airborne-inf-disease..

airborne-inf-disease..
Airborne Infectious
Disease Management
Methods for Temporary
Negative Pressure Isolation
Minnesota Department of Health
Office of Emergency Preparedness
Healthcare Systems Preparedness Program
Airborne Infectious
Disease Management
Methods for Temporary
Negative Pressure Isolation
This guide has been produced by:
Office of Emergency Preparedness
Healthcare Systems Preparedness Program
Acknowledgements
This user guide has been written by
The authors gratefully acknowledge the
the Minnesota Department of Health
Minnesota Emergency Readiness
in conjunction with the University of
Education and Training (MERET) at the
Minnesota to assist hospital personnel
University of Minnesota Centers for
in the management of airborne
Public Health Education and Outreach
infection isolation.
and the following individuals for their
participation, assistance, and support
Airborne Infectious
Disease Management
Methods for Temporary
Negative Pressure Isolation
AUTHORS:
of this project:
Jeanne Anderson
Infection Control Practitioner
Office of Emergency Preparedness
Minnesota Department of Health
Keith Carlson
Director of Facilities Management
Mercy Hospital and Health Care Center
Moose Lake, MN
Andrew Geeslin
Engineering/Infection Control Intern
University of Minnesota
Gary Davis
Plant Engineer
LakeWood Health Center
Baudette, MN
Andrew Streifel
Hospital Environmental Health Specialist
Environmental Health and Safety
University of Minnesota
Pete Swanson
Facility Services Manager
Pipestone County Medical Center
Pipestone, MN
For further Information, please contact:
Office of Emergency Preparedness
Minnesota Department of Health
625 Robert Street North
P.O. Box 64975
St. Paul, MN 55164-0975
The following individuals are gratefully
Minnesota Department of Health
acknowledged for their invaluable
does not endorse particular brands among
suggestions:
competing products. Examples shown
in these materials are for illustration only.
Phone: (651) 201-5701
Fax: (651) 201-5720
All material in this document is in the public
domain and may be used and reprinted
This user guide is available on the
Minnesota Department of Health Web site:
http://www.health.state.mn.us/oep/training/
bhpp/isolation.html
without special permission.
Judene Bartley
Vice President
Epidemiology Consulting Services Inc.
Beverly Hills, MI
Rick Hermans
Senior Project Manager
Center for Energy and Environment
Minneapolis, MN
Curtain TNPI photographs courtesy
of Ken Meade, Research Mechanical
Engineer, NIOSH/CDC, USPHS
MERET photos provided
by Paul Bernhardt
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
References
Appendix
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
37
20
16
13
5
3
2
Hospital preparedness for
Introduction
bioterrorism and other public health
emergencies such as emerging airborne
infectious diseases requires strategic
planning to ensure that all components
of respiratory protection programs,
including environmental controls,
are in place for airborne infection
isolation rooms (AIIRs). Hospitals
have insufficient facilities to provide
airborne infection isolation for large
numbers of patients with airborne
infectious diseases presenting in
a short time period.1, 2 However, AIIRs
have been increased recently, due to
requirements of National Bioterrorism
Hospital Preparedness Program.3
Introduction
1
to other patients and health care
workers.4 Heating, ventilation,
and air conditioning (HVAC)
expertise is essential for proper
environmental management when
planning control of airborne infectious
disease outbreaks (natural or
intentional). Design manuals and
guidelines provide direction for
infectious disease management.5-11
Refer to Appendix A, “2006 AIA
Criteria” on page 21.
Without adequate environmental
controls, patients with airborne
infectious diseases will pose a risk
This guide will assist health care facility
plant maintenance and engineering
staff, in coordination with infection
control professionals, to prepare for
a natural or terroristic event, involving
an infectious agent transmitted by
airborne droplet nuclei. Examples
of such agents include measles,
varicella, and tuberculosis.5
Audience for this Guide
Purpose of this Guide
Goal of this Guide
The intended audience for this
guideline includes health care:
Provide guidance on environmental
A timely response is crucial for
identification and containment
of potentially infectious patients.
The goal is for facilities to develop
a 12-hour response to implement
containment measures. Temporary
negative pressure isolation methods
are a safe alternative for hospitals
that lack engineered AIIRs.
These can be utilized in facilities to
meet increased surge capacity for
patient isolation. TNPI should also
be used during hospital construction
projects to reduce risks associated
with airborne infectious diseases.
facility engineering and maintenance
infection control
environmental health and safety
management personnel
controls for airborne infectious
disease management
Provide a general guide for
temporary setup, installation,
and operation of portable HEPA
machines when used to create
negative pressure in a hospital
room/area
Provide instruction on the use of:
Pressure gauges
Particle counters
Outline of preventative
maintenance schedule for
HVAC equipment related to AIIR
These temporary measures should
be incorporated into the facility’s
infection control and emergency
response plans. AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
37
20
16
13
5
3
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Principles
of airborne
infectious
disease
management
Introduction
2
1
Airborne infection isolation
is based on the following hierarchy
of control measures.
Principles of
airborne infectious
disease management
Administrative (work practice) controls
Environmental controls
Personal protective equipment (PPE)
These measures are intended to
reduce the risk for exposure to
airborne infectious disease agents
by uninfected persons. AIIRs and
hospital systems in general must
be monitored to provide continual
protective measures. Refer to
Appendixes B and C, AIIR and
HVAC System Maintenance
Schedules, on pages 22 and 23.
Administrative
Environmental
Personal
(work practice) controls
controls
protective equipment (PPE)
Managerial measures that reduce
the risk for exposure to persons
who might have an airborne
infectious disease.
Physical or mechanical measures
Equipment worn by health care
Work practice controls include
using infection control precautions
while performing aerosol-generating
procedures, closing doors to AIIRs,
hand hygiene, and signage.
EXAMPLES
written policies and
protocols to ensure
the rapid identification,
isolation, diagnostic
evaluation, and
treatment of persons
likely to have an
airborne infectious
disease
(as opposed to administrative
workers and others to reduce
control measures) used to reduce
exposure to communicable
the risk for transmission of airborne
diseases.
infectious diseases.
EXAMPLES
ventilation
EXAMPLES
gowns
filtration
gloves
ultraviolet germicidal
irradiation
masks
AIIRs
eye protection
local exhaust
ventilation devices
respirators
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
37
20
16
13
5
Environmental
controls
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Principles of airborne
infectious disease
management
Introduction
2
1
3
••• A difference in pressure
Environmental
controls
This user guide will focus on the
environmental controls necessary
for airborne infection isolation.
The ventilation parameters essential
for airborne infection isolation
rooms/areas include:
Pressure management for
appropriate airflow direction;
Room air changes for
dilution ventilation; and
Filtration to remove
infectious particles.
Pressure management
L
NEGATIVELY
PRESSURIZED
H
POSITIVELY
PRESSURIZED
FIGURE 1
Illustrations used to identify
Negatively (top) and Positively (bottom)
pressurized air space.
For the purposes of this guide,
pressure refers to the differential
pressure between two spaces
(FIGURE 1).
In health care settings, the two spaces
are typically the isolation room and the
corridor. For AIIR, the room should
be negatively pressurized in relation
to the corridor. This helps to prevent
infectious particles from escaping the
room envelope.
If an anteroom is present between the
AIIR and the corridor, the AIIR may be
negatively or positively pressurized to
the anteroom. However, if the AIIR is
positively pressurized to the anteroom,
the anteroom must be negatively
pressurized to the corridor.
causes movement of air from areas
at higher pressure to those at lower
pressure. The greater the pressure
difference, the greater the resulting
air velocity. The movement of air is
used to help provide containment of
infectious particles by providing clean
to dirty airflow. Refer to Appendix D,
“Using a Pressure Gauge to
Measure Relative Pressurization
Between Two Spaces” on page 24
for instructions on using a pressure
gauge to determine differential
pressure.
