Fresh air
Air purification systems meet the challenge
by Jeannie Akridge

The recent tragedy that spiraled from Hurricane Katrina showed us that disasters can happen anyplace, anytime. Be they the wrath of Mother Nature, acts of terrorism, or disease pandemic like bird flu or SARS, such disasters are destined to happen again.

Even those hospitals not directly affected by such an event may face an influx of victims who need immediate critical care and who are likely to be infected with various contagions. Having the appropriate ventilation systems and surge-capacity isolation units will go a long way towards containing bio-contaminants and preventing spread of disease in a disaster situation. Equipment and ventilation systems that clean the air, ridding it of contaminants and preventing leakage of contaminated air to other areas of the hospital are as important to daily operation as in an emergency situation. Portable air purification units that can turn any room of the hospital into an isolation room; rapidly deployable decontamination/isolation shelters; HEPA-grade filters; and patient transport units, are just a few pieces of air purification/filtration equipment that could help to save lives.

“When it comes to bioterrorism, most hospitals, I believe, do not feel they will be the primary target of a bioterrorism attack, however they’re considered among the first responders,” said Ken Rubin, senior vice president, sales, marketing & business development, StrionAir Inc. (Louisville, CO). “The guys in the ambulance are starting to bring people into the E.R. Those people could have been exposed to God knows what. Now they’re in your E.R. or your isolation rooms. So the concern tends to be on secondary contamination.”

“We’ve been seeing a lot of interest and concern in hospitals,” said Keith Reals, director of infection control technology, TVI Corporation (Glenn Dale, MD), of its domestic preparedness products that include rapidly deployable decontamination shelters and chemical/biological isolation shelters with the capacity to accommodate 50-60 beds or more. “We’ve been meeting with infection control directors and directors of bioterrorism preparedness to show them our product line to gear up for what a lot of people fear is inevitable with a pandemic,” said Reals.

Airsonett Airshower

According to vendors, the primary reason hospitals are looking at products such as these is to meet surge-capacity requirements set by the Health Resources and Services Administration (HRSA) under the National Bioterrorism Hospital Preparedness Program. Many hospitals across the nation have been granted funds from the HRSA in order to boost their preparedness efforts.

“With the recent HRSA funding coming from the U.S. Department of Health and Human Services, many hospitals have been able to prepare for outbreaks caused by airborne pathogens, such as the SARS problem we saw in Asia recently. The same preparation allows hospitals to be ready in the case of biological attack or some other need for ‘surge capacity’ like natural disasters, epidemic, etc. The HRSA guidelines have some very specific requirements that hospitals need to do in order to qualify for funding,” said Brad Miller, medical market manager, ENVIRCO (Albuquerque, NM). 

Obligations of grant recipients include establishing systems that can provide triage treatment and initial stabilization, above the current daily staffed bed capacity, within three hours in the wake of a terrorism incident or other public health emergency. The guidelines also call for appropriate negative pressure isolation room provisions. The guidelines for surge capacity are based on those set by the 2003 CDC and AIA Guidelines for Healthcare Infection Control in Airborne Infectious Isolation (AII) rooms and Protective Environment (PE) applications.  

“Essentially the CDC guidelines call for the hospitals to determine themselves what adequate surge capacity may be,” said Dave Shagott, president, Abatement Technologies (Suwanee, GA). Determining factors, he said, include: Is the facility a major trauma center? Where is it located? “It’s based on what they would call their normal surge capacity. In most cases if there were some catastrophic event – be it manmade or a natural disaster – normally what they have for surge capacity is probably not going to be sufficient to handle all of the influx that they might have at that point,” said Shagott.

“What do you do if you have an outbreak of SARS, or AVIAN flu? Is your hospital capable of handling an additional 150 people at a minute’s notice? Certainly they’re not,” commented Reals. “Many healthcare facilities do not have adequate isolation room capacity for emergency situations,” said Reals. TVI’s new MK-1 Isolation Room Conversion converts a regular patient room to airborne infection isolation in less than five minutes.

Even with cash in hand and best intentions, many facilities may be faced with a confusing array of products from which to choose. “There are a multitude of different product solutions in each state – everything from anteroom solutions to fully functional portable hospitals. However, no single solution has emerged as the dominant theme for hospital domestic preparedness,” said Azure Frioni, channel manager, healthcare marketing, Fisher Safety (Hampton, NH), a distributor for disaster preparedness equipment suppliers such as TVI Corporation, Mintie Technolgies, FailSafe Air Safety Systems and others.

