The ability to quickly isolate patients with infectious diseases is a key function of indoor air quality maintenance in healthcare facilities. While ideally all hospitals would have a bevy of permanent fixed isolation rooms with dedicated ventilation systems at their disposal, a more practical solution involves the use of portable HEPA filtration units to achieve temporary negative pressure isolation of single rooms to entire floors.

Whether it be an airborne flu outbreak or a small spike in stubborn cases of multi-drug resistant tuberculosis, few hospitals would have enough existing fixed isolation room capacity to properly respond. "It’s becoming more and more common that hospitals are maxing out on their ability to put patients into isolation using their fixed isolation capacity," said David Lutz, director of marketing, Mintie Technologies. "H1N1 has served to refocus many people’s attention on the risk pandemic disease can pose and increased awareness of gaps in pandemic preparedness. It is widely recognized that the US healthcare infrastructure is not equipped to handle an airborne transmissible pandemic," he added. "According to the American Hospital Association 61 percent of hospitals have even one Airborne Infection Isolation Room (AIIR), let alone mass isolation capacity. Appropriately cohorting a real surge in droplet transmissible patients is also a major challenge."

Mintie’s ECU2 collapsible, portable containment solution quickly and easily converts standard patient rooms into negative pressure isolation rooms. Combined with Mintie’s corridor flange, the ECU2 allows facilities to use any point in a hallway or ward as a separation point to temporarily contain a larger space to cohort groups of infected patients for mass isolation. "The solution not only meets droplet precaution recommendations, but also eliminates potential airborne risk," said Lutz. "A comprehensive containment solution is an important part of pandemic planning as it is immediately deployable and not disease-specific."

John Pierson, marketing/product development and sales manager for Fiberlock Technologies, makers of Kontrol Kube Mobile
Containment Solutions, noted, "Portable containment that is easy to move, build and maintain is a critical component to increasing a hospital’s surge capacity as mentioned in HRSA critical benchmark 2-2."

Mintie ECU2 bundle

The HRSA (Health Resources and Services Administration) National Bio-Terrorism Hospital Preparedness Program Critical Benchmark 2-2 states: "Ensure that all participating hospitals have the capacity to maintain, in negative pressure isolation, at least one suspected case of a highly infectious disease (e.g., smallpox, pneumonic plague, SARS, influenza and hemorrhagic fevers) or febrile patient with a suspect rash or other symptoms of concern who might be developing a highly communicable disease. Recipient must identify at least one regional healthcare facility, in each Recipient defined region, that is able to support the initial evaluation and treatment of at least 10 adult and pediatric patients at a time in negative pressure isolation within 3 hours post-event."

Fiberlock’s Kontrol Kube Abacus is a temporary anteroom designed to convert any operating, patient or procedure room into an emergency airborne isolation room. It can be set up within minutes to provide containment wherever needed without costly disruptions to patients and schedules. For smaller facilities where fixed AII rooms are either cost or space prohibitive, The Abacus works as temporary containment. For larger facilities that have fixed AII rooms, The Abacus can provide additional mobility and surge capacity. It also provides a convenient solution for situations where patients cannot be moved to a fixed AII room.

"In many cases, staff does not discover the nature of an infectious patient’s illness until after they have been admitted," said Pierson. "In this situation it is dangerous to move the patient throughout the facility. By placing a negative pressure anteroom device like Kontrol Kube Abacus on the door, the risk of harmful pathogens escaping into the hall is eliminated."

Anterooms, also known as airlocks, are often used as an additional precaution, providing a transition area from the airborne infectious isolation room to the hallway. The Ante Up inflatable emergency anteroom from Abatement Technologies features a slim profile that takes up only 10" of corridor space when mounted within the door opening, and can be deployed in three minutes or less.

Abatement’s HEPA-CARE filtration systems are available in portable and ceiling mounted versions to convert standard patient rooms to negative pressure isolation. All components of the HEPA-CARE units, including filters, are individually tested and certified by the Environmental Testing Laboratory to be 99.99% efficient at 0.3 microns, and are gel-sealed to prevent particulate bypass.

Abatement’s HEPA-AIRE Model PAS5000 Portable Air Scrubber provides 4,000 CFM peak airflow and can be used to convert entire hallways or spaces as large as a gymnasium into negative pressure isolation. "One of the things that is concerning to consultants that we talk with in the healthcare field is that if we ever get hit with a major event like a terrorist attack, an anthrax situation, or large pandemic outbreak, we don’t have enough patient rooms to go around," said Dave Willyard, vice president, Abatement. "So they look at these large surge areas to function as a hospital ward in a sense."