•••
The differential pressure or
pressure offset is established by
mechanically adjusting the supply
and exhaust air. For a negative
pressure room, the sum of the
mechanically exhausted air must
exceed the sum of the mechanically
supplied air. This offset forces air to
enter the room under the door and
through other leakages and prevents
infectious particles from escaping.9
•••
In order to maintain consistent
offset airflow, the difference between
exhaust and supply should create
a pressure differential of about
0.01 inch water gauge (in. w.g.)
or 2.5 Pascals (Pa).9 Pressure in
this application is used to induce
airflow from adjacent spaces into
the isolation room. AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
37
20
16
13
5
Dilution ventilation
Environmental
controls
Dilation ventilation
Filtration
Filtration
Mechanical ventilation is used
to exchange the air in a space.
The time required for removing
a given percentage of airborne
particles from a room or space
depends on the number of
air changes per hour (ACH),
location of the ventilation
inlet and outlet, and the physical
configuration of the room or space
(FIGURE 2).
Refer to Appendix E, “Using
a HEPA Filter for Dilution
Ventilation” on page 26. •
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Principles of airborne
infectious disease
management
Introduction
2
1
4
When used correctly, portable HEPA
filters prove to be an effective method
for achieving an airborne isolation
environment.12 When properly installed
and maintained, filters for clinical
spaces should be able to remove at
least 90% of particles (0.5 microns
in size and larger) 9 from outside and
inside air.
For the purposes of this guide,
filtration refers to the process of
passing air through a filter. Hospital
buildings have some of the highest
filtration requirements. Without filtration,
particle concentrations accumulate in
indoor environments. This can cause
toxic effects even in healthy people.
For evaluation of hospital HVAC systems
and HEPA filters refer to Appendix G,
“Using a Particle Counter to Assess
Indoor Air Quality and Filter Efficiency”
on page 29.
Filtration reduces the risk for
transmitting airborne infectious agents.
Depending upon their size, particles
may be deposited in the upper
respiratory tract or the lower respiratory
tract of humans. Particles can also be
deposited in open wounds during
dressing changes or invasive
procedures. See Appendix F,
“Microorganisms Associated with
Airborne Transmission” on page 28.
For information on filter selection
and performance, see Appendix H,
“Data Interpretation” on page 34.
See Appendix I, “Sample Log for
Measuring Particle Counts” on page 36.
FIGURE 2: ACH AND TIME REQUIRED FOR REMOVAL EFFICIENCIES
90%
99%
99.9%
EFFICIENCY
EFFICIENCY
EFFICIENCY
2
69
138
207
4
35
69
104
6
23
46
69
8
17
35
52
10
14
28
41
12
12
23
35
15
9
18
28
20
7
14
21
50
3
6
8
ACH
Modified from Table B.1, CDC Guidelines for
Environmental Infection Control in Health-Care Facilities,
2003.5
M INUTES
Time (minutes) required for removal of 90%, 99%, and 99.9% of airborne-contaminants.
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
90% EFFICIENCY
99% EFFICIENCY
99.9% EFFICIENCY
2
4
6
8
10
12
15
20
50
AIR CHANGES PER HOUR (ACH)
Perfect mixing of air is assumed. For rooms with stagnant air spaces, the time required may be much longer
than shown. This is intended only as an approximation and is for ideal ventilation configurations.
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
37
20
16
13
TNPI
Temporary
Negative
Pressure
Isolation
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
3
2
1
TNPI Installations Must Observe Building & Fire Codes
All of the TNPI installations must observe state building and fire codes, and National
Fire Protection Association (NFPA) 101 (Life Safety Code). Being able to set up a
TNPI requires planning and early contact with the authority that has jurisdiction
(your State Health Department) to establish and verify compliance with applicable
codes. In Minnesota, you can contact Fernando Nacionales, P.E., Engineering Services
Section at (651) 201-3712 or [email protected]
There are three types of temporary
isolation. The two most effective
methods of achieving temporary
isolation are:
H
1 2
Discharging air
to the outside
H+
Discharging
air to return
air system
infection isolation is needed and there
are no available or insufficient AIIRs,
such as can happen when there is
an outbreak of an airborne infectious
disease with large numbers of
communicable patients. Temporary
isolation is designed to protect
patients and staff from contracting or
transmitting highly infectious diseases.
HEPA Filter Maintenance
If the HEPA filter is in place for an
extended period of time, the pre-filter
should be changed when lint buildup
becomes visible (FIGURE 3). It is
important to completely follow
the manufacturer’s directions for
operation and maintenance of
portable HEPA filter machines.
One less effective methods
of achieving temporary isolation is:
H
5
TNPI is considered when airborne
Temporary
Negative Pressure
Isolation TNPI
Portable HEPA filters have been
used in the past to isolate patients.
These filters can also be used as
an air scrubber. When used in this
fashion, the filter simply cleans the air.
It does not provide pressure
management for appropriate
airflow direction. The filter is placed
in the room and turned on, without
attached ductwork. This is known
as room recirculation and is not a
preferred method for isolation.
•
3
Curtain TNPI
FIGURE 3
Pre-filter at inlet side of HEPA machine
(is shown).
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
37
20
16
13
TNPI
Temporary
Negative
Pressure
Isolation
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
3
2
1
6
Discharging air to
the outside
1
Discharging air
to the outside
H
1
Steps for
+
discharging
air
to the outside
This option is one of the two preferred
methods for achieving TNPI.
In this method, a HEPA filter is used
to exhaust room air outside through
the window. (Clearly, a window is
required for this method.) (FIGURE 4)
1. Select a room
L
2. Set up pre-constructed
window adapter
NEGATIVELY
PRESSURIZED
• The two main purposes of the
HEPA machine in this application
are to clean contaminated air
and induce negative pressure
in the room.
3. Set up HEPA machine and
flex duct
Creates negative
pressure room
(airflow into patient
room from the
corridor or anteroom)
4. Seal return air grille
5. Turn on HEPA machine
and adjust flow
• Because the discharged
air is HEPA filtered, no extra
consideration for air discharge
location is required.
To prevent pulling air from return air system,
the exhaust/return grilles should be sealed
with tape.
EXHAUST/RETURN
SUPPLY
Set up HEPA machine and flex duct.
tip
CLEANED AIR
HEPA
MACHINE
Becoming familiar
with operating the
negative pressure
HEPA filter machine
FIGURE 4
HEPA fan exhausting clean air outside through the window.
on a regular basis
(e.g., during
construction projects),
will better prepare the
user for an emergency
response. AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
37
20
16
13
TNPI
Temporary
Negative
Pressure
Isolation
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
3
2
1
7
Select
a room
You should choose a room to set up
TNPI. The HEPA machine should be
set up in advance to placing the
patient with a suspected airborne
infectious disease in the room.
STEP
If possible, select a room without
transfer grilles. If no such room
exists, completely seal the grilles
to promote negative pressure.
2
Set up pre-constructed
window adapter
3
Set up HEPA machine
and flex duct
Connect the flex duct to window
adapter and HEPA machine. (FIGURE 6)
4
Seal return
air grille
To prevent pulling air from return
air system, the return grilles
should be sealed with tape.
A sheet of plastic or cardboard can
be used provided that the edges
are completely sealed with tape.
5
Turn on HEPA machine
and adjust flow
Once the flex duct is connected
to the window template and the HEPA
machine, the machine should be
turned on. (FIGURE 7)
Adjust the flow on the output until
the desired pressure differential of
negative 2.5 Pa (pressure in corridor
is greater than pressure in patient
room) is reached. Increasing the flow
will increase the pressure differential,
and decreasing the flow will decrease
the pressure differential.
The pressure differential should be
measured with a hand-held digital
pressure gauge. The pressure
should be monitored daily.
When using this option to establish
TNPI, a window adapter must be
constructed. This is used to provide
a connection to the flex duct. (FIGURE 5)
The template should be constructed out
of wood to fit into a standard window in
your hospital’s patient care rooms and
should provide an airtight fit.
