Negative Pressure or Positive Pressure Isolation Rooms
Canberra Health ServicesOperational Procedure Negative Pressure or Positive Pressure Isolation Rooms. Operation, Performance Monitoring and MaintenanceContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc533165314 \h 1Purpose PAGEREF _Toc533165315 \h 2Scope PAGEREF _Toc533165316 \h 2Section 1 – Roles and Responsibilities PAGEREF _Toc533165317 \h 2Section 2 – Background PAGEREF _Toc533165318 \h 3Section 3 – Maintenance PAGEREF _Toc533165319 \h 5Section 4 – Operation PAGEREF _Toc533165320 \h 6Implementation PAGEREF _Toc533165321 \h 6Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc533165322 \h 7References PAGEREF _Toc533165323 \h 7Definition of Terms PAGEREF _Toc533165324 \h 8Search Terms PAGEREF _Toc533165325 \h 8Attachments PAGEREF _Toc533165326 \h 9ATTACHMENT A. Isolation Rooms PAGEREF _Toc533165327 \h 10ATTACHMENT B. UCH Negative Pressure Room Instructions and Check list PAGEREF _Toc533165328 \h 12ATTACHMENT C. Negative pressure analogue gauge: PAGEREF _Toc533165329 \h 15ATTACHMENT D. Negative pressure analogue gauge DAILY CHECK: PAGEREF _Toc533165330 \h 16ATTACHMENT E. Positive pressure analogue gauge: PAGEREF _Toc533165331 \h 18ATTACHMENT F. Positive pressure analogue gauge DAILY CHECK: PAGEREF _Toc533165332 \h 19ATTACHMENT G. Negative pressure or Positive pressure electronic gauge: PAGEREF _Toc533165333 \h 21ATTACHMENT H. Negative pressure or positive pressure electronic gauge DAILY CHECK: PAGEREF _Toc533165334 \h 23 PurposeTo provide Canberra Health Services (CHS) employees relevant guidelines to appropriately and safely operate, monitor performance, and plan maintenance for negative pressure or positive pressure isolation rooms.This procedure should be read in conjunction with the Healthcare Associated Infection (HAI) Procedure 2.6.3 Airborne Precautions.Back to Table of ContentsScopeThe procedure pertains to all Canberra Health Services (CHS) staff.Back to Table of ContentsSection 1 – Roles and ResponsibilitiesInfection Prevention and Control Infection Prevention and Control are required to know the location and types of all negative pressure and positive pressure rooms throughout CHS (Attachment A and B) and to assist the Bed Access Unit in correctly allocating rooms to patients with an infectious disease.Infection Prevention and Control should be notified when a negative pressure or positive pressure room fails to achieve required pressure. Facilities Management Facilities Management are to ensure that ongoing maintenance and testing of negative pressure and positive pressure rooms are undertaken and reported to National Safety and Quality Health Service Standards Healthcare Associated Infections Committee. Facilities Management are responsible for the education of health care workers in the reading and interpreting of monitoring instrumentation regarding pressure variants, system functions and interpretation of the alarming system.Health Care WorkersWard Clinical Nurse Consultants/ Clinical Midwife Consultants (CNC/CMCs) are responsible for ensuring ward/unit performance monitoring and compliance to the procedure. Health care workers are expected to maintain a process of daily monitoring, recording and reporting of non-compliance in accordance with this procedure.Health care workers are to report detected errors to Facilities Management as they occur. CNC/CMCs and Bed Management are to allocate correct isolation room in accordance with clinical isolation requirements. Health care workers should be suitably educated in the reading and interpreting of monitoring instrumentation regarding pressure variants and system functions. This shall be Ward/Unit specific induction that includes education on the interpretation of the alarming system. Clinical Development Nurses are to facilitate 6 monthly in-service training sessions. Back to Table of Contents Section 2 – BackgroundIsolation for Infectious/Immunocompromised PeopleSome diseases or conditions require more than Standard Precautions to protect staff and patients.Patients with these diseases/conditions will require physical separation from other patients by placing them in a single room to reduce contact and/or airborne spread of the infective agent.Negative Pressure or Positive Pressure Isolation Rooms Selected patient rooms have been provided with air pressure control to maintain either a negative or positive air pressure.Room air pressure, or pressure differential, is created when one space (corridor/anteroom) is at a different pressure than an adjoining space (patient room). When a pressure differential is created between two spaces, air is forced to flow from the higher pressure space to the lower pressure space. The direction of air flow is one component of proper room air pressure. The second component of room air pressure is the speed or how fast is the air moving between the two spaces. Negative room pressure in a room is supplied by the air ventilation system that generates negative pressure to allow air to flow into the isolation room, but not escape from the room. Air will naturally flow from areas with higher pressure to areas with lower