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

It is important for facilities managers at critical access hospitals 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 keeping logs is recommended.

Standard 03.07.03 states temperature and humidity logs are not mandatory, but it also states that temperature, humidity, and airflow in the locations that use anesthesia must be maintained within acceptable standards. During a survey, the organization will be assessed for maintaining temperature, humidity, and airflow in high-risk and non-high-risk areas.

In high-risk areas, it’s strongly recommended that organizations conduct daily monitoring and document corrections. Keeping a daily log would be considered best practice. 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. If an organization chooses to monitor less frequently than daily, our recommendation is to perform a risk assessment with the participation of your infection prevention and risk management teams. Once complete, the risk assessment should be routed to an oversight committee for approval, and the organization should reassess the risk assessment annually to determine whether the decision was effective. During survey, the organization will be surveyed for compliance with this policy while the ACHC Surveyor reviews logs.

Tips for Compliance

Starting with a risk assessment, developing a policy, and ensuring diligent monitoring will help your organization maintain compliance.

• Perform a risk assessment with Infection Prevention, Facilities, and other stakeholders. The risk assessment would address questions like:
  • Is there a standard/guideline defining a specific frequency based on the space?
  • 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 areas have been defined as high risk or non-high risk, choose a frequency that makes the most sense for the organization.
• 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 into a policy.
• 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 hospital’s policy.

Additional Standards to Review

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

18.02.01 – Risk mitigation measures for infection prevention.

18.04.08 – Environmental requirements in decontamination rooms.

03.07.06 – Assessing risk prior to construction.

Here to Help

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