A piece of sheet metal (a flange)
of the same diameter as the flex
duct should be fixed to the circular
hole in the wood to serve as an
adapter between the wood template
and the flex duct. The use of a
window template, flex duct, and fan
is common in hospital construction.
STEP
STEP
1
STEP
STEP
Discharging air
to the outside
Additional Notes for
Discharging Air to the Outside
FIGURE 6
Flex duct connected to window template.
The other end of the flex duct should be
connected to the HEPA machine.
• In locations with seasonal cold
(below-freezing) weather, it may
be necessary to install a damper
or louver on the outside of the
window template. This will help
to prevent airflow restriction due to
condensation or ice/snow buildup.
• When no longer needed,
the HEPA filter and flex duct
should be wiped down with
a hospital-approved disinfectant.
FIGURE 5
Window adapter
with flex duct
attached.
FIGURE 7
The flow rate on this machine is adjusted
with the dial on the right-hand side.
• HEPA filters can also be used
to enhance dilution ventilation.
Refer to Appendix E, “Using
a HEPA Filter for Dilution
Ventilation” on page 26
for a discussion and example
of dilution ventilation. AIRBORNE
AIRBORNE INFECTIOUS
INFECTIOUS DISEASE
DISEASE MANAGEMENT
MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
37
20
16
13
TNPI
Temporary
Negative
Pressure
Isolation
•
•
PREPARED
PREPARED BY
BY THE
THE MINNESOTA
MINNESOTA DEPARTMENT
DEPARTMENT OF
OF HEALTH
HEALTH
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
3
2
1
8
Discharging
air to return
air system
2
Discharging air to
return air system
H
2
Steps for
discharging air
to return air system
1. Select a room
L
2. Attach flex duct adapter
to desired return grille
NEGATIVELY
PRESSURIZED
3. Set up HEPA filter machine
and flex duct
Creates negative
pressure room (airflow
into patient room from
the corridor or
anteroom)
4. Seal remaining return air grilles
5. Turn on HEPA filter machine
and adjust flow
This option is one of the two preferred
methods for achieving TNPI.
In this method, a HEPA filter machine
is used to discharge room air into the
return air system. (FIGURE 8)
• You must be careful when
exhausting additional large volumes
of air through the return air system.
• Because the air is HEPA filtered,
it is okay to exhaust it through the
return air system. If air was being
exhausted by a regular (non-HEPA
filtered) large fan, it should not
be discharged through the return
air system.
Care must be taken
EXHAUST/RETURN
tip
when exhausting
SUPPLY
a large volume of
air into the return
air system, as it can
over-pressurize the
duct. Such changes
can disturb the
air-balancing
HEPA
MACHINE
of rooms on the
same return/exhaust
air system. FIGURE 8
Discharging air to return air system
Attach flex duct adapter to desired return grille.
AIRBORNE
AIRBORNE INFECTIOUS
INFECTIOUS DISEASE
DISEASE MANAGEMENT
MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
37
20
16
13
TNPI
Temporary
Negative
Pressure
Isolation
•
•
PREPARED
PREPARED BY
BY THE
THE MINNESOTA
MINNESOTA DEPARTMENT
DEPARTMENT OF
OF HEALTH
HEALTH
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
3
2
1
9
Select
a room
You should choose a room to set up
TNPI. The HEPA machine should be
set up in advance to placing the
patient with a suspected airborne
infectious disease in the room.
STEP
If possible, select a room without
transfer grilles. If no such room
exists, completely seal the grilles
to promote negative pressure.
2
Attach flex duct
adapter to desired
return grille
Next, attach flex duct adapter to
desired return grille. Ideally, if the
return is low, connect the flex duct
here. However, most returns are high
on the wall or ceiling and these can
be connected in the same way.
It is important to provide a tight
seal between the flex duct and
the adapter as well as between the
adapter and the return grille. (FIGURE 9)
4
Seal remaining
air grilles
To prevent pulling air from return air
system, additional exhaust/return
grilles should be sealed with tape.
(FIGURE 11)
Most rooms have only one supply,
a return grille, and one bathroom
exhaust. 100% of bathroom
discharge is exhausted outside,
so no extra consideration is required.
If there is more than one return grille,
which is uncommon, the additional
grille(s) should be sealed. A sheet
of plastic or cardboard can be used
provided that the edges are
completely sealed with tape.
FIGURE 9
A return grille
adapter.
STEP
Set up HEPA
machine and flex duct
Connect the flex duct to return grille
adapter and HEPA machine. (FIGURE 10)
5
Turn HEPA machine
on and adjust flow
Once the flex duct is connected to
the window template and the HEPA
machine, the machine should be
turned on.
Adjust the flow on the output until
the desired pressure differential of
negative 2.5 Pa (pressure in corridor
is greater than pressure in patient
room) is reached. Increasing the flow
will increase the pressure differential,
and decreasing the flow will decrease
the pressure differential.
The pressure differential should be
measured with a hand-held digital
pressure gauge. The pressure
should be monitored daily.
Additional Notes for
Discharging Air to
Return Air System
• You must be careful when
exhausting additional large volumes
of air through the return air system.
Generally, it is easy to differentiate
between a supply grille and return
grille. If you are not sure, you can
use a smoke stick to check
airflow direction.
3
STEP
1
STEP
STEP
Discharging
air to return
air system
• When no longer needed,
the HEPA filter and flex duct
should be wiped down with
a hospital-approved disinfectant.
FIGURE 10
A return grille adapter with flex
duct attached.
FIGURE 11
This return
duct must
be sealed to
prevent pulling
air from return
air system.
• HEPA filters can also be used
to enhance dilution ventilation.
Refer to Appendix E, “Using
a HEPA Filter for Dilution
Ventilation” on page 26 for
a discussion and example of
dilution ventilation. AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
37
20
16
13
TNPI
Temporary
Negative
Pressure
Isolation
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
3
2
1
10
Curtain TNPI
3
The TNPI methods 1. Discharging Air
Curtain TNPI
to the Outside, and 2. Discharging
Air to Return Air System are
preferred over 3. Curtain TNPI.
TNPI Installations
Must Observe
Building & Fire Codes
ADJACENT
SPACE
INFECTIOUS
DISEASE
ZONE
Curtain TNPI does not
provide negative pressure
for the entire room,
but induces airflow into
the enclosed space from
surrounding areas and
discharges HEPA filtered
air from the enclosure
to the surrounding space.
In this method, a HEPA filter is used
to provide a type of relative negative
pressure around a patient. (FIGURE 12)
• This method should be used for
non-ambulatory patients.
• The area around the bed can be
“sealed off” by attaching fire-rated
plastic sheeting to the curtain
track along with duct tape to attach
the plastic to the floor.
As stated earlier, Temporary Negative
Pressure
Isolation
(TNPI)
is
considered when airborne infection
isolation is needed and there is no
available or insufficient AIIRs. This
could happen when the number of
infectious patients exceeds the
number of available rooms.
FIGURE 12
Curtain TNPI
observe state building and fire codes,
and
PLASTIC
CURTAIN
HEAD WALL
All of the TNPI installations must
National
Fire
Protection
Association (NFPA) 101 (Life Safety
The area around the bed can be “sealed
off” by attaching fire-rated plastic sheeting.
Code). Being able to set up a TNPI
requires planning and early contact
with the authority that has jurisdiction
(your State Health Department) to
establish and verify compliance with
The intake must be within the plastic
enclosure and the output must be outside
the plastic enclosure.
applicable codes. In Minnesota,
you can contact:
Fernando Nacionales, P.E.
Engineering Services Section
at (651) 201-3712 or
[email protected]
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
37
20
16
13
TNPI
Temporary
Negative
Pressure
Isolation
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
3
2
1
11
3
1. Select a room
2. Attach fire-rated plastic to ceiling
3. Set up portable HEPA
filter machine
4. Attach remaining surfaces
with strong tape
5. Turn on portable HEPA filter
1
Select
a room
If the patient is already in a hospital
room, the room can be adapted for
the Curtain TNPI method.
