Outstanding patient care extends beyond medicines and procedures. Environmental aspects affect comfort and safety as well.

It is important for leaders at ambulatory surgery centers to monitor temperature, humidity, and airflow because each contributes to patient safety and comfort, as well as infection control and equipment safety. Accreditation Commission for Health Care (ACHC) Accreditation Standards address the importance of monitoring, and documentation is required.

Standard 15.01.02, Temperature, Humidity, and Air-Flow Requirements states temperature and humidity logs and air pressure records must be maintained and recorded daily (at least once per operating room on days procedures are performed) and maintained in compliance with the 2008 American Society for Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) Standard 170. During a survey, the organization will be assessed for maintaining temperature, humidity, and airflow in high-risk and non-high-risk areas.

Reference standards acknowledge that:

• Maintaining proper temperature protects patients from hypothermia. The Association of periOperative Registered Nurses (AORN) recommends a temperature range of 68°F to 75°F.
• Maintaining proper humidity levels protects against condensation and the increased risk for surgical-site infection at high levels of humidity. Maintaining proper humidity also reduces risk of static at low levels of humidity. The range of 30% to 60% relative humidity is also more comfortable for staff and patients. With a risk assessment, the lower limit is permitted to be 20%.
• Maintaining proper pressure and airflow reduces the risk of surgical-site infection to patients during a procedure. Typical operating rooms have a minimum of either 15 air changes or 20 air changes, depending on year of construction.

Not all organizations are the same. Some may perform procedures only occasionally, therefore a daily check may not be necessary. The frequency of recording temperature, humidity, and air pressure is determined by organizational policy but must be conducted at least once per OR/procedure room on days of operation. During survey, the organization will be evaluated for compliance with organizational policy while the ACHC Surveyor reviews logs.

Tips for Compliance

• Perform a risk assessment with your infection prevention team and other stakeholders. The risk assessment would address questions like:
  • Has the organization attributed, specifically or in part, any incidents and/or infections to pressurization issues?
  • Are there high-risk areas and non-high-risk areas that can be defined?
  • Historically, based on past testing and maintenance, have the defined areas consistently been within compliance or is there frequent variability?
• Once the risk assessment process has been approved, formalize the room parameters into a policy for temperature, humidity, and air pressure requirements, along with the frequency and method of monitoring.
• Maintain logs to comply with the policy and to identify whether the frequency has led to the level of compliance required.

During survey, the ACHC Surveyor will evaluate compliance with this standard by checking pressures at high-risk and non-high-risk areas, reviewing logs, and reviewing the ASC’s policy.

Additional Standards to Review

Here are other related standards that include air quality requirements that organizations should be aware of:

05.01.10 – Sterile Supply Storage.

10.03.04 – Surgical Procedures: Infection Prevention and Control Requirements.

15.03.04 – Lighting and Room Temperature.

Here to Help

To access the most recent ACHC Accreditation Standards Manual, contact your Account Advisor or email us at [email protected].