Molds, toxic gases, dust from construction—all of these contribute to a “sick” hospital. Experts share ways in which health care facilities can clean up their acts.

f03a.jpg (14978 bytes)At many hospitals these days, it is hard to tell which is in worse condition—the patients or the air they breathe.

Sick hospitals—so called because they experience frequent bouts of unhealthful indoor air quality—are found in all parts of the country and in buildings both old and brand-spanking-new. Notably, their air quality problems are not limited to patient rooms and clinical areas. Hospital administrative offices are equally prone to falling under the pall of noisome indoor atmospherics.

Poor air quality is cause for concern because it impacts the health of occupants, which tends to drive up a hospital’s costs, says L. Christine Oliver, MD, MPH, owner of Occupational Health Initiatives Inc, a consulting firm in Brookline, Mass.

“Patients exposed to airborne particulates—toxic or otherwise—may take longer to recover or improve, thus adding to length of stay," she says. “Employees may become less productive when forced to breathe unhealthful air over prolonged periods, possibly requiring the hiring of additional personnel. In addition, if someone on staff becomes injured and can legally establish a direct or indirect link between the accident and an unhealthful work environment, the hospital may be held liable.”

Sources of Problems
Episodes of poor indoor air quality occur for many reasons, ranging from mechanical failures of physical-plant systems to cleaning crews mopping floors with unduly harsh chemical agents. One of the most common sources of air-quality woes turns out to be mold.

“There are opportunities aplenty for molds to spawn and multiply when water—sometimes behind walls, sometimes in ventilation ducts—condenses or infiltrates and mixes with organic materials to form a kind of biological soup," says clinical engineer Richard Congdon, PE, CCE, an independent consultant in Providence, RI, who works with hospitals on improving their environmental health.

Air quality problems also can take wing as a result of construction or renovation work around the hospital.

“Construction materials can be a source of chemicals and odors," Congdon says. “The construction process tends to generate lots of dust. The dust is problematic in and of itself if you breathe it. But its worst effect can be the way it overtaxes a hospital’s HVAC [heating, ventilation and air conditioning] systems. When that happens, the systems may not be able to turn over the interior air as frequently or as thoroughly [as it should]. That can allow interior pollutants and microorganisms to run rampant.

“Dust isn’t the only thing that can disrupt the normal operation of HVAC systems. During renovation, for instance, you often have HVAC control lines temporarily cut, ducts opened, and corridors blocked off in a manner that prevents proper ventilation from occurring in one or more parts of the building."

Sometimes, air quality problems—that is, the perception that there is a problem—have more to do with behavioral responses than with anything else.

“There are instances where your HVACs are working well and the air quality actually seems fine—except, that is, to employees suffering from workplace-imposed stresses," Congdon says. “Stress can affect the way people react to the environment, making them feel the air is of poor quality when it might not actually be."

In a similar vein, complaints about air quality may be voiced by people with environmental sensitivities, Congdon adds.

Move Fast to Investigate
Congdon says that when word is received that staff, visitors, or patients have encountered befouled indoor air, the facility manager should respond promptly with an investigation, for rarely do these air-quality problems go away by themselves.

“There needs to be in place a standardized investigation process whereby you can quickly rule out easy-to-remedy problems like the HVAC having a broken fan belt or a filter clogged with construction dust," he says.

However, Congdon advises, problems that defy ready explanation should be more fully investigated using a team approach.

“It’s rare that any single person will possess the talents and experience needed to uncover and then address indoor air quality issues," he says. “A viable team is one that will include not only personnel from facility management but also representatives of the employee health and human resources departments."

The first order of business for the investigative team is to focus on possible suspected causes. A customary way to approach that is to interview those affected by the problem for clues as to what is going wrong.

“It can be helpful, too, to develop a questionnaire relevant to the exposures and/or symptoms people are experiencing," suggests Oliver. “This mini-epidemiologic survey will help you understand the nature and prevalence of symptoms and to detect whether there is clustering by demographic variables, by job title, or by area of the building in which the employees are working."

In conjunction with interviews and surveys, monitoring of the air quality in identified trouble spots should be initiated, experts recommend.

“Most HVAC systems today, depending upon the design installation, can accommodate the installation of sensors in the ‘fresh air’ intakes to measure local outdoor air quality conditions," says Congdon. “You’ll want to weigh what’s occurring outdoors because certain weather phenomena or nearby traffic pollution can be responsible for generating ozone and carbon monoxide that can infiltrate the building."

A relatively inexpensive monitor that should be deployed is one capable of measuring carbon dioxide levels, Congdon recommends.

“For general internal monitoring purposes, CO2 monitors are indispensable," he says. “HVAC systems are supposed to remove CO2 exhaled by a building’s occupants. But sometimes [the systems] don’t operate at peak efficiency, so you have a buildup of indoor CO2. Outdoor fresh air has CO2 levels around 330 parts per million. Indoors, if the parts-per-million count rises to about 800, you’re starting to get into a problem area, although OSHA [Occupational Safety and Health Administration], which is one of several government and industry entities that have defined what is and isn’t acceptable indoor air quality, allows for an appreciably higher concentration of CO2 before requiring corrective action."