Due to the proximity of the machine
to the patient, noise considerations
and patient comfort must be
addressed. (FIGURE 13)
As with the health care workers
caring for the patient, the health care
workers setting up Curtain TNPI
must also wear PPE.
STEP
H
Steps for
setting up
Curtain TNPI
STEP
Curtain TNPI
2
Attach fire-rated
plastic to ceiling
It is important to note that the plastic
must be able to fit nearly all the
way around the bed. (FIGURE 14)
Also, the height should be at least
six inches taller than the ceiling,
which allows for the plastic to be
taped to the floor. For accessibility
to the patient, the plastic should be
at least three feet from the bed
on all sides.
Most patient care rooms have curtain
tracks installed around the bed on the
ceiling. These can be adapted for use
with the plastic sheeting.
In addition, clips can be purchased
that will allow the plastic sheeting
to be attached to the ceiling grid
(assuming the room has a suspended
ceiling). (FIGURE 15)
FIGURE 13
Standard patient room.
FIGURE 15
Plastic can be attached to ceiling tile
grid or curtain track with clips.
FIGURE 14
Health care workers setting up
Curtain TNPI must wear PPE.
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
Surge
capacity
Portable
anteroom
37
20
16
13
TNPI
Temporary
Negative
Pressure
Isolation
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
3
2
1
12
The HEPA filter should be inserted
into the plastic sheeting. (FIGURE 16)
The plastic needs to be cut so that
the HEPA filter can be fit into the
space. The intake must be within the
plastic enclosure and the output must
be outside the plastic enclosure.
This will draw the air from the enclosure,
filter it, and exhaust it to the rest of the
room. This will provide an airflow that
will help to isolate the patient.
4
Attach remaining
surfaces with
strong tape
Once the HEPA filter is installed
and sealed with tape, the remaining
surfaces need to be sealed with tape.
(FIGURE 17)
The hanging plastic curtain
should be taped to the floor.
This will help to minimize the “leakage
area” of the enclosure and provide
stronger airflow and containment.
The curtain near the HEPA filter
must be taped to the head wall.
This will also help to minimize the
leakage area of the enclosure.
STEP
3
Set up portable
HEPA filter machine
STEP
STEP
Curtain TNPI
5
Turn on portable
HEPA filter
The last step is to turn on the HEPA
filter. If set up correctly, the sides of
the plastic will pull in (as if under
a vacuum). This will indicate that the
enclosure is under negative pressure.
Additional Notes for
Curtain TNPI
• This method is not the preferred
method for isolating a patient.
Health care workers will not be able
to move the patient to another area
in the building without completely
disassembling the Curtain TNPI
setup.
In addition, the set up process
can be time consuming and the
majority of the set up takes place
while the patient is within the
enclosure which could increase
transmission risk.
FIGURE 16
Portable HEPA filter machine installed in
plastic sheeting. The plastic should be taped
around the HEPA machine to provide a seal.
Andy G, take a picture
FIGURE 17
Plastic curtain taped to wall.
FIGURE 2
Portable HEPA filter machine installed in
plastic sheeting. The plastic should be taped
around the HEPA machine to provide a seal.
• When no longer needed,
the plastic curtain and HEPA
filter should be wiped down with
a hospital-approved disinfectant.
• HEPA filters can also be used
to enhance dilution ventilation.
Refer to Appendix E, “Using
a HEPA Filter for Dilution
Ventilation” on page 26 for
a discussion and example
of dilution ventilation. AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
Appendix
Surge
capacity
Surge
Portable
Capacity
anteroom
Portable
TNPI
Anteroom Negative
Temporary
Pressure Isolation
TNPI
Environmental
Temporary Negative
controls
Pressure Isolation
37
20
10
16
10
510
310
Portable anterooms can be
purchased with portable filters
to create a space at the entrance
to a standard room for TNPI.
Portable
anteroom
(FIGURE 18)
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Principles of airborne
airborne disease
infectious
infectious disease
management
management
10
2
Introduction
Introduction
1
Steps for using a
Portable Anteroom
1. Set up anteroom to
manufacturer’s recommendations
The advantage of a portable anteroom
is the relatively easy conversion
of regular rooms to AIIRs without
manipulation of the existing room
ventilation. Portable anterooms are
easy to set up and convenient to use
because any chosen room can be
converted quickly.
2. Attach the HEPA machine
A disadvantage of a portable anteroom
is the inability to move beds through
the door. Another disadvantage is that
they do not depressurize the room
unless the room door is open.
5. Both doors should never
be open at the same time
PORTABLE
ANTEROOM
3. Open the doors while
HEPA machine is on
4. Close the doors after the patient
and/or caregiver enters or leaves
the room
6. Clean and disinfect the portable
anteroom cover
tip
Before you purchase
BATHROOM
an anteroom, be sure
the anteroom and
HEPA filter are
compatible and that
HEPA
FIGURE 18
Portable Anteroom
the anteroom is
compatible with the
Attach the portable HEPA filter
to the appropriate sized portal
on the side of the portable
anteroom.
When turned on, the HEPA
machine should cause the
sides of the portable anteroom
to pull inward.
The anteroom should be placed
in front of the patient room door
and taped to the wall to secure
and cover the seams.
2
13
door frame. AIRBORNE INFECTIOUS DISEASE MANAGEMENT
Appendix
Surge
capacity
37
20
16
STEP
References
1
Portable
anteroom
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
5
3
2
1
Set up
anteroom
STEP
The anteroom should be set up
according to manufacturer’s
recommendations. The anteroom
should be placed in front of the
patient room door and taped to the
wall to secure and cover the seams.
2
Attach the
HEPA machine
3
Open
the doors
The door to the patient room and portable anteroom
are opened for patient transport while the HEPA
machine is on.
STEP
STEP
Attach the portable HEPA filter to the
appropriate sized portal on the side of
the portable anteroom. When turned
on, the HEPA machine should cause
the sides of the portable anteroom
to pull inward, indicating suction.
4
Close
the doors
After the patient and/or caregiver enters or leaves the room,
the room door and portable anteroom door should be closed.
14
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
Appendix
˚x
Surge
capacity
Surge
Portable
Capacity
anteroom
Portable
TNPI
Anteroom Negative
Temporary
Pressure Isolation
TNPI
Environmental
Temporary Negative
controls
Pressure Isolation
37
20
10
16
10
510
310
STEP
References
5
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Principles
Principles of
of airborne
airborne
infectious disease
infectious
disease
management
management
10
2
Introduction
Introduction
1
Both doors not open
at same time
STEP
If individual health care workers or
visitors enter the room, one door
should be closed before the other
is opened. Both doors should
never be open at the same time.
This prevents short circuiting of
air through an open doorway.
6
Clean portable
anteroom cover
When no longer needed,
the portable anteroom cover
should be cleaned and disinfected
with a hospital-approved disinfectant.
Additional Notes for
Portable Anterooms
• The door on the portable anteroom
and patient room should be closed
except for entry and egress. In addition,
only one door should be opened
at one time.
• There are no standards on the
magnitude of anteroom pressure.
Therefore, there is no suggestion on
airflow output or pressure
differential for portable anterooms.
It is only suggested that the
airflow is strong enough to pull
in the sides of the anteroom while
not so strong that it produces
excess noise. tip
Some permanently
engineered AIIRs
are designed with
anterooms. 2
15
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
20
Surge
capacity
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
13
5
3
2
1
Isolation surge capacity is the
Surge
capacity
•
ability to manage high volumes of
specialized patients.
Under extraordinary circumstances
where the quantity of engineered
airborne infection isolation rooms is
insufficient to meet surge demand for
patient isolation, hospitals can take
various measures to protect patients
and staff.13 This section describes
different methods of isolating large
numbers of patients, including:
Smoke Zones
Engineered System
16
The Goal
of Isolation Surge Capacity
Housing large numbers of patients
with airborne infectious diseases is
challenging. The goal of surge
capacity is to provide areas with
safeguards to protect you and other
patients from exposure to airborne
infectious agents. (FIGURE 19)
An infectious disease zone
(IDZ) is a space used to isolate
large numbers of patients.