ENVIRCO

“Disaster preparedness isn’t an easy concept to get your hands around,” she continued. “Even with homeland security funding, many hospitals are working with limited budgets and are struggling to find solutions that function with the dynamics of their local or regional healthcare environment. Despite these challenges, we’ve seen a tremendous level of dedication from the healthcare community,” Frioni added. “They are embracing the challenge and working very hard to prepare for any potential healthcare crisis. As a distributor, our role is to help educate these communities on their options, and to provide them with quality products, competitive pricing, service, and training on their solution.”

Fisher Safety offers a Quartermaster Program designed to help hospitals manage HRSA grant spending and acquisitions. “As with most domestic preparedness funding, hospitals carry a greater level of financial accountability for hospital preparedness grants than they have seen with previous rounds of funding. Fisher’s Quartermaster Program provides an unparalleled resource for managing and tracking multiple grants, allowing the user easy visibility of their spending. The system tracks how and where grants are used, as well as the amount of funding they have used for each of the HRSA critical benchmarks,” said Frioni.

Dr. Charles Akers, chief scientist for FailSafe Air Safety Systems (Tonawanda, NY), recommends that facilities also look to guidance from the Federal Emergency Management Association (FEMA). “FEMA has long been the leader in emergency preparedness and should be fully leveraged for their extensive product evaluation and precise selection of surge capacity and isolation products.”

Dr. Akers discussed the importance of selecting products designed to provide long-term operational benefits. “Healthcare facilities are certainly committed to achieving bioterrorism preparedness. However, they typically face a myriad of challenges such as navigating through an extensive funding process, gaining purchase consensus from a diverse decision committee of medical and administrative staff, and stretching limited budgets to effectively meet the HRSA benchmarks and CDC guidelines critical to adequately protecting their communities. Many are missing the ‘total cost of ownership’ evaluation in their purchase decisions by going with products that appear to be best price today, but will be expensive overall with poorer performance, frequent component replacement and associated red bagging costs,” Dr. Akers said.

Isolation techniques
CDC guidelines require negative pressure isolation rooms to maintain at least .01 inches of negative pressure and/or twelve or greater air changes per hour. These negative pressure spaces pull air into the space rather than expelling contaminated air out into the hallways or patient rooms. 

One way to achieve negative pressure isolation is to have dedicated engineered isolation rooms with separate HVAC systems that allow for negative pressure isolation conditions – which can be very expensive to retrofit. A more flexible and affordable option involves the use of portable HEPA filtration units or ceiling-mounted stand-alone systems that provide the necessary air changes per hour. 

“When they’re looking for surge-capacity they’re generally looking for maximum flexibility,” said Shagott. “They have certain areas that they know they’re going to want to set up as negative pressure, or HEPA isolation areas. And sometimes they will use a ceiling-mounted system in those cases where they know they’re going to have a fairly frequent ongoing use for that room as a negative pressure isolation area. The nice thing about the ceiling mounted [units] is they’re up and out of the way, and they’re highly tamper-resistant.” He explains that the ceiling mounted units can be ten times less costly than installing a dedicated negative pressure system for the room, and it’s much less disruptive, and much quicker to implement. The portable systems, he said, offer maximum flexibility and can be used wherever a facility needs negative pressure HEPA filtration.

Honeywell International (Golden Valley, MN) offers both permanent ceiling-mounted and portable isolation units. “What some big cities have found out is that you may want to have 10 permanent iso-rooms, but you need another 20 as backup. And that’s where you can roll in these portables and you’ve got a backup of 20 rooms. I’ve seen some of these guys buying 50, 60 or 70 of these things,” said Scott Roberts, North American sales and marketing manager, commercial indoor air quality, Honeywell International.

IQAir (Santa Fe Springs, CA) offers its Cleanroom series of air purifiers with inflow and outflow attachments that can quickly turn a facility into a negative pressure or positive pressure isolation. The outflow attachments provide the added benefit of filtering the air that is released to the outside environment.