pressure, thereby preventing contaminated air (e.g. airborne microorganisms) from escaping the room, such as entering the corridor/anteroom. Typically air flows from the corridor/anteroom into the negative pressure room, ensuring that contaminated air cannot escape from the negative pressure room to other parts of the ward. This technique is used for isolation of patients with airborne contagious diseases, such as Tuberculosis, Varicella (chicken pox) and Measles.Positive room pressure in a room is supplied by the air ventilation system that generates positive pressure greater than the environment that surrounds that room. This technique is used to prevent transmission of pathogens from the outside environments to profoundly immune-compromised patients, such as severely neutropenic patients, allogeneic bone marrow recipients. Air will flow out of the room instead of in, preventing any airborne microorganisms (e.g. bacteria, etc.) from entering the room. Note:If an immune-compromised patient has an infection transmitted by the airborne route (e.g. chickenpox, measles, tuberculosis) then they may pose a risk to other immune-compromised patients if placed in a positive pressure room. Urgent advice should be sought from Infection Prevention and Control or the on-call Infectious Diseases physician. Negative Pressure or Positive Pressure Isolation Room FeaturesThe negative pressure room will continue negative air flow at all times. The positive pressure room will continue positive air flow at all times. All negative pressure or positive pressure rooms will have pressure alarms installed. There is no manual over-ride for adjusting the pressures in these rooms.An alarm indication is displayed on the Annunciator panels and staff station terminal within the respective ward identifying the room in which the pressure loss/gain has occurred. Back to Table of Contents Section 3 – MaintenancePreventative Maintenance Schedule Routine performance monitoring and maintenance for Isolation Rooms are critically important due to the high risk of transmission and possible outbreaks if systems are not adequately maintained.There should be a documented Preventative Maintenance Schedule for each negative pressure or positive pressure isolation room. A documented record of maintenance activities shall be available from Facilities Management and Maintenance for inspection when required. Maintenance Program There shall be a scheduled Maintenance Program at not greater than 13-week intervals to check and ensure performance of negative pressure or positive pressure isolation rooms. The following should be checked and a corresponding record of maintenance shall be documented and available: Air change rate Supply and exhaust quantities Terminal high efficiency particulate air (HEPA) filters Supply air diffuser or registers, return/exhaust air grilles and ductwork Room pressure gauges and alarms Supply and exhaust fans and dampers Room seals and door closer Clinical hand basin and ensuite plumbing Room signageA Facilities Maintenance schedule for the exhaust grills and filters is available on request from Facilities Management and Maintenance. Facilities Management and Maintenance or Maintenance and Engineering staff will contact ward staff when this is due. In some clinical areas the alarm will appear on the Building Management System if there are any problems with the negative or positive pressure isolation mode. Staff in the area will be alerted to this by Facilities Management and Maintenance or Maintenance and Engineering staff, and again when the problem has been resolved. Emergency Electric Power Supply A back up emergency electric power supply shall be available to ensure fans, alarms and monitoring systems do not fail if main supply is disrupted.Ward/Unit Performance MonitoringThe nursing and midwifery staff need to maintain a process of daily monitoring and recording of the pressure indicated on the pressure gauge located just outside the entrance to the room. The doors of the room (and the anteroom) need to be closed prior to the monitoring of the pressure.Recording system needs to indicate:Daily room pressure checks Alarming system functional = YES/NO (if NO, maintenance request completed = YES/NO)Annual Service and Maintenance - label – dated and signed. A documented record of daily performance check shall be available and kept at the staff station. Back to Table of Contents Section 4 – OperationNegative pressure or positive pressure isolation room When the room is used for a patient that requires a negative pressure or positive pressure isolation room, the key controlled alarm is to be activated.When the negative pressure or positive pressure isolation room is not used for a patient that requires a negative pressure or positive pressure isolation room the key controlled alarm can be deactivated.Each negative pressure or positive pressure isolation room is fitted with a functional pressure gauge outside the room. The pressure gauge is either Negative pressure analogue gauge (Attachment C & D)orPositive pressure analogue gauge (Attachment E & F)orNegative pressure or positive pressure electronic gauge (Attachment G & H)Back to Table of Contents Implementation This procedure is to be communicated to all CHS staff via the Deputy Director General email alerts notifying staff of new Policy. Staff will be reminded by email each year of the procedure around the management of negative and positive pressure isolation rooms. In addition, this will be forwarded to the Bed Access Unit to allow appropriate bed management of admitted patients. Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesPatient Identification and Procedure Matching PolicyProceduresHealthcare Associated Infections Clinical ProcedurePatient Identification and Procedure Matching ProcedureInfectious Threats Operations ManualInfectious Threats Clinical ProcedureControl of Tuberculosis ProcedureCancer and Blood Disorders – care of paediatric patients (infants, children and adolescentsStandardsStandards Australia, 2003, Handbook HB 260: Hospital acquired infections - Engineering down the risk Standards Australia, 2012, AS 1668.2: The use of ventilation and air-conditioning in buildings. Part 2: Mechanical ventilation in buildings.Standards Australia, 2000, AS 1807.6: Cleanrooms, workstations, safety cabinets and pharmaceutical isolators - Methods of test. Method 6: Determination of integrity of terminally mounted HEPA filter installations.Standards Australia, 2000, AS 1807.10: Cleanrooms, workstations, safety cabinets and pharmaceutical isolators - Methods of test. Method 10: Determination of air pressure of cleanrooms and pharmaceutical isolators.LegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferencesAustralian Commission on Safety and Quality in Health Care. (2010). Australian Guidelines for the Prevention and Control of Infection in Healthcare. National Health and Medical Council. Health Infrastructure Alliance (AHIA). Australasian Health Facility Guidelines (AusHFG) 2016. Part D - Infection Prevention and Control. for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR 2005;54(No. RR-17): Advisory Committee on Infection Control, 2007, Guidelines for the Classification and Design of Isolation Rooms in Health Care Facilities. Back to Table of ContentsDefinition of Terms Air changes - The ratio of the volume of air flowing through a space in a certain period of time (that is, the airflow rate) to the volume of that space (that is, the room volume). This ratio is usually expressed as the number of air changes per hour (ACHR).Air Purification - a High Efficiency Particulate Air (HEPA) filter that purifies air from the atmosphere and removes solid particulates such as dust, pollen, mould, and bacteria from the air. To qualify as HEPA by standards, an air filter must remove (from the air that passes through) 99.97% of particles that have a size of 0.3??m. The system is controlled automatically and requires no input from occupants. Air purification is located to the positive air pressure rooms.Anteroom - A small room leading from a corridor into an isolation room. This room can act as an anteroom and prevent the escape of contaminants from the isolation room into the corridorDifferential pressure gauge - A pressure gauge that will display the difference in pressure between one port on the gauge and the other. Normally placed to measure the difference in pressure between two rooms. Pressure is measured in Pascals (Pa).Pascal (Pa) is the?unit?of pressure or stress in the International System of?Units?(SI).?Health care workers (HCW) – All clinical staff including students.Back to Table of ContentsSearch Terms Negative and positive pressure Isolation Room, Infection Control, Negative pressure room, positive pressure room, Isolation RoomBack to Table of ContentsAttachmentsAttachment A - Isolation RoomsAttachment B - UCH Negative Pressure Room Instructions and Check listAttachment C - Negative pressure analogue gaugeAttachment D - Negative pressure analogue gauge daily checkAttachment E - Positive pressure analogue gaugeAttachment F - Positive pressure analogue gauge daily checkAttachment G - Negative pressure or positive pressure electronic gaugeAttachment H - Negative pressure or positive pressure electronic gauge daily checkDisclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval This document supersedes the following: Document NumberDocument NameATTACHMENT A. Isolation RoomsTypes of Isolation Rooms:There are four types of Isolation Rooms used for infection control. Australasian Health Facility Guidelines (AusHFG)Standards Australia HB260, 2003Class S - StandardType 4 - Standard isolation Class P - Positive pressureType 3 - Patient protectionClass N - Negative pressureType 5 - Respiratory isolationClass Q - QuarantineType 5 plus airlock - Quarantine isolation Functional Classification of Isolation Rooms:Class P / Type 3Class S / Type 4Class N / Type 5Class Q / Type 5 plus airlockKey ventilation criteriaGreater air pressure in the room than in the corridor. No air pressure difference between room and the adjacent corridor. Lower air pressure in the room than in the adjacent corridor or anteroom. Lower air pressure in the room than in the adjacent airlock. Transmission based rationale To prevent transmission of pathogens