Temporary Surge Area
Safe Areas
NON-IDZ
SAFE AREA
PATIENT CARE ROOMS
NURSES
STATION
SAFE
AREA
SUPPLY/UTILITY
IDZ
PATIENT CARE ROOMS
FIGURE 19
An infectious disease zone (IDZ) is a space used to isolate large numbers of patients.
A temporary constructed anteroom (safe area) for surge area is shown.
A safe area or anteroom (FIGURE 19)
should be created between the
IDZ and the rest of the hospital.
A portable HEPA filter is used to
pressurize the anteroom. This also
provides clean air in the anteroom.
Different models of HEPA filters have
different configurations of the air
intake. Regardless of the model,
the air intake should be drawing
air into the HEPA filter from the IDZ.
The filtered exhaust should be
discharged into the anteroom.
An airtight seal should be made
for all connections.
The anteroom should be large
enough to accommodate function
(for example, change clothes,
hang PPE, dispose of waste, etc.). AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
20
Surge
capacity
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
13
5
3
2
1
17
Smoke Zones
Smoke Zones
Hospitals have smoke zones that are designed to evacuate
the smoke if a fire occurs. The zone has smoke-stopped
barriers to prevent smoke movement between zones.
These airtight barriers would allow for potential isolation
of several hospital beds.
The patient rooms themselves may not be capable of being
depressurized by the existing ventilation system. The smoke
zone, however, is designed with fire rated doors that close
as well as entire zone exhaust capability. Zone exhaust
capability effectively isolates the wing, suite or space from
other areas of the health care facility. These zones are
routinely tested for fire management.
Smoke Zones as
Perimeter of IDZ
The smoke zones can be used as
the perimeter of an infectious disease
zone (IDZ). (FIGURE 20) This area can
also be negatively pressurized in
a method similar to TNPI #1 and #2.
That is, air can be discharged through
the window, into the return air system,
or discharged to an adjacent space
using a portable HEPA filter machine.
As always, when discharging to the
return air system, users must be
cautious with the volume of air being
discharged. CORRIDOR WALL
2 HOUR FIRE WALL
SMOKE BARRIER
FIGURE 20
Example of the hospital smoke zones that could be considered for potential isolation areas.
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
20
Surge
capacity
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
13
5
3
2
1
18
Engineered
System
Engineered System
Ducted to the Outside
If the suite or wing is exclusively
served by a single air handling unit,
the facility engineer may be able to
provide 100% exhaust from the area.
(FIGURE 21)
In this method, the infectious disease
zone (IDZ) is depressurized using
an exhaust diversion system taking
air from the IDZ and exhausting it to
the outside 25 feet away from public
access and air intakes.
Damper Manipulation and
Changes to the Ventilation
System
This method will require damper
manipulation and changes to the
ventilation system that must be
preformed by the facility’s
management. The exact steps
required will vary from hospital to
hospital. For example, some hospitals
will need to change the settings on
their Building Automation System
(BAS). Others may be designed with
pre-existing controls in the area that
allow for this scenario.
PPE should be worn inside the IDZ.
The doors to the IDZ must be kept
closed except when entering
or exiting.
FIGURE 21
Engineered System
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
20
Surge
capacity
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
13
5
3
2
1
19
Temporary
Surge Area
Temporary Surge Area
Discharging through a window
Using HEPA Filter
Some considerations to keep in mind when discharging
air through a window are:
This method can be used to
create a temporary surge area
using a HEPA filter.
• A window template can be created to exhaust a suite
of rooms through a flexible duct hookup from the HEPA
filter to the window.
The three options for creating a
temporary surge area using a HEPA
filter are listed below. (FIGURE 22)
They are similar to Types #1 and #2 of
TNPI for a patient room. Each of these
options should be used in conjunction
with a safe area (anteroom).
• Large exhaust fans placed in the window can be used
instead of HEPA filters if the air is exhausted 25 feet away
from public access and air intakes.
• More than one machine may be needed to establish
appropriate pressure differential.
Discharging through a window
Discharging to an adjacent space
Discharging to an adjacent space
Some considerations to keep in mind when discharging
air to an adjacent space are:
Discharging to a return air system
• The air must be HEPA filtered.
These three options may be used in
combination to achieve desired
pressure differential.
Discharging
to a return
air system
Some considerations
to keep in mind when
discharging air to
a return air system are:
• The air must be
HEPA filtered.
• The air in the IDZ can be discharged to an adjacent area
outside the IDZ, within the building.
BUILDING EXTERIOR
WINDOW
TEMPLATE
RETURN AIR
GRILLE
HEPA
MACHINE
• A return air grille
adapter is used to
connect a flex duct
(from the HEPA filter)
to the return air grille.
• As always, when
discharging to the return
air system, users must be
cautious with the volume
of air being discharged.
HEPA
MACHINE
HEPA
MACHINE
ADJACENT SPACE
FIGURE 22
Engineered System (shown with three different options).
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
Appendix
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
20
A: 2006 AIA Criteria
21
B: AIIR Maintenance Schedule
22
C: HVAC System Maintenance Schedule
23
D: Using a Pressure Gauge to Measure Relative Pressurization
Between Two Spaces
24
Using a Pressure Gauge
25
E: Using a HEPA Filter for Dilution Ventilation
26
F: Microorganisms Associated with Airborne Transmission
28
G: Using a Particle Counter to Assess Indoor Air Quality
and Filter Efficiency
29
Portable HEPA Filters
30
Testing Efficiency of Building Filtration System
31
Building Filtration System: Inside / Outside the Building
32
Building Filtration System: Before / After the Filter
33
H: Data Interpretation
34
I: Sample Log for Measuring Particle Counts
36
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
21
A
2006 AIA Criteria
APPENDIX A
2006 American Institute of Architects (AIA) Guidelines
for Design and Construction of Hospital and Health Care Facilities
The following AIIR criteria are specified
in the 2006 American Institute of
•
If alarms are installed, allowances shall be made to prevent nuisance alarms
Architects (AIA) Guidelines for Design
of monitoring devices. (AIA: Table 2.1-2)
and Construction of Hospital and
Health Care Facilities .9
Hospital AIIRs are required to meet
Differential pressure shall be a minimum of 0.01-in. w.g. (2.5 Pascals).
•
Provide ventilation to ensure ≥ 12 air changes/hour (ACH). (AIA: Table 2.1-2)
•
Rooms with reversible airflow provisions for the purpose of switching
criteria that was in place at the time
between protective environment and AIIR functions are not acceptable.
of construction for new construction
(AIA: Table 10.2.2.1 (3))
and major renovation. However,
upgrading AIIRs to meet the criteria
•
Airborne infection isolation room perimeter walls, ceilings, and floors, including
in the 2006 guidelines will better
penetrations, shall be sealed tightly so that air does not infiltrate the
prepare hospitals to isolate patients
environment from the outside or from other spaces. (AIA 3.2.2.4 (2a))
with airborne infectious diseases.
These criteria are consistent with
•
Airborne infection isolation room(s) shall have self-closing devices
on all room exit doors. (AIA: 3.2.2.4 (2b))
CDC Guidelines for Preventing
the Transmission of Mycobacterium
tuberculosis in Health-Care
•
Rooms shall have a permanently installed visual mechanism to constantly
monitor the pressure status of the room when occupied by patients
Settings, 2005.
with an airborne infectious disease. The mechanism shall continuously monitor
the direction of the airflow. (AIA: 3.2.2.4 (4))
•
All areas for inpatient care, treatment and diagnosis, and those areas providing
direct service or clean supplies such as sterile and clean processing, etc.,
shall have filter efficiency of 90% based on average dust spot efficiency
per American Society of Heating, Refrigeration and Air-conditioning Engineers
(ASHRAE) 52.1-1992. (AIA: Table 2.1-3) AIRBORNE INFECTIOUS
DISEASE
MANAGEMENT
TITLE OF THE
MANUAL
GOES HERE
Appendix
References
37
••
PREPARED BY
BY THE
THE MINNESOTA
MINNESOTA DEPARTMENT
DEPARTMENT OF
OF HEALTH
HEALTH
PREPARED
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
22
B
AIIR Maintenance Schedule
APPENDIX B
Sample Preventive Maintenance Schedule for AIIRs
For each item, place a “X” in the appropriate box.
