATE FAN PC PC EXPECTED ACTUAL INITIAL FINAL PERCENT PERCENT Shesebiersvencsredecess WEPA UT r REDUCTION REDUCTION ao Output ofiter SSC EEEE EANA ORE IE EEEE EER A ease PC a G F Building Air Filter Building Air Filter a Outside Before Filter Inside After Filter PC x 100 COMMENTS 36 References Appendix Surge Portable Capacity anteroom 20 16 13 References 10 di 12 13 AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH TNPI Environmental Principles of airborne Introduction 37 Temporary Negative controls infectious disease Pressure Isolation management 5 3 2 il Fraser VJ J ohnson K Primack J J ones M Medoff G Dunagan WC Evaluation of rooms with negative pressure ventilation used for respiratory isolation in seven midwestern hospitals Infect Control Hosp Epidemiol Nov 1993 14 11 623 628 Francis J Curry Isolation Rooms Design Assessment and Upgrade National Tuberculosis Center 1999 http www nationaltbcenter edu products product_details cfm productID WPT 04 U S Department of Health and Human Service
51. ubic centimeter ranging from 0 02 to 1 0 um in diameter Optical particle counts are reported as particles per cubic foot ranging 0 5 um in diameter Steps to using particle counters to determine efficiency of different types of filters as well as examples of data interpretation are found in Appendix H Data Interpretation on page 34 Steps for Using a Particle Counter to Test the Efficiency of Portable HEPA Filters 1 Turn the particle counter on 2 Measure the particle count at the air inlet of the HEPA filter 3 Measure the particle count at the air output of the HEPA filter 4 Log both measurements and note conditions at the time of the reading verify filters are functioning properly particle counter References Appendix Surge capacity 16 Portable HEPA Filters A Step 1 Turn on the particle counter The first step is to turn on the particle counter Step 2 Measure the particle count at the air inlet of the HEPA filter In order to test the efficiency of a portable or permanently installed wall or ceiling HEPA filter measure the particle count at the air inlet of the HEPA filter Portable TNPI anteroom 5 Step 3 Measure the particle count air output of the HEPA filter Measure the particle count at the air output of the HEPA filter output This will be used to compare the air inlet and air outlet Temporary Negative Pressure Isolation
52. y a regular non HEPA filtered large fan it should not be discharged through the return air system over pressurize the duct References Appendix Surge capacity 37 20 16 et Select T a room You should choose a room to set up TNPI The HEPA machine should be set up in advance to placing the patient with a suspected airborne infectious disease in the room If possible select a room without transfer grilles If no such room exists completely seal the grilles to promote negative pressure 2 Attach flex duct adapter to desired n retum grille Next attach flex duct adapter to desired return grille Ideally if the return is low connect the flex duct here However most returns are high on the wall or ceiling and these can be connected in the same way It is important to provide a tight seal between the flex duct and the adapter as well as between the adapter and the return grille FIGURE 9 Generally it is easy to differentiate between a supply grille and return grille If you are not sure you can use a smoke stick to check airflow direction Setup HEPA machine and flex duct 3 ji T Connect the flex duct to return grille adapter and HEPA machine FIGURE 10 AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH Environmental controls Portable TNPI anteroom Temporary Negative Lo Pressure 3 Isolation Discharging air to return air system S
53. y of filters is Inside Outside the Building Before After the Filter important for a number of reasons If the If you have access to the air before filters on the main air handling system 1 Turn the particle counter on and after the final filter the filter are working properly there should be 2 Measure the particle count efficiency can be checked here a significant 90 reduction in outside the building as well particles 3 Ka particle count inside Hospitals often have mechanical O HAMME OOO SO spaces with fans and filter banks 4 Record both measurements The particle count can be tested and note conditions at the time before and after the final filter of the reading 1 Turn the particle counter on 2 Measure the particle count Accuracy before the final filter increased 3 Measure the particle count after the final filter finding the average 4 Record both measurements and note conditions at the time at each of the reading AIRBORNE INFECTIOUS DISEASE MANAGEMENT PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH References Appendix Surge Portable TNPI Environmental Principles of airborne Introduction 32 Capacity anteroom Temporary Negative controls infectious disease Pressure Isolation management 37 16 13 5 3 2 Il G Building Filtration System E OUTS E H EC D D l N AC J gt E Tae DUILUTNG E Eike ATAI by FEU Step 1 Step 2 Turn on the Measure the particle counter pa
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