/policies/,/policies/administrative/,/policies/administrative/uwhc/,/policies/administrative/uwhc/department-specific/,/policies/administrative/uwhc/department-specific/facilities--engineering-services/,

/policies/administrative/uwhc/department-specific/facilities--engineering-services/ec020501-ep6.policy

201509251

page

100

UWHC,

Policies,Administrative,UWHC,Department Specific,Facilities & Engineering Services

Installing and Maintaining Appropriate Pressure Relationships (EC.02.05.01 EP6)

Installing and Maintaining Appropriate Pressure Relationships (EC.02.05.01 EP6) - Policies, Administrative, UWHC, Department Specific, Facilities & Engineering Services

EC.02.05.01 EP6

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE





Effective Date:
July 2015
X Administrative Manual
X Computer Room Manual

Policy #:
EC.02.05.01
EP6

Original
X Revision
Page 1
of 2
Title: Installing & Maintaining
Appropriate Pressure
Relationships


EC.02.05.01 EP6
I. Purpose:

To provide a procedure for installing and maintaining appropriate pressure
relationships in areas designed to control airborne contaminants in the University of
Wisconsin Hospital and Clinics (UWHC).

II. Policy:

All ventilation systems are installed and maintained in a manner that will ensure that the
appropriate pressure relationships, air exchange rates, and filter efficiencies for
ventilation systems that serve areas specially designed to control contaminants (such as
biological agents, gases, fumes, dust).

III. Procedure:

A. The Facilities & Engineering Services Department ensures that all specially
designed ventilation areas requiring pressure relationships, air exchange
rates, and filter efficiencies through UWHC are maintained per original design
criteria and code requirements.

B. Pressure relationships are checked daily in operating rooms. Pressure
relationships are checked daily in patient-occupied protective precaution and
isolation rooms that have been identified. This is documented by Facilities &
Engineering Services Maintenance Mechanics, and documentation is maintained
by the Business Operations Manager.

C. All operating procedure suites throughout the UWHC are tested for particulates and
air exchange rates annually. All filters associated with ventilation systems are on a
scheduled replacement program. All exhaust systems are maintained semi-
annually. All isolation and reverse isolation rooms are tested at least semi-annually,
and checked at least monthly when not in use for proper operation. These rooms
are tested daily while in use.

D. Construction sites are maintained with negative air machines in order to eliminate
the transmission of dust into adjoining patient care areas. These areas are tested per
ICRA standards for proper operation.


FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE





Effective Date:
July 2015
X Administrative Manual
X Computer Room Manual

Policy #:
EC.02.05.01
EP6

Original
X Revision
Page 2
of 2
Title: Installing & Maintaining
Appropriate Pressure
Relationships


EC.02.05.01 EP6
E. Biological Safety Cabinets (BSC) and Chemical Fume Hoods (CFH) are tested
annually and any filter changed as required. The copies of the certification
documentation are maintained by the Maintenance & Operations Manager.

F. The Facilities & Engineering Services Director and Infection Control Department are
jointly responsible for determining those areas within the scope of this plan that
require special air pressure and air filtering to protect patients and staff for airborne
illness. Areas evaluated for inclusion in this program are:

a. Operating Rooms
b. Special Procedure Rooms
c. Cath Labs
d. Laboratories
e. Pharmacies
f. Sterile Supply Rooms
g. Airborne Infections Procedure or Isolation Rooms (especially where
tuberculosis may be expected)

IV. Coordination: Continual Readiness Committee
Infection Control




Wayne Abbott
Director, Facilities & Engineering