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ISOLATION
ROOMS
Prepared by
Eng. Ashraf Ahmed Hussein Abdulbary
Western region Department of Municipalities &
Agriculture
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).
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.
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.
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Fig.1
Fig.2
Door should be provided with gasket at the sides and top of the door.
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).
Ceiling & walls above false ceiling should plastered and finished
according to concerned regulations.
Transfer grills and/or door grills are not allowed to avoid pressurization loss.
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
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 in our country (UNITED ARAB EMIRATES) and all tropical climate areas,
the exhausted air from air conditioned rooms 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
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).
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.
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).
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 :
A pre filter (disposable type) may be provided before HEPA filter. This will
increase the life of HEPA filter by approximately 25%.
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11
12
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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 vise-versa, 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.
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
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(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).
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 :
Keep THE doors closed & do not open both doors at the same
time.
Throw gloves & respirator in the basket beside room door after
leaving the room.
NOTE :
15
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.
To
Or
To change filter, follow the following :
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Do NOT stop the fan for any reason while room is occupied-check
nurse.
NOTES :
-
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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.
Fig.9 (Wall mounted HEPA filter unit with direct exhaust to outside)
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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to 50 CFM more extract (25 CFM for each room), as to keep both
rooms (anteroom & scrub room) under negative pressure related to
corridor).
Operating room is preferred to have 100% fresh air with HEPA filter
in supply & exhaust air ducts.
Autopsy :
& 2 ACH of fresh air can be used but 100% Fresh air is preferred.
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23
24
So, Extract air flow rate = 20342 CFH = 20342/60 = 340 CFM
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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.
Several arrangements for supply & exhaust terminal locations, but in all
arrangements clean, filtered air should enter from one side of the room, flow
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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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).
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
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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.
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%.
29
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
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Keep THE doors closed & do not open both doors at the same
time.
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.
2.1.9.2.
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 :
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Do NOT stop the air handling unit or the exhaust fan for any reason
while room is occupied-check nurse firstly.
NOTES :
-
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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.
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.
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 cross- contamination.
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References :
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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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.
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Exhaust air - air removed from a space and not reused therein.
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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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
:
2003
45