Managing and documenting critical pressure rooms

Managing critical pressure rooms in hospitals and ambulatory care centers can be made easier with a few simple steps. The first step is to understand the requirements for critical rooms by reviewing requirements from the appropriate accrediting organization (AO) along with the authorities having jurisdiction (AHJs) and ensuring the site’s policies in place are aligned with those requirements.

The accreditation, quality, infection prevention and facilities management teams need to review the site’s list of all its critical pressure rooms to confirm that all rooms have been identified and ventilation management plans are aligned. Facilities managers should reference the March 2021 Health Facilities Management article “Nine steps to developing a ventilation management plan” for more information.

Once the list is determined and the requirements defined, then testing requirements can be established with the prescribed periodicity. Monitoring can be performed with such strategies as daily readings by the local team, real-time indicating devices in the room and/or building automation system alarms/monitors. 

The daily readings should be logged, and any readings that come back out of range should be documented with corrective actions taken. Facilities managers should be sure to maintain documents for at least 12 months or more depending on the AHJ’s requirements.

The measurement of air changes per hour, pressure relationship, temperature and humidity need to be validated at least annually or in compliance with the organization’s policies. There are a couple of methods for managing critical pressure room verification, including using a computerized maintenance management system (CMMS) and/or having a certified air balancer to document balance reports. These documents should be in line with the codes, guidelines and AHJ requirements. If accepting the report from a certified air balancer or vendor, the owner should review the document immediately for completeness, because once ownership is taken, the report is accepted.

If a critical pressure does not meet all defined criteria and cannot be corrected at the time of the test, the facilities team should be notified immediately. The facilities team should then connect with the rest of the multidisciplinary team to determine if the space is acceptable for patient use and if additional mitigations are needed. These actions should be documented either in the CMMS or in the organization’s compliance binder because, as the saying goes, “If it isn’t documented, it didn’t happen.”

A compliance tool from the American Society for Health Care Engineering can help in devising a ventilation management plan,.