ASHRAE/ASHE Guideline 43

Over the last several years one of the leading survey findings within the physical environment is the control of ventilation systems throughout health care facilities. As reported by both DNV Healthcare USA (DNV) and The Joint Commission (TJC) one of the most frequently cited higher-risk accreditation requirements within the physical environment is a failure to properly control ventilation systems.

While the design requirement for the temperature range within OR’s is 68⁰ - 75⁰ F even the 2008 edition of ASHRAE/ASHE Standard 170, Ventilation of Health Care Facilities, realizes that this temperature range may not be sufficient and provides a footnote that allows the requirements to be exceeded if surgeons or surgical procedures indicate that the range is insufficient. Many organizations use this footnote to address surgeon requests to maintain the temperature within the OR outside of the 68⁰ - 75⁰ F design temperature range.

This clearly indicates that there are times when operationally ventilation systems need to function outside of the design requirements. Hence the 5-year effort to create this new guideline, ASHRAE/ASHE Guideline 43, Operations Guideline for Ventilation of Health Care Facilities, to help health care organizations.

The intent of Guideline 43 is to provide an operational guideline for health care facilities that will work in collaboration with Std 170. It is the intent of the Guideline to provide guidance to operating personnel, thus providing consistency in the operation of health care ventilation systems.

The purpose of the Guideline is to address health care HVAC systems as a comprehensive whole while also providing consistency in the maintenance and operations of these systems. The Guideline covers the implementation of a ventilation management program (VMP) through defining the responsible party, the minimum elements of a maintenance program along with providing guidance on legacy systems, condition indicators, excursion variations, and program improvement opportunities.

It is important to understand that ASHRAE/ASHE Guideline 43, Operations Guideline for Ventilation of Health Care Facilities, was purposely written as a guideline and not a standard. Essentially, guidelines are advisory. The guideline has been developed to provide guidance on how to properly operate ventilation systems within health care facilities.

Similar to how the Centers for Medicare & Medicaid Services (CMS) has recommended handbooks and standards as reference documents for alternative equipment maintenance and water management programs it is ASHE’s goal to have CMS recommend Guideline 43 as a guideline for ventilation management.

By health care organizations incorporating the recommendations within Guideline 43 and establishing ventilation management program plan (VMP) to operate ventilation systems will encourage accreditation organizations and CMS to accept Guideline 43 as the best way to operate ventilation systems within health care facilities.