Abatement Aire Guardian

With as much as five percent of healthcare acquired infections estimated to be a result of airborne contaminants that are released during construction and maintenance activities, noted Lutz, proper containment of construction and maintenance is essential. He referenced the Infection Control Response Assessment (ICRA) Matrix of Precautions for Construction and Renovation, endorsed by APIC and other professional organizations, as a primary means of determining the level of containment needed during various activities. For example, any type of maintenance or construction work performed near highly sensitive environments, such as the OR, requires the use of HEPA-filtered negative pressure isolation and sometimes an anteroom to the contained space. "On the flip side," said Lutz, "if you’re doing work in the CEO’s office, well away from patients, in the administrative part of the hospital, you may be able to do the same job using just the containment device without negative pressure because you’re not putting patients at risk."

The most common application for Mintie’s products is for containment of ceiling penetrations, noted Lutz, a great deal of which are due to IT infrastructure renovations. Mintie’s ECU CC provides basic containment for ceiling and floor penetrations, while the modular ECU2 can be used as a stand-alone system for small scale construction and maintenance activity, or, two ECU2s can be hooked together with a 5 ft. connector cuff and corridor flange to contain larger sites.

Due to the nature and variety of challenges that facilities maintenance crews face, containment solutions should be mobile, durable and flexible, advised Pierson. "Maintenance workers and contractors have to be able to move the environment into position with ease, and once they get it there they need to be able to lock it into position safely. Ceiling access, appropriate heights, wall access, ports for cable and power lines to run through are all important features needed when dealing with containment for facilities maintenance. "As hospital infrastructures age and modernization projects are implemented, hospitals are undergoing more construction, renovation and maintenance projects now than ever," he added.

Featuring a solid working platform, Fiberlock‘s Kontrol Kube Topsider mobile containment solution accommodates an 8’ ladder and allows workers to reach heights of up to 10’ while the Abacus containment system features a beveled base and wall flange that allows it so serve as an anteroom to contain larger room-sized renovations. The Kontrol Kube Complete is a solution-based system that combines a containment unit, patent-pending AirBase and Negative Air Machine, and all other components necessary to establish temporary containment. The Complete system offers total mobility and ease of use for the user, and the assurance that all components have been designed to work seamlessly with one another.

Abatement’s Aire Guardian mobile containment cube generated a great deal of interest at the ASHE (American Society of Healthcare Engineering) 2009 Annual Conference in Anaheim, CA. The Aire Guardian can be combined with a portable air scrubber such as the company’s new compact and lightweight Mini-Predator 600. An optional AG Caddy Cart makes it easy to attach an air scrubber to the containment cube as well as allows for convenient storage of tools and equipment.

Willyard described today’s new generation of air scrubbers as more efficient and higher-performing versions of traditional negative air machines. With motorized blowers that create a more efficient airflow, the air scrubbers can help extend filter life, as well as accommodate multiple stages of filters including carbon.

Bioquell decontamination unit

Mintie Technologies introduced the PureAir Blaster Negative Air Machine this Spring, a compact and versatile construction and maintenance containment solution that offers the choice of operating with a HEPA filter that provides 99.97% efficiency at 3 microns particle size for more stringent air purification requirements; or a more economical and longer-lasting Geo95 filter that is 95% efficient at 3 microns for containment in non-patient areas. Featuring an impact-resistant, lightweight, polyethylene shell versus traditional metal, the variable-speed PureAir Blaster is stackable and includes a built-in convenience outlet that allows up to five units to be chained together for additional CFM.

While it may be tempting to cut costs on construction containment with the use of disposable makeshift barriers, Pierson noted that solutions such as Fiberlock’s Kontrol Kube can rapidly pay for themselves in labor and material costs alone. "The ability to quickly establish containment and then move it from place to place is perhaps the most valuable cost saving factor when building temporary containment," he said. "Consider the amount of time spent building a small containment barrier out of poly sheeting and poles and then multiply that by the number of locations in a facility where work like light bulb replacement must be done. The labor costs associated with building and removing disposable materials adds up quickly, while the costs associated  with the Kontrol Kube system are the opposite because each time the unit is used the per-use cost is actually reduced. From start to finish, the time spent on building adequate containment barriers for either maintenance applications or patient isolation is one of the largest contributing factors to the expenses incurred by healthcare facilities related to airborne infection control requirements."

Steril-Aire single-ended (SE) UVC Emitter

Ultraviolet germicidal irradiation (UVGI) has long been used to disinfect air and surfaces in healthcare facilities and is recommended by organizations such as the American Society of Heating, Refrigerating and Air-conditioning Engineers, the American Institute of Architects and the Centers for Disease Control and Prevention as a supplement to essential engineering control methods.