“Y” indicates “Yes. Room is in compliance.” “N” indicates “No. Room does not comply.” “NA” indicates “Not Applicable to this room.”
DATE
ROOM
WINDOWS
DOORS
ALARMS
MECHANICAL
CLOSED/SEALED
SELF-CLOSING
OPERATIONAL
ELECTRONICS
FUNCTIONING
DEVICE ZEROS
WHEN DOOR OPENS
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
Y N NA
* Pressure should be checked daily when occupied, or monthly when unoccupied.
PRESSURE READING*
HAND-HELD
ELECTRONIC
COMMENTS
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
23
C
HVAC System Maintenance Schedule
APPENDIX C
Sample Preventive Maintenance Schedule for HVAC Systems
For each item, place a “X” in the appropriate box. “Y” indicates “Yes. Fan is in compliance.” “N” indicates “No. Fan does not comply.”
FAN ID/LOCATION:________________________________________________________________
INSPECTION DATE:________________________________________________________________
TASK
Inspect and clean exhaust grilles
to prevent blockage & airflow retardation
Visually inspect filter housing
for holes and proper filter seal
Clear outside air intake
of debris
Check return/exhaust dampers
move freely
Check filters
for proper installation/spacers
Check pressure
set points
Check steam/CW lines
have no leaks
Check return/exhaust
belts are tight
Check fan bearings/sheaves
are lubricated
Check humidifier controls
are in working order
Check fan lights
are in working order/PSI
Check fan cleanliness
YES
NO
Y
N
FOLLOW UP
DATE
DATE
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
DATE
COMMENTS
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
24
D
Using a Pressure Gauge to Measure
Relative Pressurization Between Two Spaces
APPENDIX D
Airflow management requires monitoring of the
ventilation system. Airborne infectious disease environments
require airflow control to avoid potential infection. Although the
airflow can be checked with a smoke stick for direction, it is
Steps for Using a Pressure
Gauge to Measure Relative
Pressurization Between
Two Spaces
important to know the magnitude of the flow. A pressure
gauge is a quantitative method to measure the relative
pressurization of two spaces.
1. Turn on the digital pressure
gauge (DPG).
2. Close the door of the area
to be pressure tested.
3. Connect flexible rubber tubing
to the DPG.
4. Place the tubing under the
closed door.
5. Note the airflow direction.
6. Record the value and date.
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
25
D
Using a Pressure Gauge
Step 1:
Turn on the Digital
Pressure Gauge
(DPG)
Step 3:
Connect flexible
rubber tubing to
the DPG
Step 4:
Place the flexible
rubber tubing
under the door
The first step is to
turn on the Digital
Pressure Gauge
(DPG). The display
should read zero
when both hose
connections are
reading the same air
pressure. Note the
sensitivity of the
machine (tapping one
of the connections will
cause a reading).
Next, connect flexible
rubber tubing to
the DPG.
To measure the
relative pressure
of a room from the
corridor, connect the
rubber tubing to the
input pressure
connection on the
DPG. The reference
connection is left
open to corridor air.
Step 2:
Close the door
of the area to be
pressure tested
Make sure the door
is closed.
There is a set of
connections on the
DPG. One connection
is for input pressure
and the other is for the
reference pressure.
The DPG (as shown
in the graphic) has two
sets of connections.
With the door
closed, place the
tube at least four
inches under
the door.
Step 5:
Note the airflow direction
If a negative sign (-) is displayed on the screen,
the room is under “negative pressure.” There will
be no sign displayed on the screen if the room is
positively pressurized. Record the sign of the
reading on a log.
Step 6:
Record the value and date
The final step in the process is to note the value
on the screen and record the value and date
in the log.
You should consult the pressure gauge user
manual to change measurement units (in. w.g.
or Pa) and to set the time interval over which
the pressure will be averaged. A common time
average interval is 1, 5, or 10 seconds.
Measurements should be recorded on a form
similar to the “AIIR Maintenance Schedule”
shown in Appendix B on page 22.
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
26
E
Using a HEPA Filter
for Dilution Ventilation
Portable HEPA filter machines are used to provide
temporary pressure management, dilution ventilation, and
APPENDIX E
Steps to Determine and
Achieve Necessary Airflow
For these two parameters, the HEPA filter acts as an
You are not required to follow these steps.
They are given to simply provide an
example of the required steps for
achieving a given air exchange rate.
enhancement. Because standard rooms are not designed to
1. Calculate room volume.
filtration (the three environmental controls required for airborne
infection isolation). The ventilation systems that serve standard
rooms are designed to provide dilution ventilation and filtration.
be negatively pressurized, the HEPA filter serves as the
primary control for pressure management. As a result, the
primary motivation for using a HEPA filter for TNPI is pressure
(and airflow direction) management. Secondary to pressure
management are dilution ventilation and filtration.
2. Calculate necessary HEPA
output airflow.
3. Measure airflow from HEPA
filter with flow hood.
4. Adjust intensity control
The recommended air exchange rate for AIIRs is 12 air
changes per hour (ACH). As designed, most rooms provide
some amount of air changes through mechanical ventilation.
This is most likely less than the amount recommended for
AIIRs. Although the primary purpose for HEPA filter usage is
negative pressure, the HEPA filter output required to achieve 12
ACH can be determined by following the steps presented here.
on HEPA filter.
5. Mark intensity level on machine.
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
C
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
27
E
Step 1: Calculate room volume
Example calculation given a room with the following dimensions:
Determine the room volume by measuring
the length, width, and height of the room.
Floor Area = 10 feet by 12 feet = 10’ x 12’ = 120 square feet
Ceiling Height = 8 feet
Volume = Floor Area x Ceiling Height = 120 sq. ft. x 8 ft. = 960 cu. ft.
The floor area may be calculated by counting
ceiling tiles (most are 2ft x 2ft or 2ft x 4ft)
or floor tiles (many are 1 ft 2 ).
Note: A typical room has an 8 ft ceiling.
Step 2: Calculate necessary HEPA output airflow
The recommended air change rate is 12 ACH.
Using the volume and the recommended
air change rate, calculate the necessary
HEPA output airflow using the formula
to the right:
ACH = Air changes per hour
Airflow = Mechanically exhausted airflow rate in cubic feet per minute (cfm)
3
Volume = Room air volume (length x width x height) in cubic feet (ft )
Airflow =
ACH x Volume
60
Step 3:
Measure airflow from HEPA
filter with flow hood
Step 4:
Adjust intensity control
on HEPA filter
Step 5:
Mark intensity level
on machine
As previously mentioned, the primary
purpose for using a HEPA filter is
pressure management. The
minimum airflow required to achieve a
pressure differential of negative 2.5 Pa
was found by varying the HEPA filter
intensity until the desired differential
pressure was reached. When
determining the airflow needed for
dilution ventilation, the HEPA filter will
already be operating at the minimum
intensity required to induce the desired
pressure differential.
Once the airflow output has been
determined, the intensity control on
the HEPA filter can be adjusted and
re-measured if the airflow is below
the desired airflow. If the airflow
is above that required for dilution
ventilation, do not change the intensity
of the HEPA filter.
Mark the intensity level on the HEPA
filter required to obtain 12 ACH.
It is important to note that this airflow
will only be constant for rooms of
the same volume. A flow hood is used to measure
airflow. Following the user manual for
the flow hood, measure the airflow
‘Q’ (in cfm) of the HEPA filter. In order
to provide 12 ACH in a room with
a volume of 960 cubic feet,
the required airflow is 192 cfm.
