Maintaining air, steam, water quality simply elemental

By air, steam or water, microbes and contaminants can spread throughout healthcare facilities, including those areas that play a key role in patient care and safety. This includes the Central Service/Sterile Processing & Distribution (CS/SPD) department, where instruments are reprocessed, and the operating room (OR) and other procedural areas where patient care is delivered.

Because it is often difficult – if not impossible - to monitor effectively air circulating in a room and the water and steam used for cleaning and sterilizing instruments with the naked eye, the quality of these elements can sometimes be overlooked. Poor air, steam or water quality in a healthcare environment can endanger staff members and patients, and damage infrastructure, equipment and instruments.

Manufacturers of systems for air, steam and water quality management, mitigation and treatment in healthcare environments offer their insights into the challenges faced in this area, the impact of poor quality, and best practices for measuring and monitoring these critical elements.

Quality in the air

Air quality is quickly becoming the next frontier in infection prevention, explains Jim Dacek, Senior Product Manager, Surgical Solutions, STERIS.

“In recent years, healthcare has addressed room surfaces, hand hygiene, gowning, etc., in the OR, but there hasn’t been much emphasis placed on air as a primary source of contamination.  Hospital staff members need to be aware of potential risks associated with air quality that is out of spec (temperature, humidity, particle counts, differential pressure, etc.) per American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 170-2017, Ventilation of Health Care Facilities.”

In the OR and other procedural areas, James Marsden, Ph.D., Executive Director of Science and Technology, RGF Environmental, notes how air-borne or particle-borne pathogens including bacteria, virus and mold, can result in nosocomial infections and reinfection rates. He points to a recent case where a hospital’s failed efforts to contain Aspergillus mold led to a one-month-old baby’s heart infection following open heart surgery, and the family’s subsequent lawsuit.¹

“Poor air quality presents considerable risk to patients and staff through nosocomial infections,” said Marsden. “Airborne viruses like SARS-CoV-2 and influenza can cause patient and staff issues, as can air and surface born bacteria like MRSA, strep, C-diff, as well as mold and yeast issues in HVAC and air-conditioned spaces.”

Karen Hoffmann, RN, MS, CIC, FAPIC, FSHEA, an infection preventionist consultant for the Vidashield UV24 from Nuvo Surgical, echoes the risks.

“Contaminated air in CS/SPD has been a factor in surgical site infection outbreaks primarily involving mold and fungi (e.g., Curvularia),” said Hoffmann.

“CS/SPD staff, who must work in close contact with disinfectants and sterilant products, can also suffer from breathing respiratory irritants for prolonged periods.” 

Specific to the CS/SPD, Oyvind Birkenes, CEO of Airthings, points to how harmful contaminants, such as airborne pollutants, particulate matter, bacteria and more, can undermine sterilization efforts if they are not removed from the air in the department.

“There’s a reason we refer to air quality contaminants as ‘the invisible enemy’ – cracks in the building’s foundation, outdated or poorly functioning HVAC systems, and windows that are not properly sealed (or conversely, left open for too long) can all carry air pollutants into an environment and make achieving sterilization difficult,” Birkenes explained.

“The goal of a hospital CS/SPD is to provide the right items to the user at the right time and under the right conditions,” Hoffmann added. “Providing a sterile item in the right condition to the end user’s area requires not only good work practices, but also good environmental conditions. The challenge for CS/SPD is to ensure that environmental monitoring systems are used routinely (according to the established standards) for proper quality assurance to ensure good environmental conditions.”

As Birkenes indicates, the impacts of poor air quality can also have a major impact on health and well-being of CS/SPD staff members. He references the risks of “Sick Building Syndrome,” which the Environmental Protection Agency (EPA) defines as:

“A set of symptoms that affect some number of building occupants during the time they spend in the building and diminish or go away during periods when they leave the building. Cannot be traced to specific pollutants or sources within the building.”²

“Poor air quality, caused by a broad range of factors like CO2, airborne pollutants, particulate matter and more, can lead to a number of detrimental outcomes ranging from triggering asthma and allergies all the way to radon-induced lung cancer and the transmission of airborne viruses,” said Birkenes. “Mold or mildew spores can also irritate the respiratory system.”

Birkenes says another contributing factor to poor air quality in the hospital environment is the heavy use of chemical cleaners, coupled with “notoriously dry air” that increases the risk for chemical exposure and virus transmission due to lower-than-recommended humidity levels.

“Bottom line, if you don’t know what’s lurking in your air, you’re likely making it harder to achieve a sterilized environment,” Birkenes added.

Monitoring and measuring air quality

With an estimated 1 in 25 hospital patients suffering at least one healthcare-associated infection (HAI) each year, according to the Centers for Disease Control and Prevention (CDC),³ hospitals and other healthcare facilities have good reason to identify and address the factors increasing infection risk, including the quality of air in the OR.

“Air quality can have a big impact on preventing HAIs, so it is critical that patients are provided the best possible indoor air quality (IAQ), especially in the OR,” said Dan Diehl, CEO of Aircuity. “Key parameters to healthy air in the OR include Total Volatile Organic Compounds (TVOC), particles and dewpoint.”

Diehl explains that if dewpoint/humidity levels get too high, it can affect equipment performance by damaging circuit boards or other components which were not designed for those levels of humidity exposure. This in turn directly impacts the level of patient care a hospital provides.

To ensure CS/SPD departments have the right air quality ventilation measures and monitoring in place, NUVO Surgical’s Hoffmann suggests hospitals following indoor air quality standards, including ASHRAE guidelines 62.1 and 170 and ISO 14644. These specify that the clean air must be particle free, and the air-filter pore size should range between 0.05 µm and a maximum of ≤10 µm. She adds that tests for differential air pressure (minimum, 2.5 Pascals), air velocity (minimum, 2,500 cfm), air exchange rate (≥10 per hour) and air microbiology (measuring bacterial and fungal colony counts) are required to minimize air impurities in the sterile zone.

“The entire CS/SPD decontamination processes (from cleaning to sterilization) can only be safe if the surrounding environment is clean and controlled,” she said. “Air should always move from the sterile zone to the dirty zone to avoid cross contamination. Purified and moisture-free air is essential for preparing sterile materials and preserving them for a long time. An environmental quality monitoring system can reduce unnecessary sterilization cost and increase the shelf life of medical devices.”

Marsden recommends hospitals employ negative or positive pressure monitoring in isolation rooms, per CDC guidance; ATP (adenosine triphosphate) testing to show evidence of microbial activity for verification of cleanliness for critical equipment and areas; HVAC equipment monitoring operational and maintenance status; and general monitoring of indoor air quality (e.g., temp, humidity, particle counts and evidence of microbial activity).   

Birkenes says healthcare facilities can leverage technology solutions for continuous monitoring of CO2, radon, PM 2.5 and 1, airborne chemicals, virus risk, mold risk, and many more factors that can lead to contamination.

“By monitoring for these factors constantly, CS/SPD departments can achieve an informed and data-rich knowledge base of what needs to be addressed specifically and where the issue may be stemming from,” Birkenes said. “Once that’s determined, they can take more aggressive action, such as using air sterilization techniques like Ultraviolet Germicidal Irradiation (UVGI) – but before that can happen, it all starts with diagnosing the problem.”