analyzing icu patient room environmental quality through

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Analyzing ICU Patient Room Environmental Quality through Unoccupied, Normal, and Emergency Procedure Modes

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Page 1: Analyzing ICU Patient Room Environmental Quality through

Analyzing ICU Patient Room Environmental Quality through Unoccupied, Normal, and Emergency Procedure Modes

Page 2: Analyzing ICU Patient Room Environmental Quality through

Participants Dr. Jennifer Wagner, Ph.D. - Principal- Prism Environmental Dr. Stephanie Taylor – Stephanie H. Taylor MD, M Architecture, CIC, FRSPH(UK) Harvard Medical School InciteHealth Fellow Damon G. Greeley -PE, CEM, HFDP, CBCP, EDAC, CHFM -Founder & Managing Partner Onsite-LLC John Ostojic – Industrial Hygienist, Artec Environmental Monitoring Support Dr. Troy Markel – Pediatric surgeon/Associate Professor- Indiana University Health Dr. Tom Gormley, Ph.D - Associate Professor – FGI Guidelines Committee Member, Construction Management Middle Tennessee State University “Luigi”- K9

EQI Research Team

Page 3: Analyzing ICU Patient Room Environmental Quality through

Disclosure

This research was funded by Phoenix Controls. The

testing was administered by OnSite-LLC, an independent

healthcare spaces environmental quality testing and

research firm based in Indianapolis, IN. Both VAV and

Phoenix technical personnel were onsite and involved with

the configuration, programming, and execution of the

ventilation systems.

Page 4: Analyzing ICU Patient Room Environmental Quality through

Purpose

Intensive care unit functions change over time and facilities could benefit from multi-use type

spaces that can be minimally altered to meet future needs.

Intensive care unit rooms that support a number of configurations and have the necessary

ventilation infrastructure are necessary to support continuously adaptive clinical uses.

This research would be of interest to healthcare administrators, ICU departments, infection

prevention, and other clinical leaders who are concerned with their ICU space designs being

applicable for today and an uncertain tomorrow.

It will go into depth on how surgical procedure adaptability can be accommodated without certain

ventilation restrictions.

Page 5: Analyzing ICU Patient Room Environmental Quality through

Purpose

FACT: ‘Real’ procedures are performed in ICUs everyday

1. Besides emergencies or Code Blues what would be

different if an ICU had procedure capabilities?

2. “ICUs are the dirtiest areas in our hospitals”

- West Coast based multistate healthcare system

Chief Operating Officer

3. What might you find in a typical ICU corridor?

• Human – Staphylococcus and Micrococcus

• Environment - Bacillus, Aspergillus, and

Cladosporium

Page 6: Analyzing ICU Patient Room Environmental Quality through

Background

Intensive Care Units (ICUs) are sometimes challenged to provide surgical

procedure quality indoor air environments when the patient has an abrupt

decompensation of a clinical status, i.e. "crashes" or is not able to be transferred

to an available operating room.

An environmental quality research team tested a modern ICU room design, per

Facility Guidelines Institute, to determine if a procedure mode during a Code

Blue condition could provide an improved level of sterility.

Page 7: Analyzing ICU Patient Room Environmental Quality through

Why Hybrid Testing Environment

• Previous literature reviews or body of work was comprised of studies in clean or

empty rooms, staged in laboratories, or utilization of computation fluid dynamics

(computer modeling)

Dynamic Environment Testing or EQI Process

• In real everyday used ICUs with real bio load (turn around not terminally cleaned)

• Uses real doctors, nurses, and scrub techs

• Includes environmental engineers, mechanical engineers, and industrial hygiene

technicians trained in OR procedures, sterile techniques to both internally generate

particles and gather qualitative and quantitative data about them

Page 8: Analyzing ICU Patient Room Environmental Quality through

EQI Process would be ASHRAE 170 Likely Quality Level of Evidence - Level 2

Building EQI database for meta-analysis

Page 9: Analyzing ICU Patient Room Environmental Quality through

European Approach uses Air Changes Plus Particle and Microbiological Contamination which have Clean Room/ISO Standards NF –French, UNI-Italian, DIN –German and HTM -British