“They can use this product for local indoor air quality as opposed to incurring the high expense of retrofitting and putting in filters in an HVAC system,” said Glory Dolphin, CEO, IQAir. “Some hospitals may immediately think ‘now I’ve got to change my entire HVAC system.’ Instead, they can look at these local air quality treatment systems that can provide big savings for a lot of hospitals, and can meet the same requirements.”

Envirco’s HospiGard IsoClean product family includes portable and fixed (wall or ceiling mounted) HEPA filtration devices. “Envirco has been making the HospiGard IsoClean products since the early 1990s when we worked with Dr. Byron Tepper at the Johns Hopkins Institute to develop a product that could be used to create a clean air zone for immunocompromised patients,” said Miller. The IsoClean products were designed to provide a great deal of power in a small footprint.   

FailSafe Air Safety Systems’ Mobile Containment Systems provide room conversion to isolation as well as employ ozone capability for post-event decontamination, explained Dr. Akers. The FailSafe Model 77 Portable isolation bed unit isolates an infected patient while protecting healthcare workers from infectious aerosols in the patient zone, said Dr. Akers. “An FDA-cleared device, the Model 77 provides emergency medical isolation that is portable to bring isolation to the patient within minutes, thereby minimizing full-facility contamination,” he said.

Units that allow for safe transport of contaminated patients are another essential tool to help hospitals maintain indoor air quality in any situation.

FailSafe offers its Transport Isolation Chair that features a high capacity HEPA filter providing air change every six seconds in the patient zone.

TVI’s Patient Isolation Transport Unit (Iso-Pod) was designed to protect the First Responder, ambulance, helicopter and healthcare workers from getting contaminated during patient transport.

The CDC Guidelines for Environmental Infection Control in Healthcare Facilities strongly recommends using an anteroom (airlock). “By using an anteroom you have created an airborne infectious isolation to the patient, hospital staff and general patient population. They don’t compromise the room or let the contaminant escape into a hallway or adjacent patient room,” said Reals.  

Additional systems provide protection for patients who may be immunocompromised. The Airsonett Airshower is a portable isolation unit that provides a shower of clean air to the direct breathing zone of an individual. “The Airshower’s task is close to that of an over pressurized air tent, but without the tent,” said Dan Kristensson, president, Airsonett Inc.

The Airshower can be rolled in whenever a patient needs a zone of HEPA-filtered air around his or her breathing zone, around a wound or anything similar that could be infected from airborne viruses, bacteria or other aggressive particles in the air. “Inside the ‘clean air’ zone, patients are protected from all of these airborne particles,” said Kristensson. The Airshower has proven particularly beneficial to patients with asthma or other respiratory problems. 

Once a hospital has established negative-pressure isolation rooms, CDC guidelines also call for monitoring of that pressure.

“One of the things that sometimes fails to get addressed sufficiently, in our mind, is pressure monitoring,” said Shagott. “Some facilities are still doing periodic monitoring with smoke tubes or flutter strips or other manual methods. Things can happen during the day where pressure can be lost for a period of time, and they would be unaware of that unless that happens to be the time they are doing the monitoring.”

Abatement offers both a fixed, wall-mounted differential pressure monitor that provides audible and visual alarms, and a portable differential pressure monitor. While the electronic wall-mounted version provides continuous, 24-7 monitor and provides a complete record that can be verified, the portable monitoring systems are being used in conjunction with portable HEPA filtration systems. “There are a lot of options, yet not nearly as many people buy the pressure monitors as buy the HEPA equipment,” said Shagott.

TVI’s MK-1 negative pressure filtration system monitors room pressure, includes audible and visual alarms, and has data logging capability that records time and event, providing recorded documentation for risk management.

Many air purification/filtration systems on the market today also incorporate germicidal benefits to not only capture, but kill contaminants. For example, IQAir uses anti-microbial HEPA and pre-filters; StrionAir uses ion oxidation; Abatement and Honeywell offer UV modules. AirOcare (Rockville, MD) offers an air filtration system that works by altering the oxygen molecule and creating singlet and atomic oxygen to create an oxidizing agent for the contaminants in the air. “The systems use no chemicals or bottled gases, instead using the oxygen in the air as a cleaning agent and returning the air to its original clean state with no by products,” said Robert McDonald, president and CEO, AirOcare.

