Erin Clark, RN, MSN, HTS, Inc. Project Coordinator helps prepare clinical staff for a CDPH
Erin Clark, RN, MSN, HTS, Inc. Project Coordinator helps prepare clinical staff for a CDPH

TJC, CMS and state agencies have raised the bar when it comes to staff awareness of proper pressure relationships for infection prevention.  These regulatory agencies have begun to focus on maintaining proper pressure relationships based upon room function and positive or negative pressure requirements with respect to adjacent rooms or spaces.  The emphasis is on ensuring negative pressure environments are genuinely negative and positive pressure environments are genuinely positive and that the # of air exchanges are appropriate, for example:

  • ORs, endoscopy procedure rooms, sterile storage areas are examples of positive pressure environments;
  • Decontamination areas, bronchoscopy rooms, Soiled Utility Rooms are examples of negative pressure environments.

Regulatory surveyors will request documentation of the proper pressure relationships and the appropriate air exchanges rates for these spaces.

If issues are discovered at the time of a TJC survey, this can result in a Condition Level Deficiency reported to CMS and will then require Evidence of Standards Compliance and a re-survey within 45 days.  (refer to TJC Standard EC.02.05.01)

The Facilities Engineering staff need to partner with clinical staff so all understand the function of the room and the appropriate pressure relationships.  Staff must understand the importance of keeping doors closed to ensure that appropriate pressure relationships are maintained between spaces.

We strongly recommend that organizations prepare an inventory of all spaces that are required to maintain a record of proper pressure relationships and appropriate air exchange rates.

– Michele Rubin, Ph.D., MHSM, Project Specialist, Transition Planning, HTS, Inc., MRubin@consultHTS.com