Page 10: Analyzing ICU Patient Room Environmental Quality through

2x4 HEPA

66” Clear

Patient Bed

EA

Corridor

Return Grille

RA

SA

Toilet Room 56 SF

36” Clear

54” Clear 96”

40”

18’-0”

13’-0”

Mock ICU Patient Room

Mock ICU Patient Room (~230 SF)

1. Per current FGI Guidelines

2. Simulation Test Site for

Environmental Quality Indicators

during

3. Occupied, Unoccupied, and

Procedure Modes

Page 11: Analyzing ICU Patient Room Environmental Quality through

`

Procedure Ready ICU

“Continued success requires new thinking.”

Section A

Floor Plan L1

A

Page 12: Analyzing ICU Patient Room Environmental Quality through

`

Procedure Ready ICU

Unit Floor Plan

“Continued success requires new thinking.”

Page 13: Analyzing ICU Patient Room Environmental Quality through

Research Methodology

The team's methodology for analyzing this surgical procedure mode adaptable

ICU consisted of developing mock clinical patient care procedure methods

applied to three airflow operating modes; 1) unoccupied, 2) normal, and 3)

emergency procedure. Particulate (tracer gas) and fungal contaminant

generation and the instrumentation to quantify the levels were arranged in the

ICU room and adjacent corridor. Prior to the testing, particulate and microbial

levels were measured in an actual ICU room and adjacent corridor in order to

establish mock contaminant levels that would simulate realistic conditions.

Page 14: Analyzing ICU Patient Room Environmental Quality through

2x4 HEPA

ICU Room

EA

Return Grille

RA

SA

Toilet Room 56 SF

Mock ICU Patient Room

Instrumentation

1. MIRAN SapphlRe Portable

Ambient Analyzers – Tracer

Gas

2. SAS Super 180 high volume

air sampler, - Yeast

3. Microscope plates, eductor,

tubes, etc… - DNA Trax

SAS – Yeast

Slides – DNA Trax POO SAS – Yeast POO

MIRAN – Tracer Gas Detector

MIRAN - Tracer Gas POO

Hallway

Monitors

Slides – DNA Trax

Page 15: Analyzing ICU Patient Room Environmental Quality through

Methods-EQI “What Was Measured”

1. MIRAN SapphlRe Portable Ambient Analyzers – Tracer Gas

2. SAS Super 180 high volume air sampler, - Yeast

3. Microscope slides, eductor, tubes, etc… - DNA Trax

Page 16: Analyzing ICU Patient Room Environmental Quality through

Research Methodology

Multiple and repeatable clinical patient care procedure tests were performed on

a mock patient (for necessary statistical significance purposes) utilizing two

commonly applied room airflow control technologies. During each particulate

(tracer gas) and fungal contaminant test, the room environment maintained

constant temperature, relative humidity, and pressure relationships during each

mode and for each room airflow control technology.

Page 17: Analyzing ICU Patient Room Environmental Quality through

Factors Relating to HAI During Procedure per NIH EQi Qualifies & Quantifies Epiphenomenon

1. Aerosol and droplet transmission dynamics – Tracer Gas

2. The nature of the dust levels - Yeast

3. The health and condition of individuals naso-pharyngeal mucosal linings

4. Population density – 4 staff

5. Ventilation rate

6. Air distribution pattern

7. Humidity and temperature

8. Number of susceptibles

9. Length of exposure

10. Number of infected people producing contaminated aerosols - Yeast

11. Infectious particle settling rate – DNA Trax

12. Lipid or non-lipid viral envelope or microorganism cell wall

12. Surrounding organic material

13. UV light or antiviral chemical exposure

14. Vitamin A & D levels

15. Microorganism resistance to antibiotic or antiviral therapy

16. Type and degree of invasive procedure

17. Spatial considerations

18. Contact with a carrier

19. Persistence of pathogens within hosts

20. Immuno-epidemiology

21. Transmission resistance and role of host genetic factors

Dr. Farhad Memarazadeh

Page 18: Analyzing ICU Patient Room Environmental Quality through

Hypothesis

1. There would be a statistically significant difference in

ICU room cleanliness compared to the hallway

(tested by three controlled contaminant releases in

the hallway) as a result of cycling between

unoccupied, occupied, and emergency procedure

modes.

