March 09, 2011 | | Comments 2
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Mac’s Safety Space: Temperature and humidity in the operating room

Q: My engineering manager is telling me that they only have to monitor temperature and humidity in the operating rooms on a quarterly basis. Can this be true? What’s the industry standard?

Steve MacArthur: Brace yourself: there is no specific requirement or standard that indicates the frequency with which one would monitor temperature and humidity in anesthetizing locations.

There are numerous guidelines that come into play for this: NFPA 99 Standard for Healthcare Facilities; the American Society of Heating, Refrigeration and Air-Conditioning Engineers (ASHRAE) Standard 170 – Ventilation of Health Care Facilities; and the CDC Guidelines for Environmental Infection Control, none of which speak to monitoring temperature and humidity, never mind indicating a frequency, though in the CDC Guidelines, they do indicate that activities should occur in accordance with engineer or manufacturer recommendations for the system. To be honest, the only place that even hints at a monitoring requirement is in the Conditions of Participation Interpretive Guidelines, and even there the only indication of a requirement is that surveyors are instructed to review the temperature and humidity logs during a CMS survey.

To be honest, with what I know about the folks conducting the environmental surveys, in some instances their background is extremely limited and tends to reside around basic fire safety concepts. That’s not to say that a clinical surveyor might not ask the question, but as there is no specific frequency requirement (unless there’s something in the state regulations–they should probably check to make sure), quarterly may be acceptable. I would say that in a small majority of hospitals with building automation systems, they pretty much keep a constant record of building conditions, including temp and humidity in the ORs. But I find equally as often that they have no real process in place to respond to out of range conditions, so you have them print out the data (and nobody really looks at this in real time. This is really an inconsequential pressure point until there is a requirement to have some sort of alarm signal, etc. to indicate when levels are out of compliance) and ask them “what happened on such and such date when the humidity was at 72%” and they have no response.

Most of the “management” of this issue revolves around the personal comfort of the occupants as much as anything, so if nobody squawks that it’s too hot or too damp, it is generally not noted.

All that said, I would advise them to document a risk assessment that provides sufficient evidence that a quarterly frequency of monitoring temperature and humidity is effectively managing the environment (Infection Control has a role to play here, and actually have ultimate veto power when it comes to decisions that could impact infection rates, etc.)

Entry Information

Filed Under: CDC/infection controlEnvironment of careEnvironmental protection

Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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  1. I work for a 12 hospital system. Our state surveyors (contracted by CMS to perform CoP surveys here) do review whether OR temp and humidity is monitored daily. Both the Health Services side and Life Safety side of our state health department are surveying to the requirements here in Colorado. If out of range, they want to see action taken. So real time monitoring is important. CMS CoPs are cited in two places- under Surgical Services (A0940) and Physical Environment (A0726). A0749 states “Temperature, humidity and airflow in the operating rooms must be maintained within acceptable standards to inhibit bacterial growth and prevent infection, and promote patient comfort. Excessive humidity in the operating room is conducive to bacterial growth and compromises the integrity of wrapped sterile instruments and supplies. Each operating room should have separate temperature control. Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the American Institute of Architects (AIA) should be incorporated into hospital policy.”

  2. Great article – just what I was lookin for

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