from the outside environment to profoundly immunocompromised patients. To prevent contact or droplet transmission. To prevent airborne transmission. Quarantine of patients with highly transmissible pathogens to prevent airborne transmission. Examples for use (noting this is not a complete list) To prevent infections such as aspergillus (fungal infection) in allogeneic bone-marrow transplant recipients. VRE / MRSAGastroenteritisCutaneous anthraxHepatitis A Measles and Varicella, suspected or proven. Pulmonary or laryngeal tuberculosis. Suspected contact of measles, Varicella, and SARS if symptomatic.Highly infectious pathogens such as haemorrhagic fevers, pneumonic plague.Reference: Australasian Health Facility Guidelines Part D - Infection Prevention and Control March 2016 For further information refer to section B5.2 of NHMRC, 2010, Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010).Target room ventilation parameters of Isolation Rooms used for infection control:Room ClassificationSupply air quantityExhaust air quantityRoom Differential Pressure (DP) to surroundingsCalculated Air Changes per Hour (ACH)Positive pressure> 15 ACH effective10% lower than Supply Air quantity2 Pa to 10PA Positive> 15 ACHStandard> 6ACH10% higher than Supply Air quantity2 Pa to 10PA Negative> 6ACHNegative pressure> 15 ACH effective10% higher than Supply Air quantity5 Pa to 10PA Negative> 15 ACHATTACHMENT B. UCH Negative Pressure Room Instructions and Check listRefer to the Alarm Panel Diagram below for display ranges in normal operationInitiating the alarm for patient requiring negative pressure isolationStepAction1To set up room before admitting the patient, the alarm is to be activated.To confirm the alarm is activated open the respective doors – the displayed pressures will rise to 0 Pascals (Pa). Allow the doors to remain open for up to 2 minutes (threshold period to prevent nuisance alarms)Alarms must annunciate from the respective alarm panelsContact the Help Desk on Ext 47000 where alarms fail to annunciate (priority 1)With the alarm activation available, close both doors (anteroom and patient room)The pressures displayed on each panel should fall within the ranges shown on the diagram below. Contact the Help Desk if displays are not within the ranges specified.2Once the patient is in the room, access should be via the anteroom door when possible. Ensure both main door and anteroom door remain closed at all times. 3If the negative pressure room alarm is no longer required, (i.e. patient is determined to be non-infectious) contact the Help Desk to mute the alarm and record the same on the log sheetNegative pressure room process when patient who had a clinical requirement for a negative pressure room is discharged.The following steps must be undertaken following discharge of an infectious patient.The room CANNOT BE USED FOR NEW ADMISSIONS until the steps have been undertaken in the following order.4When the patient is discharged, close the door and leave vacant for 30 minutes prior to terminal clean (to ensure transmission is reduced).5If Ward/unit staff or contracted staff enter the room during this 30 minutes period they must wear a N95/P2 respirator particulate mask. 6Contact the Help Desk to mute the alarm7Complete terminal cleanUCH Negative Pressure Room Checklist Ward /Unit:Month / Year: Room Number:Negative pressure: DatePressure readingRN/M InitialsCorrective ActionDatePressure readingRN/M InitialsCorrective Action11721831942052162272382492510261127122813291430153116CN/MC Comments:Date: CN/MC signature after monthly review and check:Date:Negative Pressure Room Digital Alarm Display – Operating Range46581123421852Patient Room15 – 18 Pascals (Pa)00Patient Room15 – 18 Pascals (Pa)46338091512098Anteroom7 – 9 Pascals (Pa)00Anteroom7 – 9 Pascals (Pa)444555943500ATTACHMENT C. Negative pressure analogue gauge: Alarm Panel -Red light indicate insufficient Negative pressure inside roomPressure Gauge –Sufficient Negative pressure= between -5 to -10 Pascals.Pressure Gauge –Insufficient Negative pressure = less than -5 Pascals Initiating key controlled alarm for patient requiring Negative pressure IsolationStepAction1To set up room before admitting the patient, the alarm is to be activated.To enable the alarm of the Negative pressure room, access the alarm key. The key to enable the alarm is located with the ward/unit DD keys.Close the door to the Negative pressure plete the procedure for checking negative room as in flowchart of daily Check Sheet.Start the alarm by turning the key/switch from ‘off’ to ‘on’. Remove the key - the Negative pressure room alarm has now been activated.If this does not occur contact FM (out of hours via switch board).2Once the patient is in the room, access should be via the anteroom door when possible. Ensure both main door and anteroom door remain closed at all times. N.B. The anteroom doors are designed to allow only one door to be opened at any one time. 3If the Negative pressure room alarm is no longer required, (i.e. patient is determined to be non-infectious) turn the key for the alarm on the panel to ‘normal/off’. Negative pressure room process when patient who had a clinical requirement for a Negative pressure room is discharged. The following steps must be undertaken following discharge of an infectious patient. The room CANNOT BE USED FOR NEW ADMISSIONS until the steps have been undertaken in the following order. 