March 02, 2015 | | Comments 3
Print This Post
Email This Post

I guess it really doesn’t matter where you set your humidity…

Because someone else will come along and move it—and it’s always been the same…

Returning to the Adding Insult to Injury desk here at the Safety Space plaza (with apologies to the Magliozzi clan), last week we learned of a delightful new development in the ongoing saga of the management of environmental conditions in surgery. You can find the opening salvo in this little skirmish here. To recap, back in January, AHA/ASHE/AHRMM issued a Joint Quality Advisory indicating that there may be supplies and equipment that are not/were not manufactured to tolerate the lower humidity levels (down to 20% relative humidity) that could be in place based on the Categorical Waiver issued back in 2013 (details here). In the Quality Advisory, there was a recommendation for a risk assessment, etc., to ensure that any risks associated with equipment/supplies and the lower humidity levels are being appropriately managed.

But apparently, that was not enough tumult to introduce into the mix (it almost makes me long for those halcyon first days of the relocatable power tap dictum). To wit, CMS (in its way beyond infinite wisdom) has weighed in on the topic of supplies and equipment that may not tolerate the lower temperature and humidity levels allowed by the categorical waiver. The sum and substance of the CMS position echoes the risk assessment process outlined by AHA/ASHE/AHRMM, but does it one step further by indicating that until the assessment has been completed and you know all your “stuff” can appropriately tolerate the lower humidity levels, you have to go back to the pre-waiver humidity levels. By the way, that could mean either the 30% low point indicated by ASHRAE or the 35% low point indicated by NFPA 99-1999. You can find links to the memorandum issued by CMS here.  By the way, this memorandum is also notable for the appearance of a kicky new term—IFU (instructions for use)—to add to the pantheon of acronymic stardom. Welcome IFU!

Now, I think we can all agree that looking at all the supplies and equipment being stored in these sensitive areas is going to be a fairly labor-intensive pursuit (Can you say pain in the gluteus maximus? I knew you could!) and it makes me wonder if there’s a way to push back at our vendors to help in at least reducing the number and type of materials we would need to evaluate. The Joint Quality Advisory makes note of some examples of materials that could be in the mix—EKG electrodes are noted—but I can’t help but hope that someone, somewhere is starting to parse this into a more manageable pursuit. I fully recognize that this is probably something of which everyone should already be aware; the CMS memo is rather pointed in mentioning just that: “The CMS expects hospitals, CAHs, and ASCs to follow the current IFUs for supplies and equipment used in their ORs. Failure to adhere to the IFUs must be cited, even if the facility has opted to use the categorical waiver of the [Life Safety Code] RH requirements.”

Sometimes doing the right thing ain’t so easy…

(P.S. If you’re interested in learning more about this topic, Jorge Sosa and I will host a webcast, “Surgical Environment Compliance: Meet Joint Commission and CMS Requirements,” on Friday, May 8 at 1 p.m. Eastern. Find out more and register online here.)


Entry Information

Filed Under: CMSEnvironment of careLife Safety Code


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

RSSComments: 3  |  Post a Comment  |  Trackback URL

  1. Great article, Mac. Thank you.

    I recall that a certain patient monitor manufacturer snuck some warranty language past us that allows them to refuse claims if room humidity was below 30% at the time of device failure. Static discharges were frying their circuit boards, and they know the risk to be far less at higher relative humidity levels.

  2. When is common sense going to prevail? The 30% RH low point recommendation of ASHRAE or the 35% RH low point recommendation by NFPA99-1999 don’t take into account how much work will be involved in determining what/which supplies and equipment will have to be surveyed to compile a complete list of those items that meet either threshold. Why haven’t the manufacturers of this products stepped up and sent their RH data to some of the regulatory or standards organizations, to be compiled and subsequently shared with all.
    Instead, each hospital, ASC, or CAH will have to compile their own list of OR products and equipment. The combined man hour costs for this work will be staggering. And what will hospital, ASCs and CAHs get for their respective efforts; probably little to nothing. Can anyone predict the return on this investment of time/labor? Sure, someone will respond that this will add some greater demension of patient safety. But will it really? Is there some science or evidence, out there, that we can cite to force expensive modifications to our already expensive air handling/conditioning systems?
    OK, I’m done. I’ll just wait for the common sense bus to come by, then I’ll hop on.

  3. We recently purchased a smaller rural hospital, the Joint Commission cited them for EC. 02.05.02 EP 15. They observed in the OR that the organization had adopted the CMS categorical waiver for humidity levels below 30% but had not conducted an assessment for equipment and supplies to ensure safety and efficacy. This hospital has 4 ORs and 4 ambulatory surgery ORs. Temperature and humidity is measured daily in the ORs and sterile processing areas. There were occasional times where the humidity dipped to 20-30%.

    We created a risk assessment for the major pieces of equipment used in the ORs and major supplies used and stored. The Joint Commission looked at the Risk Assessment and indicated that there was not enough sterile supplies on the list. I have reached out to the Corporate APIC Group asking about templates, if the group had heard of this citation, but had very little response. I decided to email specific Infection Preventionists (IP) in states that I thought might have humidity issues (New Mexico, Arizona, Utah, etc.,). Banner Health (AZ) replied with an elaborate Risk Assessment. A hospital in Ohio said that they tried to conduct a risk assessment but it was too extensive and opted to try to maintain humidity levels at above 30%.

    I am worried about the larger implication for the other hospitals. While the ASCs are not included with the waiver, they still must comply with the assessment for the supplies and equipment. My question is really how many hospitals around the country have been cited for this issue? Does anyone have a template to use for the risk assessment? How long can the supplies and equipment be in the humidity range of 20-30% without having to be discarded? Additionally, there is no new information out there since the Joint Interim Guidance: HVAC in the Operating Room and Sterile Processing Department dated 9/2015.

RSSPost a Comment  |  Trackback URL