2. Use a well established method of assessing

Environment Quality Indicators

A. Gormley et al 2017

Page 19: Analyzing ICU Patient Room Environmental Quality through

Ventilation Configuration & Equipment

2x4 HEPA Patient

Bed

Return Grille

Supply Air Control

Toilet Room 56 SF

Exhaust Control Valve

Return Air Control

Pressure Monitor Control by Offset

Method

Page 20: Analyzing ICU Patient Room Environmental Quality through

ICU Ventilation Parameters

System Unoccupied Mode

Occupied Mode

Procedure Mode

Supply CFM 75 186 468

Return CFM 0 111 111

Toilet Exhaust CFM 75 75 75

Air Changes 3 6 15

Room Differential Pressure (in wc)

0.00 0.00 +0.012

Note: Rooms had MER 17 (HEPA) supply air filtering. VAV and Phoenix units selected for range of 53-473 CFM. Room Temp ranged from 71.5 F to 72.2 F and 49.3% RH to 63.2% RH.

Page 21: Analyzing ICU Patient Room Environmental Quality through

Methods-EQI “The Script”

Page 22: Analyzing ICU Patient Room Environmental Quality through

Equipment Setup Inside Hallway

www.globalhealthsystemsinc.com

Page 23: Analyzing ICU Patient Room Environmental Quality through

Equipment Setup Inside Room

www.globalhealthsystemsinc.com

Page 24: Analyzing ICU Patient Room Environmental Quality through

Statistical Analysis Key

1. Hallway Levels by Run – compare values of tracer gas in hallway for

consistency of contamination levels between runs. Runs 1-2 were longer

time periods compared to Runs 3-6 due to sugar molecule settling time.

2. Hallway to Room Comparison – compares values in hallway (tracer gas and

yeast) to overall levels of contamination detected in the room by combining

air terminal (VAV) and Phoenix

3. In Room Comparison – compare levels of contamination detected in the

room by run 1-2 and 3-6 between air terminals (VAV) and Phoenix air valves

Page 25: Analyzing ICU Patient Room Environmental Quality through

Tracer Gas (SF6) – Hallway Levels by Runs

Significantly Different @ P < 0.05

Page 26: Analyzing ICU Patient Room Environmental Quality through

Tracer Gas - Hallway to Room Comparison

Significantly Different @ P < 0.05

Page 27: Analyzing ICU Patient Room Environmental Quality through

Tracer Gas – In Room Comparison

Significantly Different @ P < 0.05

Page 28: Analyzing ICU Patient Room Environmental Quality through

Tracer Gas – In Room Comparison Phoenix 1 & VAV 1

-5

0

5

10

15

20

25

30

0

T-1

T-2

T-3

T-4

T-5

T-6

T-7

T-8

T-9

T-1

0

T-1

1

T-1

2

T-1

3

T-1

4

T-1

5

T-1

6

T-1

7

T-1

8

T-1

9

T-2

0

T-2

1

T-2

2

T-2

3

T-2

4

T-2

5

T-2

6

T-2

7

T-2

8

T-2

9

T-3

0

T-3

1

T-3

2

T-3

3

T-3

4

T-3

5

T-3

6

T-3

7

T-3

8

T-3

9

T-4

0

T-4

1

T-4

2

T-4

3

T-4

4

T-4

5

T-4

6

T-4

7

T-4

8

T-4

9

T-5

0

SF

6 (

pp

m)

Time (Min)

Phoenix DNA-1 VAV DNA-1

3 ACH 6 ACH 15 ACH 6 ACH

Physician Entered

Room

Code Blue Began

Code Blue Ended

Test Ended

Page 29: Analyzing ICU Patient Room Environmental Quality through

Tracer Gas – In Room Comparison Phoenix 2 & VAV 2

-5

0

5

10

15

20

25

SF

6 (

pp

m)

Time (Min)

