PROCEDURE/PROTOCOL



PURPOSE

To reduce the risk for potential contamination of hospital personnel from airborne contagious diseases.

PERSONNEL

R.N., Clinical Manager, Plant Operations, Environmental Services

COMPETENCIES

SUPPORTIVE DATA

The High Efficiency Portable Air filtration machine will be used in patient rooms who are suspect (r/o out) of airborne contagious disease (i.e., pulmonary TB).

PROCEDURE/PROTOCOL

1. Obtaining HEPA Unit:

1. New Admissions: Unit Manager will notify the Maintenance Department of the room number where a HEPA portable filtration machine needs to be set up for patients who are suspect for a contagious airborne disease, according to diagnosis or information obtained via the admitting clerk.

2. Emergency Room: The nurse caring for a patient who is suspect for a contagious airborne disease will notify the Maintenance Department of the room number in ER where a HEPA portable filtration machine needs to be set up if Room #11 and Decontam. Room ( negative pressure rooms) are unavailable.

3. Medical Imaging - Outpatient:

1. The registrar will notify the supervisor of Medical Imaging and/or the receptionist that a suspect for contagious airborne diseases is here for a diagnostic test. The medical imaging supervisor or receptionist will notify the Maintenance Department of the room number in Medical Imaging Department where a HEPA filtration machine needs to be set up if room #4 and #5 are unavailable.

2. The registrar will notify the supervisor of the department where services are needed. The supervisor of the department will notify Maintenance if the machine is indicated.

4. Inpatients: If it is determined during the patient’s hospital stay that the patient is suspect for an airborne disease (i.e., pulmonary TB), airborne precautions need to be instituted. It will be the responsibility of the nurse caring for the patient to notify the Maintenance Department of the room number where the HEPA portable filtration machine needs to be set up.

5. Medical Imaging – Inpatient: the nurse caring for the patient in airborne precaution will notify the supervisor of medical imaging and/or the receptionist that the patient is in airborne precaution isolation. Medical Imaging will then notify the Maintenance Department of the room number where the HEPA portable filtration machine needs to be set up if Medical Imaging negative pressure rooms #4 and #5 are unavailable.

6. When entering a patient room with a potentially infectious patient, Engineering personnel will use respiratory protection equipment as described in the Exposure Control Plan/Policy (N95 Respirator). They will follow all standard/universal precautions.

7. The ideal placement of the unit is in the center of the room. Then placement in this position is not possible, positioning the unit close to breathing zone is recommended.

8. The “MED” setting provides the most acceptable combination of air changes through the HEPA filter at the unobtrusive noise level. The HEPA filter unit should remain on continuously with the doors closed.

9. When removal is requested, the HEPA machine will be retrieved by Maintenance personnel and returned to the Maintenance Department.

1. The nursing personnel removing the machine will insure that the room has been empty with the door closed, for 45 minutes with the machine running and place a work order in Meditech for Maintenance to pick up the machine.

2. The machine shall be disinfected with hospital-approved disinfectant by Environmental Services who will place a plastic cover over the unit.

3. Disposable of the prefilter or the HEPA filter will be performed by bagging the filter and following standard disposal procedures. This function will be done by the Maintenance Department according to manufacturer recommendations.

1. Points of Emphasis

1. This machine must be set up as soon as possible after the patient has been identified as a suspect (r/o) TB case or other contagious airborne disease.

2. If the machine must be placed in the corner of the room, it is recommended that it be placed diagonally to prevent over restricting the airflow.

3. Never place anything on top of the machine, it will restrict the airflow.

4. Daily cleaning of the outside of the machine will be done by Environmental Services according to routine procedures using hospital-approved disinfectant.

5. Leave the machine one with the door closed for 45 minutes after the patient is discharged in order to remove the airborne infectious droplet nuclei. The room can be cleaned during this time period. The housekeeper cleaning the room must wear the N95 respirator.

6. If airborne precautions are discontinued before discharge, the HEPA machine can be removed (1.9.2).

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