"There are no known pathogens resistant to a proper dose of UVGI," explained David Skelton, marketing director, Lumalier Corp. "We know, with a great deal of certainty, the amount of cleansing UV energy required (dose) to neutralize a microorganism. These UV-C germicidal ‘kill-rates’ are known and published. For instance, viruses are highly susceptible to relatively low doses of UVGI. Vegetative bacteria are neutralized by moderate doses of UVGI. And while spores can be quite hardy and resistant to chemical disinfection, they can be neutralized with a specific higher dose of UVGI."

Applications for UVC technology in hospitals include direct irradiation of the cooling coils and air in HVAC systems; UVC applied directly to surfaces in areas such as ORs and laboratories; and in-room indirect fixtures for upper air disinfection." Lately there is an increased interest in upper air disinfection systems which are installed in patient rooms and hospital corridors to disinfect the air and control the transfer of infections," observed Warren Lynn, president, American Air & Water Inc.

 Steril-Aire Inc. offers a range of products for healthcare applications including UVC Emitters designed for installation in HVAC systems where they destroy microorganisms including flu viruses, bacteria and biofilm/mold. The devices come in a range of sizes and configurations to fit all types of air handlers, large and small. For example, Steril-Aire single-ended (SE Series) UVC Emitters install from the exterior of HVAC equipment, providing high output germicidal protection for systems that are limited in space or difficult to access. Applications include heat pumps, fan coils, unit ventilators, terminal units and ductwork. The device is available in a variety of tube lengths and voltage options. Portable room air purifiers using the technology are also available for spot air cleaning. In addition, Steril-Aire offers both installed and portable UVC devices that provide targeted decontamination of surfaces in laboratories, surgical suites and other critical areas.

Mintie Pure Air blaster

"Properly designed and installed UVC systems in the hospital’s air handlers can provide measurable cost savings via: reduction in patient and staff medical expenses resulting from nosocomial infections, operating room infections and aspergillosis; reduction in routine maintenance costs for cleaning of cooling coils; and improving AC efficiency resulting in energy savings and extended life of the systems," said Lynn.

UV systems from Lumalier include wall-mounted and ceiling-mounted UVGI fixtures (upper room UV disinfectors) that create a plane of germicidal energy parallel to the ceiling of a room to target airborne pathogens in high-risk areas such as waiting rooms where undiagnosed patients are found, in TB and respiratory exam rooms, patient rooms, hallways, bathrooms and over nurse stations. HVAC or in-duct mounted UVGI fixtures disinfect contaminated air as it passes through the duct-work of the air conditioning system and are often used as facility-wide air disinfection systems to stop the spread of respiratory illnesses, as well as to provide energy savings. Bio-tech/clean room UV fixtures are designed for after-hours surface disinfection of work areas, food processing lines, infirmaries, etc.

A number of new technologies are available to help decontaminate air and surfaces, serving as an adjunct to conventional surface cleaning and air filtration methods to help reduce risk of cross-contamination.

Decontamination equipment from BIOQUELL Inc. produces a hydrogen peroxide vapor that permeates all areas of a treated room, reaching the top, bottom and sides of every surface so that "a truly ‘three-dimensional kill’ is obtained, with no limit on distribution and no shadow or shading effect," explained Mark Hodgson, sales manager, North America, Bioquell. "The very high level kill of the product allows us to demonstrate a six log kill of a wide range of microorganisms including all of those pathogens commonly found in a hospital environment," he said. Turnaround time for a room is anywhere from 90 to 180 minutes, although the company is working towards a 60-minute average turnaround. The hydrogen peroxide solution used in Bioquell breaks down to form oxygen and water, leaving no chemical residue and no environmental impact, and is compatible with most electronic devices found in hospitals, noted Hodgson.

Service and equipment solutions from Bioquell include a proactive service option, scheduled service, and emergency outbreak response, as well as fixed equipment installations and hybrid solutions tailored to individual hospital needs. Hodgson noted that the Proactive Service option, in which an onsite Bioquell team practices a "search and destroy" style approach, provides the most significant opportunity for long-term reduction in hospital acquired infection rates. The Bioquell system helped play a role in reducing rates of C.diff by over 53 percent facility-wide during a one year period at the Hospital of Saint Raphael in New Haven, CT, related Hodgson. "We have a number of other papers produced including one from Johns Hopkins showing the risk of VRE acquisition for subsequent patients in the ICU was reduced by over 80 percent," he said.