4When the patient is discharged, close the door and leave vacant for 30 minutes prior to terminal clean (to ensure transmission is reduced).5If Ward/unit staff or contracted staff enter the room during this 30 minute period they must wear a N95/P2 respirator particulate mask. 6Using the alarm key, turn the key to alarm off position.7Complete terminal cleanATTACHMENT D. Negative pressure analogue gauge DAILY CHECK:Ward /Unit:Month / Year: Room Number:Negative pressure: DatePressure readingRN/M InitialsCorrective ActionDatePressure readingRN/M InitialsCorrective Action11721831942052162272382492510261127122813291430153116CN/MC Comments:Date: CN/MC signature after monthly review and check:Date:NOTE: The Negative pressure analogue gauge is near the door of the positive pressure room.ATTACHMENT E. Positive pressure analogue gauge: Alarm Panel -Red light indicate insufficient Positive pressure inside roomPressure Gauge –Sufficient Positive pressure = between +2 to +10 Pascals.Pressure Gauge –Insufficient Positive Pressure = less than +2 or greater than +10 PascalsInitiating key controlled alarm for patient requiring positive pressure Isolation StepAction1To set up room before admitting the patient, the alarm is to be activatedTo enable the alarm of the Positive pressure room, access the alarm key. The key to enable the alarm is located with the ward/unit DD keys.Close the door to the Positive pressure plete the procedure for checking Positive pressure as in flowchart of daily Check Sheet.Start the alarm by turning the key/switch from ‘off’ to ‘on’. Remove the key - the Positive Pressure room alarm has now been activatedIf this does not occur contact FM (out of hours via switchboard).2If the positive pressure room alarm is no longer required, turn the key for the alarm on the panel to ‘normal/off’. Positive pressure room process when patient who had a clinical requirement for a Positive pressure room is dischargedStepAction3Using the alarm key, turn the key to alarm off position.4Standard cleaning requiredATTACHMENT F. Positive pressure analogue gauge DAILY CHECK: Ward /Unit:Month / Year: Room Number:Positive Pressure: DatePressure readingRN/M InitialsCorrective Action;DatePressure readingRN/M InitialsCorrective Action;11721831942052162272382492510261127122813291430153116CN/MC Comments: Date: CN/MC signature after monthly review and check:Date:NOTE: The Positive pressure analogue gauge is near the door of the positive pressure room.ATTACHMENT G. Negative pressure or Positive pressure electronic gauge:E.g. used in Centenary Hospital for Women and Children (CHWC)Electronic Gauge Pressure Alarm Initiating key controlled ‘Pressure Alarm’ for patient requiring Negative pressure or Positive pressure rooms StepAction1To set up room before admitting the patient, the ‘Pressure Alarm’ is to be activated.To enable the ‘Pressure Alarm’ of negative pressure or positive pressure room, use the alarm key. The key to enable the alarm is located with the ward/unit DD keys.Close the door to the pressure plete the procedure for checking negative pressure or positive pressure room as in flowchart of DAILY CHECK sheet.To enable the alarm by turning the key/switch from ‘Disabled’ to ‘Enable’. Remove the key - the negative pressure or positive pressure room alarm has now been activated.If this does not occur contact Facilities Management and Maintenance (out of hours via switch board).Negative pressure room process only2Anterooms are only required for negative pressure rooms. The anteroom doors are designed to allow only one door to be opened at any one time. Once the patient is in the room, access should be via the anteroom door whenever possible. Ensure both main door and anteroom door remain closed at all times. Negative pressure room process when patient who had a clinical requirement for a negative pressure room is discharged. 3When the patient is discharged, close the door and leave vacant for 30 minutes prior to terminal clean.4If Ward/unit staff or contracted staff enter the room during this 30 minutes period they must wear a N95/P2 respirator particulate mask. 5Complete terminal cleanPositive pressure room process when patient who had a clinical requirement for a Positive pressure room is discharged6Using the alarm key, turn the key to alarm ‘Disabled’ position.7Standard cleaning requiredATTACHMENT H. Negative pressure or positive pressure electronic gauge DAILY CHECK: Ward /Unit:Month / Year: Room Number:Positive pressure or Negative pressure: DateGreen light is on. ‘Normal’ RN/M InitialsCorrective ActionDateGreen light is on. ‘Normal’RN/M InitialsCorrective Action11721831942052162272382492510261127122813291430153116CN/MC Comments: Date: CN/MC signature after monthly review and check:Date:NOTE: The Indication Panel is near the door of the negative pressure or positive pressure room. ................
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