February 10, 2015 | | Comments 0
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And to further complicate matters… (aka: Adding insult to injury)

On January 21, 2015, the American Society of Healthcare Engineering (ASHE), in coordination with the American Hospital Association (AHA) and the Association for Healthcare Resource & Materials Management (ASHRMM), issued a Joint Quality Advisory, offering new guidance on humidity levels in the OR. The short version is that the CMS waiver allowing hospitals to maintain humidity levels in operating rooms at a level down to 20% relative humidity (RH) is presenting some conflicts relative to the care and feeding of certain sterile supplies and surgical equipment that were designed to be in surgical environments with a humidity level of no less than 30% RH. Can I get an “Oh yeah!”?

One of the conversations I’ve bene having with greater frequency with clients relates to the storage of sterile supplies as a function of ASHRAE 170 Standard for Ventilation of Health Care Facilities, which has very clear design specifications for sterile storage (must have positive pressure, a minimum of two outdoor air exchanges, a minimum of four total air exchanges, a maximum of 60% RH (no identified minimum) and a temperature between 72 and 78 degrees F). The conversations generally grow out of thinking about all the areas in a hospital where sterile supplies can be found and whether all of those locations constitute “sterile storage” and thus would have to adhere to the design specifications listed in ASHRAE 170.

The upshot of those conversations is typically the need for a risk assessment of what supplies are being stored where (so to speak) and determining what locations and products need to be considered in the mix for “protection” in accordance with the ASHRAE standard. For all intents and purposes, the ASHE Joint Quality Advisory is recommending the same type of process (with the “net” being cast a little further afield to include equipment stored in these locations).

As we have learned over the past little while (and reinforced through TJC surveys pretty much everywhere), there is a concerted effort on the part of regulators to scrutinize the management of special environments with an ever-broadening list of locations to be included in those ranks. I believe that I have recommended using the table in ASHRAE 170 as a starting point for conducting a risk assessment of all the potentially applicable locations in each organization, so I’m just going to put it back out there—if you haven’t looked closely at how you are maintaining compliance with this stuff, I can only encourage you to do so. But please know that any lack of preparedness on this count can lead only to survey peril.

Be prepared!

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Filed Under: CMSEnvironment of careThe Joint Commission

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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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