AirOcare is currently installing and testing its system in several healthcare application areas including critical care, storage and closed and facility-wide air circulation systems. “We are also looking for healthcare facilities with air quality and mold issues to serve as additional demonstration sites,” said McDonald. “We have proven outcomes in many other fields of air purification. Our tests show high levels of effectiveness against all common hospital pathogens including MRSA,” said McDonald.

Gaining efficiencies
CDC guidelines call for HEPA-grade filtration in certain areas of the hospital, including critical care and isolation areas. Unfortunately HEPA filters can also be extremely expensive to operate. 

“Removing economics, HEPA filters are the optimum for providing protection for any airborne particulate contaminants, both health-facility oriented and those that may be introduced through an act of terrorism,” said Charles Seyffer, market manager, Camfil Farr (Riverdale, NJ).

“A HEPA filter is extremely efficient, but it comes at an enormous energy cost,” added Rubin. “HEPA filters are required in a lot of cases so a hospital doesn’t have a choice. But they pay an exorbitant cost to have them in there. Not only are they very expensive filters, $250 to $400 every time they have to replace one, the energy cost is enormous because it offers enormous resistance to air flow,” said Rubin.

StrionAir technology offers a unique approach to reducing energy costs by serving as a barrier to the HEPA filter in order to extend its working life. The technology was designed by Lawrence Livermore National Laboratories in California. “The Department of Energy asked them to come up with a way for them to protect the HEPA filters in a nuclear facility in the event of a fire,” said Rubin. “If there was a fire in a nuclear facility, the HEPA filters will clog very quickly, because they take so much out of the air. It used to mean that you had to start venting the air outside. And if there was a fire in a nuclear facility that probably meant there was radiation, and they didn’t want to release the radiation outside.”

Tests conducted at Livermore showed that the StrionAir technology extended the life of a HEPA filter by as much as five to ten times. With anywhere from 10 to 20 filters in a facility’s HVAC system, at $250-$400 apiece, a StrionAir system in front of the HEPA filter can provide substantial savings, said Rubin. “What if I told you that rather than changing [HEPA filters] every three to six months or once a year, you could change them every three to five years?” He also noted that HEPA filters weigh 60 to 80 lbs. apiece, no simple maintenance task. 

In areas where a HEPA filter is not required, the StrionAir system can serve as the final filter. “We take a filter that is much less dense than a HEPA filter, so it offers far less resistance to air flow and we electrically enhance it. In a sense we pull the particles out of the air using electrostatic attraction and we can get efficiencies that are very high, near HEPA level performance, but at a pressure that’s far, far less,” said Rubin.

Rubin noted that the proposed new AIA guidelines would allow either a HEPA filter or a MERV 16 filter to be used in critical care areas. MERV (Minimum Efficiency Reporting Value) is a new standard from ASHRAE that uses a test that yields a MERV rating on a scale of 1 to 16, 16 being the best. 

“The AIA makes recommendations, but almost every code when it comes to a healthcare facility, follows the guidelines promulgated by the AIA. In the future, if they permit a MERV 16 filter to be put in place, that will open up alternatives to the HEPA,” said Rubin. (Early testing results for the StrionAir system show a MERV 16 rating.)

What else do healthcare facilities need to consider when choosing filters? “Always, always, always: They need to protect employees and patients from the increased risks inherent in placing humans in an environment that is designed to address the viral and bacteriological enemies of good health,” said Seyffer. “Standards from cognizant authorities should be followed to the letter, with filter configuration selection based upon the possible limitations of the equipment. Cost must always be a consideration without trading on the value of protection.”

Choosing the right filter truly can make all the difference in energy savings. “When considering air filtration and energy savings, two major factors come into play: the type of media used and the configuration of the filter,” said Seyffer. “Generally, a filter with more media area will have a lower energy usage over time. Even a pleated filter with increased media area can save a facility thousands of energy dollars per year. The savings experienced may be $10-20 per year, per filter, and some facilities use hundreds of these filters as prefilters or as the only filter in their system.”

“HEPA filter size is important because the generally recommended maximum airflow through a HEPA filter is 100 Feet per minute (FPM),” added Envirco’s Miller. “More than 100 FPM and the filter will allow something called ‘bleed through’ causing particles to pass through the filter minimizing its effectiveness and certainly the life of the filter.” 

