ANSI/ASHRAE/ASHE

Standard 170-2013
CDC 2003 Ventilation Requirements Table B2
Texas Administrative Code: 25 TAC 133.169(c)
NOMENCLATURE: Room Name, Type & Function
ASHRAE Standard 170 Table 7.1 provides room names, required pressure
relationships, minimum outdoor ACH, minimum total ACH, requirement to
exhaust to the outside or ability to recirculate air, humidity and temperature.
The requirements are linked to the room name
How do you determine the room name?
You need to understand the function of the room and possible procedures
performed in the rooms
ASHRAE Standard 170 outlines additional Room-Specific Requirements
7.2.1 Airborne Infection Isolation Rooms
7.2.2 Protective Environment (PE) Rooms
7.2.3 Combination Airborne Infectious Isolation and PE Rooms
7.3.1 Wound Intensive-Care Units (Burn Units)
7.4.1 Operating Rooms
7.4.2 Sterilization Rooms
7.4.3 Imaging Procedure Rooms
7.5.1 Morgue and Autopsy Rooms
7.5.2 Bronchoscopy
7.6 Psychiatric Patient Areas
Texas Childrens Hospital Policy: Adopt TAC 133.169 (c)
THE PLAN
Adopt a nationally recognized standard and create a policy.
Create an inventory of Pressure Dependent Spaces
Update the Space Management Policy to include:
Auditing rooms
Reporting non-compliance of room usage (current function) vs. room design intent
All pressure dependent spaces to be defined by nomenclature in the standard
Ensure room signage matches the standard (ensure current room names
correlate to current room functionality)
Ensure designated pressure dependent spaces meet the requirements of the
adopted standard
Develop a process to review space usage against requirements on a periodic
basis
Determine how spaces will be monitored and insure monitoring solution also
accounts for temperature and humidity requirements
Determine how often spaces will be tested
Develop a training program:
How to recognize a space has a pressure requirement
Ownership: End user responsibilities to monitor space utilization and standardization
Room symbol for pressure dependent spaces
HOW?
Form multidisciplinary Working Group
Compare nationally recognized standards
Adopt the most stringent requirements
Perform a risk assignment for conflicting standards
Insure space policy mandates standardized room names and signage
For visibility, create a symbol for room signage
Insure space policy provides process for repurposing space or requesting new
space that will have pressure dependent requirements
Define standards for the monitoring of spaces. We set up four tiers:
Tier I: Most critical spaces. These spaces are monitored for pressure, temperature,
humidity, and air exchanges. Local display and linked to BAS for critical monitoring by
engineering and archiving of data.
Tier II: Monitoring pressure only. Local display and linked to BAS for monitoring by
engineering and archiving of data.
Tier III: Monitoring pressure only locally, however, not remotely via BAS.
Tier IV: Monitoring of construction projects
Create a pilot project (i.e., an Ambulatory Surgery area)
Create policy for testing these spaces
Create a training program
Monitoring at Room
Ball in the wall: Pressure
Lamiflow: Pressure
Presura: Pressure
Primex: Temp, Humidity & Pressure
Sure Flow: Temp, Humidity & Pressure
L-VIS Panels: Temp, Humidity & Pressure
Monitoring through BAS
Monthly Sensor Report (example)
Group: Medical Center Campus
Location: WT OR #6
Serial No: 001EB38F4E41
Current Maximum Average Current Minimu Maximu
Minimum Current Minimum Maximum Average Average
Date Time Temperatur Temperatur Temperatur Pressur m m
Temperature Humidity Humidity Humidity Humidity Pressure
e e e e Pressure Pressure
12:34:00
64.2 64 70 68.5
5/1/2016 AM 45% 29.00% 50.00% 40.50% 0.02 0.005 0.025 0.015

Service Response 5/2/2016

12:46:00
AM
69.1 66 72 69
44% 42.00% 49.00% 45.50% 0.02 0.020 0.030 0.025

Center: 5/3/2016
12:14:00
AM
73 69 74 71.5
43% 41.00% 51.00% 46.00% 0.02 0.020 0.030 0.025

Must receive critical 5/4/2016

12:49:00
AM
72.3 70 75 72.5
42% 41.00% 49.00% 45.00% 0.02 0.020 0.030 0.025
12:52:00
alarms 24/7 5/5/2016 AM
71.6 64 73 68.5
41% 43.00% 50.00% 46.50% 0.02 0.020 0.030 0.025
12:54:00
Must have access to 5/6/2016 AM
12:57:00
72.3 66 72 69
45% 42.00% 49.00% 45.50% 0.02 0.020 0.030 0.025

reports 5/7/2016 AM
12:41:00
71.8 69 74 71.5
44% 41.00% 51.00% 46.00% 0.02 0.020 0.030 0.025
67.6 70 75 72.5
5/8/2016 AM 43% 41.00% 49.00% 45.00% 0.02 0.020 0.030 0.025
12:39:00
68.2 64 73 68.5
Nursing : 5/9/2016
5/10/201
AM
12:38:00
72.1 66 72 69
42% 43.00% 50.00% 46.50% 0.02 0.020 0.030 0.025

Must have access to 6

5/11/201
AM
12:42:00
75.7 69 76 72.5
41% 42.00% 49.00% 45.50% 0.02 0.020 0.030 0.025

graphical display
6 AM 45% 41.00% 51.00% 46.00% 0.02 0.020 0.030 0.025
5/12/201 12:45:00
68.7 70 75 72.5
6 AM 44% 41.00% 49.00% 45.00% 0.02 0.020 0.030 0.025
Must have access to 5/13/201 12:33:00
74.8 64 75 69.5
6 AM 43% 43.00% 50.00% 46.50% 0.02 0.020 0.030 0.025
reports 5/14/201
6
12:35:00
AM
72.5 66 72 69
42% 42.00% 49.00% 45.50% 0.02 0.020 0.030 0.025
5/15/201 12:18:00
67.6 69 74 71.5
6 AM 41% 41.00% 51.00% 46.00% 0.02 0.020 0.030 0.025
5/16/201 12:06:00
68.2 70 75 72.5
6 AM 45% 41.00% 49.00% 45.00% 0.02 0.020 0.030 0.025
5/17/201 12:08:00
67.8 64 73 68.5
6 AM 44% 43.00% 50.00% 46.50% 0.02 0.020 0.030 0.025
HOW?
Local monitoring devices that staff can easily understand
Alarms for critical spaces tied to your BAS
Rounding on spaces for functionality vs. design (i.e., EOC rounds)
Annual audits of spaces
Calibration of devices
Testing of rooms via instrumentation (in-house or outsourced)
Verification of pressure using the tissue or smoke test
Training:
What are the spaces?
How do I know the proper pressure, temperature, humidity, etc.?
What do I do if they are not correct?
What do I do if I need to use an isolation room?
Space polices and procedures
EOC rounds
Monitoring and testing
Did We Cover it All?

Questions?