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
28
F
Microorganisms Associated
with Airborne Transmission*
APPENDIX F
CDC Guidelines for Environmental Infection Control in Health-Care Facilities 2003 5
FUNGUS
BACTERIA
VIRUS
Aspergillus spp.+
Mucorales (Rhizopus spp.)
Mycobacterium tuberculosis+
Measles (rubeola) virus
Varicella-zoster virus
Acremonium spp.
Fusarium spp.
Pseudoallescheria boydii
Scedosporium spp.
Sporothrix cyanescens¶
Acinetobacter spp.
Bacillus spp.¶
Brucella spp.**
Staphylococcus aureus
Group A Streptococcus
Smallpox virus (variola)§
Influenza viruses
Respiratory syncytial virus
Adenoviruses
Norwalk-like virus
Coxiella burnetii (Q fever)
airborne transmission in health
care settings not described
Coccidioides immitis
Cryptococcus spp.
Histoplasma capsulatum
Hantaviruses
Lassa virus
Marburg virus
Ebola virus
Crimean-Congo virus
Under investigation
Pneumocystis carinii
Numerous reports
in health-care facilities
Atypical
occasional reports
Airborne in nature
*
This list excludes microorganisms transmitted from aerosols derived from water.
+
Refer to the text for references for these disease agents.
§
Airborne transmission of smallpox is infrequent. Potential for airborne transmission increases with patients who are effective disseminators
present in facilities with low relative humidity in the air and faulty ventilation.
¶
Documentation of pseudoepidemic during construction.
**
Airborne transmission documented in the laboratory but not in patient care areas
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
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29
G
APPENDIX G
Using a Particle Counter to Assess
Indoor Air Quality and Filter Efficiency
Particle counters measure the quantity of small particulate
matter in the air.
Particle counters can also be used to determine the efficacy
of HEPA filters. This can be done by comparing the
particle count at the inlet to the HEPA filter with the
particle count at the output of the HEPA filter when the
HEPA filter is running.
The efficacy of building filtration systems can be
monitored using a particle counter. This can be done by
measuring the particle count before and after the final
filters of the fans that serve those rooms. Filtration can also
be monitored by measuring the particle count outside the
building and comparing it with the indoor particle count.
Condensation and optical particle counters are two particle
counters. Both types are acceptable to use when evaluating
indoor air quality and filter efficiency. Directions for usage and
examples of data interpretation are provided here.
Steps for Using
a Particle Counter to
Test the Efficiency of
Portable HEPA Filters
1.
Turn the particle counter on.
2.
Measure the particle count
at the air inlet of the HEPA filter.
3.
Measure the particle count
at the air output of the HEPA filter.
4.
Log both measurements and
note conditions at the time
of the reading.
tip
It is important to verify
Condensation particle counts are reported as particles
per cubic centimeter ranging from 0.02 to 1.0 µm in
diameter. Optical particle counts are reported as
particles per cubic foot ranging 0.5 µm in diameter.
Steps to using particle counters to determine efficiency of
different types of filters as well as examples of data
interpretation are found in Appendix H, “Data Interpretation”
on page 34.
filters are functioning
properly before use
and between usages.
This can be done with
a particle counter by
comparing HEPA filter
discharge air to
inlet air. AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
G
Portable HEPA Filters
Step 1:
Turn on the
particle
counter
The first step is
to turn on the
particle counter.
Step 2:
Measure the
particle count
at the air
inlet of the
HEPA filter
Step 3:
Measure the
particle count
air output
of the HEPA
filter
In order to test
the efficiency
of a portable
or permanently
installed (wall or
ceiling) HEPA filter,
measure the
particle count at
the air inlet of the
HEPA filter.
Measure the
particle count
at the air output
of the HEPA filter
output. This will
be used to
compare the air
inlet and air outlet.
Step 4:
Log both measurements
and note conditions at the
time of the reading
These measurements should be
recorded on a log similar to Appendix I,
“Sample Log for Measuring Particle
Counts” on page 36.
It is important to note that this isn't a
scientific or laboratory test of the HEPA
filter, but is useful in determining that the
HEPA filter is working properly. Also, the
test is only as accurate as the particle
counter. Users should look to see a
reduction of particles near the expected
reduction for the machine.
Examples for data interpretation when
using either optical or condensation
particle counters can be found in
Appendix H, “Data Interpretation”
on page 34. 30
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
31
G
Testing Efficiency of Building Filtration System
There are two options for using a
particle counter to test the efficiency of
Steps for Using a Particle Counter
to Test the Efficiency of a Building Filtration System
a building filtration system.
Checking the efficacy of filters is
OPTION A:
OPTION B:
Inside / Outside the Building
Before / After the Filter
important for a number of reasons. If the
filters on the main air handling system
1.
Turn the particle counter on.
are working properly, there should be
2.
Measure the particle count
outside the building.
3.
Measure the particle count inside
the building.
4.
Record both measurements
and note conditions at the time
of the reading.
a significant (~90%) reduction in
particles.
tip
Accuracy can be
increased by taking
multiple readings and
finding the average
particle count
at each testing
location – inside and
outside the building
or before and after
the filter If you have access to the air before
and after the final filter, the filter
efficiency can be checked here
as well.
Hospitals often have mechanical
spaces with fans and filter banks.
The particle count can be tested
before and after the final filter.
1.
Turn the particle counter on.
2.
Measure the particle count
before the final filter.
3.
Measure the particle count
after the final filter.
4.
Record both measurements
and note conditions at the time
of the reading.
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
32
G
Building Filtration System
OPTION A: INSIDE / OUTSIDE THE BUILDING
Step 1:
Turn on the
particle counter
The first step is to
turn on the
particle counter.
Step 2:
Measure the
particle count
outside the
building
Step 3:
Measure the
particle count
inside the
building
Measure the particle
count outside the
building.
Then measure the
particle count inside
the building (away
from main doors).
Accuracy can be
increased by taking
multiple readings
outdoors and indoors.
Accuracy can be
increased by taking
multiple readings
outdoors and indoors.
Step 4:
Record both measurements and note
conditions at the time of the reading
Since conditions can vary greatly from day
to day and especially from season to season, it is
important to record any abnormal readings and
take notes on conditions at the time of the reading.
For example, it would be important to note if it is
raining, if construction activities are going on inside
or outside, if a medical nebulizer or housekeeping
chemical is being used in the area, or if there are
any other activities present that could possibly
cause an abnormal reading.
Testing the building filtration system in this way
can lead to unexpected results. For example,
the outdoor particle count may be abnormally high
due to vehicles nearby. Also, the indoor particle
count may be abnormally high due to treatments
or cleaning as described above. While this method
is useful because it provides an overall view of the
building, a more accurate test can be done to test
the filters in particular.
Measurements should be recorded on a form
similar to Appendix I, “Sample Log for
Measuring Particle Counts” on page 36.
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
33
G
Building Filtration System
OPTION B: BEFORE / AFTER THE FILTER
Step 1:
Turn on the
particle counter
The first step
is to turn on the
particle counter.
Step 2:
Measure the
particle count
before the
final filter
Step 3:
Measure the
particle count
after the final
filter
Measure the particle
count before the
final filter. If you have
access to the air
before and after the
final filter, the filter
efficiency can be
checked.
Measure the particle
count after the
final filter. If you have
access to the air
before and after the
final filter, the filter
efficiency can be
checked.
Large hospitals have
mechanical spaces
with fans and filter
banks, and the
particle count can
be tested before and
after the final filter.
Hospitals with smaller
air-handling units can
also test their filters in
a similar manner.
Accuracy can
be increased by
taking a series of
measurements and
finding the average.
Step 4:
Record both measurements
and note conditions at the time
of the reading
The final step is to record both measurements
and note conditions at the time of the reading.
This option provides a method to test the filters
installed in the air-handling units. Although this
isn't a scientific test, it is a reliable way to assess
the performance of the filters.
