OR temperature and humidity reading logs

We have heard that Joint Commission surveyors are requesting to review logs of temperature and humidity readings of all operating room suites and recovery room areas. Since the Environment of Care standards do not require the logging of such readings, it may be confusing why the surveyors are requesting to look at them. An examination of the Environment of Care standards will guide you in the event a surveyor asks to examine these logs.

 

EC.8.10, EP 7 states that “Ventilation provides for acceptable levels of temperature and humidity and eliminates odors.” The Joint Commission does not prescribe how your organization meets this requirement, but it would expect that you have an analysis or an assessment that shaped the decision as to the acceptable levels of temperature and humidity in your facility. Frequent monitoring of the temperature and humidity is certainly one method of meeting this requirement.  

 

This monitoring may be accomplished through the Building Automation System (BAS), which may automatically record readings on a periodic basis or have alarms programmed to actuate when the temperature or humidity exceeds the minimum or maximum set points.

 

Monitoring may also be accomplished through manually reading the thermostat and humidistat in each room on a periodic basis, such as prior to a procedure. A written process stating that a staff member will contact engineering when the temperature and humidity readings are beyond the minimum or maximum set points is adequate for a manual system.

 

So, what should the temperature and humidity levels be set at? The Joint Commission does not prescribe those set points, but would expect that you follow industry standards or state licensing requirements. Organizations need to define what parameters they will follow. In addition to your state requirements, check with the Association of periOperative Registered Nurses, the American Institute of Architects, and the U.S. Department of Health and Human Services. 

 

EC.7.10, EP 16 states that “The hospital designs, installs, and maintains ventilation equipment to provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies for ventilation systems serving areas specially designed to control airborne contaminants (such as biological agents, gases, fumes, and dust).” Again, The Joint Commission does not prescribe how you meet this requirement, but you should have an assessment or test results from an air balancing report calculating the appropriate air exchange rates. Nor does The Joint Commission state what the air exchange rates should be, but it expects you to follow your state licensing requirements or an industry standard, such as the American Society of Heating, Refrigeration, and Air-Conditioning Engineers, which has many recommendations for air exchange rates.

 

A Joint Commission surveyor may ask to see temperature and humidity logs to determine compliance with these two EC standards. Logs are not required, but they are an indication of compliance. You may be able to demonstrate compliance by other means, such as proof of following the state licensing requirements and adherence to industry standards. The frequency of any reading is solely up to you. CAUTION: Be careful what your policies state. If the policy says you will make temperature and humidity readings prior to each procedure, then The Joint Commission can and will hold you to that policy and logs will be much more important for proof of compliance with your policy.