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

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

2 EQI Research Team 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

3 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.

4 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.

5 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

6 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.

7 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

8 EQI Process would be ASHRAE 170 Likely Quality Level of Evidence - Level 2 Building EQI database for meta-analysis

9 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

10 Mock ICU Patient Room 13-0 Corridor Mock ICU Patient Room (~230 SF) 66 Clear 1. Per current FGI Guidelines 2. Simulation Test Site for Environmental Quality Indicators during 3. Occupied, Unoccupied, and Procedure Modes SA 2x4 HEPA 54 Clear 96 Patient Bed Clear 18-0 EA Toilet Room 56 SF Return Grille RA

11 Procedure Ready ICU A Section A ` Continued success requires new thinking. Floor Plan L1

12 Procedure Ready ICU ` Continued success requires new thinking. Unit Floor Plan

13 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.

14 Mock ICU Patient Room MIRAN - Tracer Gas POO Slides DNA Trax POO SAS Yeast POO Hallway Monitors Instrumentation 1. MIRAN SapphlRe Portable Ambient Analyzers Tracer Gas MIRAN Tracer Gas Detector SAS Yeast 2. SAS Super 180 high volume air sampler, - Yeast SA 2x4 HEPA Slides DNA Trax 3. Microscope plates, eductor, tubes, etc - DNA Trax ICU Room EA Toilet Room 56 SF Return Grille RA

15 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

16 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.

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.

17 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

18 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

19 Ventilation Configuration & Equipment Supply Air Control Pressure Monitor Control by Offset Method 2x4 HEPA Patient Bed Exhaust Control Valve Toilet Room 56 SF Return Grille Return Air Control

20 ICU Ventilation Parameters System Unoccupied Mode Occupied Mode Procedure Mode Supply CFM Return CFM Toilet Exhaust CFM Air Changes Room Differential Pressure (in wc) Note: Rooms had MER 17 (HEPA) supply air filtering. VAV and Phoenix units selected for range of CFM. Room Temp ranged from 71.5 F to 72.2 F and 49.3% RH to 63.2% RH.

21 Methods-EQI The Script

22 Equipment Setup Inside Hallway

23 Equipment Setup Inside Room

24 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

25 Tracer Gas (SF6) Hallway Levels by Runs Significantly P < 0.05

26 Tracer Gas - Hallway to Room Comparison Significantly P < 0.05

27 Tracer Gas In Room Comparison Significantly P < 0.05

28 0 T-1 T-2 T-3 T-4 T-5 T-6 T-7 T-8 T-9 T-10 T-11 T-12 T-13 T-14 T-15 T-16 T-17 T-18 T-19 T-20 T-21 T-22 T-23 T-24 T-25 T-26 T-27 T-28 T-29 T-30 T-31 T-32 T-33 T-34 T-35 T-36 T-37 T-38 T-39 T-40 T-41 T-42 T-43 T-44 T-45 T-46 T-47 T-48 T-49 T-50 SF6 (ppm) Tracer Gas In Room Comparison Phoenix 1 & VAV 1 Physician Entered Room Code Blue Began Code Blue Ended Test Ended ACH 6 ACH 15 ACH 6 ACH Time (Min) Phoenix DNA-1 VAV DNA-1

29 SF6 (ppm) Tracer Gas In Room Comparison Phoenix 2 & VAV 2 Physician Entered Room Code Blue Began Code Blue Ended Test Ended ACH 6 ACH 15 ACH 6 ACH Time (Min) Phoenix YE-2 VAV YE-2

30 SF6 (ppm) Tracer Gas In Room Comparison Phoenix 3 & VAV 3 Physician Entered Room Code Blue Began Code Blue Ended Test Ended ACH 6 ACH 15 ACH 6 ACH Time (Min) Phoenix YE-3 VAV YE-3

31 Yeast Hallway to Room Significantly P < 0.05

32 Yeast In Room Comparison Significantly P < 0.05

33 SF6 (ppm) Yeast In Room Comparison Phoenix 2 & VAV Physician Entered Room 3 ACH Code Blue Began Code Blue Ended 6 ACH 15 ACH Test Ended 6 ACH T-4 T-8 T-12 T-16 T-20 T-24 T-28 T-32 T-36 T-40 T-42 Time (Min) Phoenix YE-2 VAV YE-2

34 SF6 (ppm) Yeast In Room Comparison Phoenix 3 & VAV Physician Entered Room 3 ACH Code Blue Began Code Blue Ended 6 ACH 15 ACH Test Ended 6 ACH T-4 T-8 T-12 T-16 T-20 T-24 T-28 T-32 T-36 T-40 T-42 Time (Min) Phoenix YE-3 VAV YE-3

35 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.

36 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

37 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.

38 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 6% 14% 9% Cooling/Subcooling 50% Humidification 21% Heating Fans

Setback 33% Setback 33% Case 3 Self Generated Thermal Climate Zone 4 or 5 Notes: 1.

39 Operating Cost Savings per ICU $ 841/yr. Setback 33% Case 1 City Thermal Climate Zone 4 or 5 $ 592/yr. Case 2 Campus Co-Gen Climate Zone 4 or 5 $ 440/yr. Setback 33% Setback 33% Case 3 Self Generated Thermal Climate Zone 4 or 5 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

40 Thank You! Questions? EQI Team Applying Research to help Improve Everyday Healthcare

Using Cleanroom Technology Improving Operating Room Contamination Control

Using Cleanroom Technology Improving Operating Room Contamination Control This article was published in ASHRAE Journal, February 2014. Copyright 2014 ASHRAE. Posted at www.ashrae.org. This article may not be copied and/or distributed electronically or in paper form without permission