ASHRAE 43 to Provide Clarity on Healthcare Ventilation Management

Any hospital facilities manager who has wondered how to respond to an unexpected ventilation excursion in their healthcare facility and if their response meets the expectations of their Infection Control group and regulators will soon have an answer. The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) is finalizing its release of Guideline 43, Operations Guideline for Ventilation of Health Care Facilities, providing much-needed clarity.

For decades, healthcare facility managers (FMs) have relied on design guidance set by ASHRAE 170 or the FGI Guidelines to guide the operation of healthcare ventilation systems. Yet ASHRAE 170 was never meant to be used as an operational guideline. It provides no insight as to how to manage short excursions from temperature, humidity, or relative pressure, nor is guidance set for how often to monitor for such excursions—among many other gaps left for FMs to fill.

Accreditation organizations, including The Joint Commission, have likewise relied on these design standards to guide operational performance. Surveyors have seen firsthand the challenge of compliance with ventilation design standards, as this is consistently among the top most challenging requirements for healthcare facilities to meet. Some of this hardship comes from the lack of clarity in healthcare standards around ongoing ventilation management.

Upon its publication, slated for early 2025, ASHRAE 43 is expected to deliver some of this much-needed clarity.

The Advantages of Adopting ASHRAE 43

The most recently available draft of ASHRAE 43 indicates that the guideline will provide clear instructions on how to operate and maintain ventilation systems in healthcare facilities and describes acceptable ranges for various parameters. It also sets an expectation that healthcare FMs create a written ventilation management plan that guides preventive maintenance, establishes monitoring frequency, and identifies documentation expectations.

This provides significant advantages for healthcare FMs and all building occupants, including:

1. Clarity in how to proactively address unexpected ventilation excursions. While existing guidelines may set clear design parameters for temperature, humidity, pressure, and other conditions and provide limited framework for the allowance of planned excursions for patient comfort, medical conditions, or surgeon request, FMs have lacked guidance on what to do when systems unexpectedly perform outside the acceptable range, especially for short-duration excursions. Having a ventilation management plan in place prevents facilities teams from scrambling for a response after an unexpected variation from design conditions. Instead, teams can immediately take action, based on predetermined criteria with multidisciplinary input, to reduce risk as needed.
2. Simplicity in ensuring facility compliance. Today, hospitals have the option of complying with the design standard that was relevant at the time they were built. As facilities grow, a different design standard edition may govern each addition, adding potentially conflicting advice. Under ASHRAE 43, hospitals are expected to establish, using clear documentation, the standard(s) that govern each portion of their facility. Documenting this decision-making in a written plan will simplify operations and help surveyors appropriately assess compliance.
3. Reduced risk of findings. As noted above, accreditation organizations have likewise relied on design standards to guide expectations around ventilation systems operations and excursions. And while many of the ventilation issues cited by The Joint Commission under EC.02.05.01, EP 15 and EP 16, are valid concerns, not all citations make sense in the context of day-to-day operation. For example, if a design standard sets a requirement for a room’s relative humidity to fall between 30 to 60%, does rising to 61% for an hour warrant a citation? If the facilities team responded to this excursion with appropriate action but did not document their specific response, should that prompt a warning? These are questions that both FMs and surveyors have had to address. Now, organizations have an opportunity to document their predetermined decision-making documentation for each individual event, which is potentially less burdensome.
4. Guidance on performing baseline inspection and maintenance activities. Although healthcare FMs will typically already have an established preventative maintenance program in place, ASHRAE 43 provides guidelines related to inspection and maintenance schedules and maintenance activities for various systems. This enables FMs to incorporate these guidelines into their current established programs based on their applicability, infrastructure capabilities, and the risk incurred in the spaces in which they operate.

FMs will no longer be held to “design standards” that leave gaps in the day-to-day operations of ventilation systems —if they have implemented ASHRAE 43 with an effective written ventilation management plan.

While ASHRAE 43 will be a guideline upon publication and therefore not required, healthcare facilities have one more essential reason to consider implementing the guideline now: a facility’s risk of a citation may increase in the event problems with ventilation are managed outside of the best practices outlined within this new guideline. In time, accrediting agencies may also adopt this guideline as a standard. Preparing a program today gives FMs control over the timeline for meeting ASHRAE 43 requirements, as well as protection against the inappropriate use of ASHRAE 170’s design requirements in regulatory/accreditation citations.

First Steps for a Ventilation Management Program

The good news is that, while the process of creating a ventilation management program may at a glance seem overwhelming, most healthcare FMs have a similar experience upon which to draw. Within the last several years, virtually every healthcare facility has had to develop a water management program. In fact, developing a ventilation management program is likely to follow a similar pattern.

In creating a ventilation management program, healthcare FMs can expect to perform the following steps:

Identify internal hospital stakeholders and form a committee

ASHRAE 43 sets an expectation that the FM holds responsibility for leading the ventilation management program. However, this program is best served by input from a diverse group of stakeholders. This should include infection control professionals, as well as representatives from critical spaces such as the OR.

Assess your spaces and systems

It will be necessary to conduct an inventory of your rooms by function, pressurization, level of risk, and frequency of pressure testing or other relevant monitoring. To make this process manageable, consider beginning with critical spaces before moving to noncritical areas.

Develop a plan

FMs will need to determine a schedule for measuring pressurization, humidity, air exchange rates, and other factors in different areas of risk. They will also need to establish the steps to take in the event measurements unexpectedly fall outside acceptable levels, based on both the length and severity of the excursion, as well as the requirements for if and when a planned excursion may be requested (for example in response to addressing issues related to patient comfort, medical conditions, or a surgeon’s request).

Establish policies

In addition to deciding how to document monitoring and ventilation issues, it will be important to educate staff on expectations for identifying and documenting responses to unexpected excursions or other incidents, as well as requesting a planned excursion.

FMs have time to bring ventilation in their healthcare facilities in line with ASHRAE 43. However, working with a partner who understands both the ventilation system and accreditation authority expectations for developing an effective ventilation management program can simplify this process. It can also ensure your healthcare facilities are better prepared to respond to issues that could potentially threaten patient health.

If you need expert help in developing an effective and ASHRAE 43-compliant ventilation management plan for your healthcare facilities, contact EH&E today.

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