The SteraMist Binary Ionization system from Binary Ionization Inc. (an L3 Communications company) applies cold plasma activation to hydrogen peroxide based aerosol to create Reactive Oxygen Species (ROS). SteraMist provides fast acting, broad spectrum biological disinfection, and because the solution breaks down into oxygen and water vapors, it leaves no residue or noxious fumes, and does not damage equipment. With its patented Binary Ionization Technology (BIT), SteraMist assures that micro organisms (including spores) are destroyed in even the most hard-to-reach areas. Instant activation of the hydrogen peroxide molecules coupled with rapid, equal diffusion of the aerosolized particles allows a typical hospital room to be treated within about 60 minutes.

SteraMist spray gun and fogging unit

SteraMist is available in a fogging unit that could be used to decontaminate a patient room that contained a patient with a known or suspected high-risk microorganism such as MRSA or VRE. An optional spray gun attachment allows for point of contact spraying. "You can use the unit in hallways, on elevators, all surfaces that might be high-contact surfaces in the general hospital environment, to help prevent the transmission and carrying of infectious agents into patient rooms," said Kurt Klimpel, PhD, senior program manager, Binary Ionization.

Field trials have shown that the SteraMist system kills 99.999% of all the organisms in a treated room. "The colony counts from swabs on doorknobs, bed rails and TV remotes goes down to zero, from the hundreds, or several hundreds that are there to start," he said. The company is working to establish longer term data that shows a correlation between the use of the product and a reduction in the rate of hospital acquired infections.

The SteraMist system is currently leased by cleaning services companies to disinfect cleanrooms, pharmacies and labs, and was used to decontaminate over an acre of outdoor space at a dog park in San Diego, CA, after an infection with parvo virus was discovered. A backpack unit is in development.

With Lumalier’s TRU-D (Total Room UV Disinfection) system, disinfection is achieved by irradiating surfaces 360° with high doses of line-of-sight and reflected cleansing UV energy. As these energy waves are delivered from the Tru-D source to every surface of the room, all air within the room is similarly irradiated and airborne pathogens are neutralized. The Tru-D itself generates low levels of heat that cause the air to continually turn (convection) several times per minute during the disinfection process.

"While the healthcare industry has purchased upper-room and HVAC UV fixtures for decades, portable UV disinfection is a relatively new technological advance," described Skelton. "Portable units are used for terminal cleaning in operating suites and patient rooms, between surgical procedures, for high-level disinfection of quarantined patient rooms after the diagnosis of MRSA, C.diff, Acinetobacter, and other high risk ailments."

He added, "Conventional cleaning does not address airborne pathogens. Virus and other droplet nuclei can remain suspended in the air for days, settling and recolonizing surfaces hours to days after cleaning. C.diff spores are known to become aerosolized, meaning that spores become airborne and contaminate every surface in a room."

Installed in the ductwork of an air handling system, AirScrub Systems’ photo-hydroionization technology uses UV light in a unique way – to serve as a catalyst to create aggressive, yet environmentally-friendly, oxidizers that move throughout the facility attacking and destroying bacteria, viruses, mold, and odors in the air and on surfaces.

According to AirScrub Systems President Lin Cochran, the system has proven effective in healthcare facilities in eliminating the hard-to-kill norovirus as well as laboratory tests against the bird flu virus.

Karen Bowles, a former administrator at an assisted living center in South Carolina was instrumental in having the AirScrub System installed in the 24-bed Alzheimer’s unit of her facility five years ago. "We had problems with odors in our Alzheimer’s units due to incontinence of the residents. We tried everything – spray disinfectants, changing out the mattresses – but it only masked the smell," shared Bowles. Not only was the AirScrub System successful in removing persistent odors from the unit – employee and resident morale was raised, and long empty rooms began filling up fast. "I went from empty rooms with no revenue, to a full unit with a waiting list, and it only took about three months to get there."

She also attributes the AirScrub System to keeping more than 90 percent of residents in the Alzheimer’s unit from having to be admitted to the hospital after the system was installed, versus in a typical year as many as 60 percent of residents would require hospital services for pneumonia, etc.

A system that can improve overall air quality and reduce environmental contamination could pay for itself with the avoidance of a single outbreak, estimated Cochran. At a recent AirScrub-hosted seminar several administrators gathered to discuss their experiences with infectious outbreaks in their facilities. Not only were the administrators painfully aware of the high costs associated with implementing a quarantine, for example for a norovirus or MRSA outbreak, as they talked to each other they made each other aware of additional costs they had incurred that weren’t included in their original calculations, she recalled.