Phoenix YE-2 VAV YE-2

3 ACH 6 ACH 15 ACH 6 ACH

Physician Entered

Room

Code Blue Began

Code Blue Ended

Test Ended

Page 30: Analyzing ICU Patient Room Environmental Quality through

Tracer Gas – In Room Comparison Phoenix 3 & VAV 3

-5

0

5

10

15

20

25

SF

6 (

pp

m)

Time (Min)

Phoenix YE-3 VAV YE-3

3 ACH 6 ACH 15 ACH

Physician Entered

Room

Code Blue Began

Code Blue Ended

Test Ended

6 ACH

Page 31: Analyzing ICU Patient Room Environmental Quality through

Yeast – Hallway to Room

Significantly Different @ P < 0.05

Page 32: Analyzing ICU Patient Room Environmental Quality through

Yeast – In Room Comparison

Significantly Different @ P < 0.05

Page 33: Analyzing ICU Patient Room Environmental Quality through

Yeast – In Room Comparison Phoenix 2 & VAV 2

-50

0

50

100

150

200

250

0 T-4 T-8 T-12 T-16 T-20 T-24 T-28 T-32 T-36 T-40 T-42

SF

6 (

pp

m)

Time (Min)

Phoenix YE-2 VAV YE-2

3 ACH

6 ACH 15 ACH

6 ACH

Physician Entered

Room

Code Blue Began

Code Blue Ended

Test Ended

Page 34: Analyzing ICU Patient Room Environmental Quality through

Yeast – In Room Comparison Phoenix 3 & VAV 3

-50

0

50

100

150

200

250

0 T-4 T-8 T-12 T-16 T-20 T-24 T-28 T-32 T-36 T-40 T-42

SF

6 (

pp

m)

Time (Min)

Phoenix YE-3 VAV YE-3

3 ACH

6 ACH 15 ACH

6 ACH

Physician Entered

Room

Code Blue Began

Code Blue Ended

Test Ended

Page 35: Analyzing ICU Patient Room Environmental Quality through

Methods - “Statistics”

1. Data were assessed for normalcy by the Shapiro-Wilk and the KS normality

tests

2. Parametric data were compared with one way student’s t test or ANOVA with

post hoc multiple comparison’s test.

3. Nonparametric data were compared with the Kruskal Wallace test or Mann-

Whitney

4. P-values less than 0.05 were considered statistically significant.

Page 36: Analyzing ICU Patient Room Environmental Quality through

ICU Room-Conclusions

1. ICU Room was statistically cleaner than the hallway during all occupancy

modes for both tracer gas and yeast.

2. Phoenix air valves kept the room statistically cleaner than the air terminal

(VAV) for all tracer gas tests.

3. Higher saturation levels of yeast in the hallway did not yield a statistically

significant cleaner “in room” comparison by either Phoenix or VAV

Page 37: Analyzing ICU Patient Room Environmental Quality through

Cost Benefit Analysis

A cost benefit analysis was performed to provide information on the operational

benefits of setting up multiple ventilation operating modes based on occupancy

and room clinical acuities.

Page 38: Analyzing ICU Patient Room Environmental Quality through

Cost Factors & Energy for Upgraded ICU

• Phoenix or air terminal selected for min/max range

• Add 2 x 4 HEPA Filter

• Add pressure monitoring

• Add switch/button for Code Blue operation

• Energy Consumption Factors

• Steam - Humidification

• Cooling

• Heating

• Economizer

• Dehumidification/Sub Cooling

9%

14% 6%

21%

50% Cooling/Subcooling Heating

Humidification Fans

Page 39: Analyzing ICU Patient Room Environmental Quality through

Notes:

1. Formulas were validated by third party for custom utility incentive and national healthcare

engineering firm

2. Does not include water costs for humidification, based on 3 ACH reduction during unoccupied

times

Case 1

City Thermal

Climate Zone 4 or 5

841/yr. Setback 33%

$

Case 2

Campus Co-Gen

Climate Zone 4 or 5

$

Case 3

Self Generated Thermal

Climate Zone 4 or 5

$ 592/yr. 440/yr. Setback 33% Setback 33%

Operating Cost Savings per ICU

Page 40: Analyzing ICU Patient Room Environmental Quality through

Thank You! Questions?

EQI Team –

“Applying Research to help

Improve

Everyday Healthcare”