“Envirco uses 2’x4’ HEPA filters with as much as 800 CFM capacity. This is more than enough area in the filter to extend its life and is also more than enough capacity to overcome a loaded filter in a typical sized patient room (12’ x 18’ x 8’),” said Miller.

Camfil Farr offers a Life-Cycle Cost Air Filtration Analysis software (LCC) that considers a facility’s actual HVAC components (including fan performance, age of the equipment, filter placement and system maintenance), to recommend a best practice scenario and provide a life-cycle cost analysis. It also suggests changes to preventive maintenance strategies in place at most facilities, said Seyffer.

“It seems that new concerns or individual facility inquiries appear daily on our agendas,” continued Seyffer. “For example, in upstate New York, we now have a bacteriological outbreak wherein facilities have contacted us for immediate assistance to address their concerns. In most cases, the only reaction truly required is a re-education of proper practices wherein we will detail room-to-room negative pressure relationships, the importance or air being moved through the filters and employee precautions as prescribed by cognizant authorities. Most facilities that express concern over a current malady already have the proper filtration in place. They just have to ensure that they properly apply what they have.”

“With regard to application, the biggest problem is filters that are not securely fastened or sealed into their holding mechanism,” said Seyffer. “We all learned in school that electricity takes the path of least resistance. The same is true of air being forced through a filter. In some facilities air bypass is as high as 50%, but we find a typical level of around 20% in almost any facility we inspect. In facilities with defined indoor air quality problems, our most successful suggestion for relief is re-applying or installing permanent gaskets to ensure that all of the air is treated by the filter. In short, make sure that all of the air moving through the system is treated by the air filter.”

Air leakage is a critical component, not only for efficiency, but also for safety reasons. Leakage rates not only affect HVAC performance, but also determine the system’s likelihood to “leak” contaminants into the air stream, explained Barney High, healthcare market leader, Trane Commercial Systems (Piscataway NJ). “The lower the leakage rate, the less you’re losing conditioned air outside the unit, so that’s energy efficiency improvement,” said High. “Also, if you’ve got a low leakage rate on the low-pressure side of the fan, then you don’t get infiltration of unconditioned air into the unit. If you get unconditioned air that infiltrates the unit, you can pick up microbial that may grow.” And there’s also concern for mold and mildew.

“[A low leakage rate] maintains the integrity of the air stream going to the patient, and to the environment,” said High. “I think that having a quality unit with high leak integrity is one of the basic steps in eliminating possibilities of contamination or infection control within a hospital environment.”

Abatement offers “bypass-free” cabinets for its portable filtration units. “You can have the best HEPA filter in the world, but if your equipment isn’t designed to make sure that contaminated air can’t somehow bypass that filter, then you can still be exhausting potentially dangerous air from the unit,” said Shagott. 

Proper maintenance and timely changing of filters will also play a big role in reducing energy costs. “Cleaner air is a building asset,” added Honeywell’s Roberts. Keeping your HVAC equipment clean makes it more efficient just inherently by keeping coils clean, ductwork clean, etc. Dirty filters, poor maintenance, or improperly applied filters can have negative consequences through incremental energy costs.”

One thing to keep in mind, said Roberts of the Honeywell family of facility management products, “We can help people manage their indoor air quality so that the net result is better indoor environment at a lower cost. We want to be able to go into a medical facility and help them create operational excellence. I want them to, if they’re spending a dollar today, maybe they spend 90 cents tomorrow, and the net result is something in their operation is better: Cleaner air, more efficient equipment, more comfortable, productive environments,” said Roberts.

Trane recently introduced its new custom air handling portfolio for the healthcare industry. Trane Custom Climate Changer allows customers greater flexibility in configuration as well as increased performance. “In the past we’ve had multiple product lines within our custom portfolio and sometimes there were product gaps. Now with this new product line it’s more of a continuum of options and configurations. We can fine tune the unit to the needs of the hospital so they don’t have to buy more unit than what they really need in order to get a specific feature,” explained High.

The new Trane climate changers also allow greater flexibility in physical fit, so that the air handling unit can take up less space in the mechanical room, which is an expensive space to construct, typically $200 per square foot, said High. “By optimizing the square footage there, you can either lower your construction costs or make that space available for regular hospital activities and revenue generation.”  