A “Sample Log for Measuring Particle Counts”
is shown in Appendix I on page 36. AIRBORNE
AIRBORNE INFECTIOUS
INFECTIOUS DISEASE
DISEASE MANAGEMENT
MANAGEMENT
References
Appendix
37
•
•
PREPARED
PREPARED BY
BY THE
THE MINNESOTA
MINNESOTA DEPARTMENT
DEPARTMENT OF
OF HEALTH
HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
34
H
APPENDIX H
Data Interpretation
Filters are rated by industry standards
on their ability to remove particulate
matter from an airstream. Various rating
systems exist. Efficiency can be
measured by determining the
concentration of material upstream and
downstream of the filter. Particles
should be reduced by the percentage
efficiency of respective filtration
systems.
You should consult the user manual of
the particle counter for instructions on
how to use it. Refer to the user manual
for your particle counter to determine
whether it is a condensation particle
counter or an optical particle counter.
If you’re using a condensation particle
counter, the size range should be 0.02
to 1.0 µm. The optical particle counter
size range should be ≥ 0.5 µm. Some
particle counters have data logging
capabilities and directions for use vary
from model to model.
Note: Percent reduction of particles is
determined by subtracting the reading
after the filter from the reading before
the filter (outside air particles), dividing
by the reading before the filter (outside
air particles), and multiplying by 100.
Examples of data interpretation
for particle reduction in various filter efficiencies
TABLE A: CONDENSATION PC
PARTICLES REPORTED PER CC – RANGE 0.02 TO 1.0 µm
HOSPITAL FILTER RATING
OUTSIDE AIR PARTICLES
AFTER FILTER PC*
PERCENT REDUCTION
80
55000
11000
80%
90
55000
5500
90%
99.9
55000
17
99.97%
Condensation particle counts are reported as particles per cubic centimeter ranging from 0.02 to 1.0 µm.
*PC = particle counts
ASHRAE: American Society of Heating, Refrigeration and Air-conditioning Engineers
TABLE B: OPTICAL PARTICLE COUNTER
PARTICLES REPORTED PER CU.FT.- RANGE ≥ 0.5 µm
HOSPITAL FILTER RATING
OUTSIDE AIR PARTICLES
AFTER FILTER PC*
PERCENT REDUCTION
80
120000
24000
80%
90
120000
12000
90%
99.9
120000
36
99.97%
Optical particle counts are reported as particles per cubic foot ranging ≥ 0.5 µm.
*PC = particle counts
ASHRAE: American Society of Heating, Refrigeration and Air-conditioning Engineers
AIRBORNE
AIRBORNE INFECTIOUS
INFECTIOUS DISEASE
DISEASE MANAGEMENT
MANAGEMENT
References
Appendix
37
•
•
PREPARED
PREPARED BY
BY THE
THE MINNESOTA
MINNESOTA DEPARTMENT
DEPARTMENT OF
OF HEALTH
HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
35
H
The numbers in Table A and Table B are an approximate reduction. These numbers
will vary considerably from second to second as the environment is less controlled
due to variations in ambient particle generation both indoors and outdoors.
Because of this, the important reduction is in the order of magnitude reduction
and not necessarily in the integer.
For example, with a 90% efficient filter and an outside particle count of 100000,
it is expected that the particle count after the filter would be approximately 10000 (one
tenth of the outdoor concentration). Because of the variability in conditions,
an indoor particle of higher or lower than 10000 could be expected
(e.g. 15000 or 5000, respectively).
If you don’t see this type of reduction,
you should check the filters for
leakage, worn out gaskets, worn
out or broken clips, and proper
installation of the spacers. AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
Appendix
37
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
16
13
5
3
2
1
36
I
Sample Log for Measuring Particle Counts
APPENDIX I
This log can be used for testing portable HEPA filters as well as whole building air filters.
“PC INITIAL” and “PC FINAL” refer to the initial and final particle counts, respectively.
For testing a HEPA filter, PC INITIAL refers to the particle count at the air intake, and PC FINAL refers to the particle count at the air output of the HEPA filter.
When testing a whole building air filtration system, PC INITIAL can refer to either the particle count outside or before the filter, and PC FINAL can refer to the particle count inside or after the filter.
DATE
FAN
PC
PC
INITIAL
FINAL
HEPA:
Filter Intake
HEPA:
Output of filter
Building Air Filter:
Outside / Before Filter
Building Air Filter:
Inside / After Filter
EXPECTED
PERCENT
REDUCTION
ACTUAL
PERCENT
REDUCTION
“PC I” - “PC F”
=
“PC I”
x
100%
COMMENTS
AIRBORNE INFECTIOUS DISEASE MANAGEMENT
References
•
PREPARED BY THE MINNESOTA DEPARTMENT OF HEALTH
Appendix
Surge
capacity
Portable
anteroom
TNPI
Temporary Negative
Pressure Isolation
Environmental
controls
Principles of airborne
infectious disease
management
Introduction
20
16
13
5
3
2
1
References
1.
Fraser VJ, Johnson K, Primack J, Jones M, Medoff G, Dunagan WC
Evaluation of rooms with negative pressure ventilation used for respiratory isolation
in seven midwestern hospitals
Infect Control Hosp Epidemiol. Nov 1993; 14(11):623-628.
2.
Francis J. Curry
Isolation Rooms: Design, Assessment, and Upgrade
National Tuberculosis Center; 1999.
37
http://www.nationaltbcenter.edu/products/product_details.cfm?productID=WPT-04
3.
U.S. Department of Health and Human Services
Health Resources and Services Administration
Health Care Systems Bureau, National Bioterrorism Hospital Preparedness Program
Cooperative Agreement Continuation Guidance
Federal Fiscal Year 2003, 2004, 2005.
http://www.hrsa.gov/bioterrorism/
4.
Nicas M, Sprinson JE, Royce SE, Harrison RJ, Macher JM
Isolation rooms for tuberculosis control
Infect Control Hosp Epidemiol. Nov 1993; 14(11):619-622.
5.
CDC
Guidelines for Environmental Infection Control in Health-Care Facilities
Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).
MMWR Recomm Rep. Jun 6 2003; 52(RR-10):1-42.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
6.
Guidelines for the classification and design of isolation rooms in health care facilities
Victoria Department of Human Services; Standing Committee on Infection Control; 1999.
http://www.health.vic.gov.au/ideas/regulations/isolation.htm
7.
Isolation Rooms (Including Mechanically Ventilated Rooms):
Best Practice Standards for Capital Planning
Belfast; Department of Health, Social Services and Public Safety
Regional Advisory Committee on Communicable Disease Control; 2003.
http://www.dhsspsni.gov.uk/hssmd41-04.pdf
8.
ASHRAE
HVAC Design Manual for Hospitals and Clinics. 2003: 27-45, 47-60, 87-113, 129-141.
9.
AIA
Guidelines for the Construction of Hospitals and Health Care Facilities. 2006.
10. CDC
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Settings, 2005. MMWR. Dec 30 2005; 54(RR17).
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm
11. Streifel AJ
Design and maintenance of hospital ventilation systems and the prevention
of airborne nosocomial infections.
In: Mayhall CG, editor. Hospital epidemiology and infection control.
Philadelphia: Lippincott, Williams & Wilkins; 2004. p.1577-1589.
12. Rutala W, Jones S, Worthington J, Reist P, Weber D
Efficacy of portable filtration units in reducing aerosolized particles in the size range
of mycobacterium tuberculosis
Infect Control Hosp Epidemiol. July 1995; 16(7):391-398.
13. Mead K, Johnson D
An evaluation of portable high-efficiency particulate air filtration for expedient
patient isolation in epidemic and emergency response
Annals of Emergency Medicine. Dec 2004; 44(6):635-645.
Minnesota Department of Health
Office of Emergency Preparedness
Healthcare Systems Preparedness Program
Phone:
TTY:
651-201-5701
651-201-5797
IC# 141-1783
02/07
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