Other types of monitoring devices are available to detect harmful airborne chemicals, noxious vapors, unhealthful materials, and dangerous biologicals. These are pricey, but should be considered essential equipment if you must monitor areas in or near hazardous environments, such as laboratories or chemical storage rooms, says Congdon.

While monitoring can be invaluable, a frequently more insightful investigative technique may involve nothing more complicated than a review of the maintenance records for the HVAC system and for various other pieces of equipment (such as x-ray film processors) known for exerting an influence on indoor air quality. Congdon recommends looking for evidence that these systems and equipment have not received overhauls or undergone routine parts replacements in accordance with their manufacturer-recommended schedules. He adds that neglected systems should be considered prime suspects until proven otherwise through rigorous testing and monitoring.

It occasionally happens that reports of problems get shunted aside by managers who prefer not to have to deal with them. Watch out for situations like that, warns Wayland, Mass, consultant Bruce Shackleton, EdD, who runs Corporate and Occupational Solutions LLC.

“What often results from this dodging of responsibility is air-quality troubles reaching crisis proportions," he says. “At that stage, an institution’s response mechanisms can become paralyzed if you have a situation where managers at different levels in the chain of command who had some responsibility for acting on those ignored reports start pointing fingers of blame at one another."

Shackleton, an expert in the psychology of teamwork, says the only way the air-quality problem will be addressed then is if time first is spent restoring comity among the players.

“The team is derailed, they’ve got to be put back on track," he stresses.

Putting on Airs
The familiar aphorism that an ounce of prevention equals a pound of cure applies just as aptly to indoor air quality as it does to everything else in life. That is why trading up from a mediocre HVAC system to a state-of-the-art one may be advisable, in Congdon’s view.

“The goal should be to have a system capable of filtering out anything untoward; that can minimize creating the introduction of nasty things like bacteria, mold, and chemicals; and that can circulate clean, well-conditioned air appropriately to support occupants," he says.

Any time a new HVAC is acquired and installed, however, Congdon believes it should undergo a process of validation to ensure that it is delivering clean air and not serving as a new source of airborne contamination.

“You validate it through commissioning tests, beginning with having an independent organization validate the system’s design before and after occupancy," he says. “Remember, these systems are designed to function when there are people about; so final acceptance should wait until it is tested under load.

“And you’ll want to revalidate the system each time a renovation project is completed so that you can be certain the system can handle the new conditions."

Frequently, remediation of problems can be as simple as adjusting daily maintenance activity schedules.

“Be sensitive about the timing of the performance of certain tasks," says Oliver. “For example, in one hospital, lung-disease patients were having adverse reactions to the fumes coming from the floor cleaners and polishers the maintenance people were using in the outpatient clinic area. Basically, the maintenance crews were cleaning the floors while patients were present or just shortly before they would begin arriving for their appointments. Had those products been used at times other than when patients were present for care, this most likely would not have been an issue."

If a situation is such that patients will be present at all hours of the day and night, addressing the problem might require switching to alternative products: those designed to emit significantly lower levels of irritants while still being as effective as the supplanted products, Oliver adds.

Ready to Spend
Correcting air-quality problems oftentimes can be an expensive proposition, the more so the longer those problems are permitted to fester, says Congdon.

“It’s hard to budget for corrective measures," he cautions. “Too many variables. But what you can budget for—and what adds up to a much more reliable approach—is preventive maintenance of systems and equipment involved in supporting the building’s environment or that are known to generate fumes and vapors responsible for denigrating air quality."

Indoor air-quality should be addressed in the budgets prepared for construction projects, as well, Congdon contends.

“Each construction project should have a line item, which will vary project by project, to address air-quality issues during the preparations for construction and while contractors are performing tasks," he says. “The anticipated costs should cover monitoring and remediation. Also, there should be built into the contract monetary penalties that can be imposed if builders fail to take all specified steps to ensure that their work does not adversely impact air quality."

Among those specified steps would be things like maintaining negative air pressure at the construction site at all times.

“Continual negative air pressure goes a long way toward confining dust to just the immediate work site," Congdon explains. “What many contractors typically do that’s wrong is turn on fans when they arrive and then turn them off when they leave at the end of the work day. That allows dust to spread and settle far beyond the work site. What they should be doing instead is leaving those fans operating around the clock, 7 days a week, until after the project is completed and the site fully cleaned up."

Congdon mentions that prevention and remediation of air quality problems will differ from building to building, as no two structures nor the equipment within them are ever exactly the same. Still, he says, tackling air-quality issues needs to be a primary concern for hospitals, After all, there’s no reason why the building should be less healthy than the patients an enterprise strives to help.

Rich Smith is a contributing writer for 24×7.