The Trane handlers also include various options for thermal break. A high thermal break prevents condensation on the outside of the unit regardless of surrounding  ambient conditions, reducing the potential for damage to the unit from moisture or mold growth,” explained High.

Addressing another type of “pollution” carried through the airstream, the Trane climate changers include insulation options to abate noise. “There’s a whole school of thought right now on the healing environment and the reduction of unnecessary noise. If we want to improve the healing environment, we’ve got to make sure that we’re not injecting anything into the space that’s irritating to a patient,” said High.

In a project by the Centers for Health Design: The Role of the Physical Environment in the Hospital of the 21^st Century: A Once-in-a-Lifetime Opportunity”, research teams from Texas A&M University and Georgia Tech identified more than 600 studies that establish how hospital design can impact clinical outcomes. Among other things, the team found scientific correlation between better ventilation, as well as noise reduction, and an environment more conducive to healing.

The new Trane air handlers include an option for a technology called Cool Dry Quiet (CDQ), which lowers the dewpoint of the air below what a standard air conditioning unit has been able to do in the past.

“CDQ addresses what we’ve found is a significant need in the healthcare market, in surgery suites, as well as pharmacies and labs where they have lower temperature requirements than the rest of the facility and they want to maintain a relatively low humidity, which given the typical equipment they have in place, they’re not able to achieve the kind of results they’re looking for,” said Dan Pollack, Cool Dry Quiet product manager, Trane.

According to Pollack, CDQ requires about half the operating cost of other types of dehumidification systems, which could result in over $150,000 in savings over the twenty year life of the equipment. CDQ also allows for quicker heating and cooling of air during procedures; more optimal setting time for orthopedic glues; and reduced patient bleed times. CDQ can also help solve pesky condensation problems, such as fogging lenses and infection control issues related to moisture forming on surgical equipment.

“The hospital that offers the best operating conditions, not only for their comfort, but to improve patient outcomes, is the one surgeons are going to go to,” said Pollack.

Multiple roles
Several vendors maintained the importance of not just having the appropriate number of isolation suites, but also of protecting the integrity of the air being distributed throughout the entire hospital.

“They do a good job of protecting the surgical areas and making sure it’s clean while they’re operating on a patient, but they do very little out in the emergency room. They do very little for their public spaces,” said Roberts, Honeywell. “And one of the concerns is what do you do in a public area. Because anybody could unintentionally, or worse intentionally, walk in while infected and walk around a public area exposing a tremendous population of people who are already susceptible.”

In order to reduce the chance that someone could gain access to the facility’s HVAC system and purposely release contaminants into the system, Roberts stresses the importance of securing the area around the HVAC system, ‘whether there are fences built around the air conditioning equipment with surveillance cameras on them, or coded card entry, like you use in a hotel, to gain access to certain parts of the facility that are sensitive.” 

“A lot of people start in the critical care areas, but we can provide the benefits of near-HEPA level performance to every area of the hospital. We believe the person at the admin desk should have the same level of protection as the surgeon,” said Rubin.

“Most of FailSafe’s healthcare facility clients are taking a ‘dual use’ approach to procuring their portable isolation and surge capacity solutions. While preparing for the of threat of a highly infectious disease, either from a terrorist attack or natural event such as SARS or avian flu, IC professionals are addressing their day-to-day challenges of TB, flu or mass casualty response by procuring the best-performance, highly mobile infection control systems that meet CDC guidelines and HRSA requirements,” said Dr. Akers.

Shagott agreed. “These are not really things that you have to tuck into the corner,” he said, referring to the company’s portable HEPA-CARE units. “They can be used on a daily basis for any number of applications through the hospital for general air cleaning and disinfection. [There are] new pharmaceutical standards for hospitals that have any type of compounding of sterile products, which they virtually all do. There are waiting areas and emergency rooms wherein every day of the week, people walk into the hospitals from the street. And until they’ve been seen and diagnosed, there’s no way to know whether these people who are sitting in your waiting room or your ER or your outpatient clinic have an infectious disease of some type. There are also positive pressure applications where you’re trying to protect patients, bone marrow treatment patients, burn victims, people like that who have a high degree of sensitivity to airborne contaminants,” said Shagott.

“Any product that lowers contamination rates among the hospital population is extremely desirable and worth its weight in gold,” said Envirco’s Miller. HPN