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HVAC Design Criteria for Isolation Ro

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Issue : July-September 2002

HVAC Design Criteria for Isolation Rooms

By Pranab K. Chowdhury
General Manager Engineering
Blue Star Ltd., Gurgaon
and
Samta Bajaj
Consulting Engineer, New Delhi
Pranab K. Chowdhury is a mechanical engineer from the University of
Pantnagar with 23 years experience in HVAC design. He is a member of ASHRAE,
ISHRAE and The Institution of Engineers.
Samta Bajaj is a mechanical engineer from Delhi College of Engineering with 13
years of HVAC experience, of which 11 years were in Blue Star Ltd. She now works as
an independent consultant and has been involved in the design of eight different
hospital projects. She is a member of ISHRAE.
Airborne transmission of respiratory diseases in indoor environments remains a
problem of indoor air quality. Microbial predators have existed since time immemorial,
but transmission had always required direct contact, because they could not tolerate the
sunlight and temperature extremes outdoors. Mans cozy new habitats made it possible
for these ancient parasites to survive short airborne trips between hosts.
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All hospitals knowingly or unknowingly admit patients with communicable diseases.

In recent years, the transmission of nosocomial infection has become a serious threat for
health care facilities. Technically, nosocomial infections relate to those who are
hospitalized, but health care professionals may themselves be at risk. OSHA* states that,
The most effective way to prevent or lessen transmission of nosocomial infection
(hospital acquired) is to isolate the airborne contaminant and to provide an environment
that will promote reduced exposure to contaminant.

Infectious or protective Isolation rooms in hospitals prevent nosocomial

transmission and provide safety and protection for patients, staff and visitors. An
airborne infectious isolation room is constructed to minimize the migration of air from an
isolation room to other areas of health care facilities. Where possible, a patient known or
suspected to harbour transmissible microorganisms should be placed in a single room.
This prevents direct or indirect contact transmission or droplet transmission. A single
isolation room with appropriate air handling and ventilation is particularly important for
reducing the risk of airborne transmission of microorganisms from a source patient to
susceptible patients and other persons in hospital.
Infection and disease can be contained by maintaining a pressure differential
between the isolation room and the surrounding areas. Rooms held at negative pressure
are used for patients with highly infectious diseases such as tuberculosis (TB). Similarly,
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immuno-suppressed patients who are vulnerable to disease and infection, such as burn
victims, bone marrow and organ transplant recipients, patients with leukemia etc. are
put into isolation rooms held at positive pressure to keep contamination out.

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Modes of Infection Transmission

Transmission-based infection control practices are central to preventing the
transmission of microorganisms within health care settings. Microorganisms are
transmitted in hospitals by three main routes : Direct or indirect contact with patient
and patient care items; droplets (particles larger than 5m) that are generated from a
source person during talking, coughing, sneezing or during medical procedures like
bronchoscopy and autopsy (Figure 1); and the airborne droplet nuclei (particles 5 m
or smaller) that are generated as the airborne droplets lose their weight through
evaporation. While transmission through contact or via large particle droplets requires
close contact between source and recipient persons, the airborne contaminants can
remain suspended for hours and spread by diffusion or air currents.
These airborne microbes lose viability over time with air decay rates depending on
size. (Figure 2).
The control of airflow through special provisions made in HVAC systems designed
for isolation rooms can help to prevent the spread of these infectious contaminants to
surrounding areas. This is achieved by controlling the quality and quantity of intake and
exhaust air, diluting infectious particles in large volumes of air, maintaining differential
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air pressure between adjacent areas and designing air flow patterns for specific usage of
areas.
This article is intended to touch upon the engineering practices and technology
required for effective HVAC design for isolation rooms meant to prevent airborne
transmission route.

Where are Isolation Rooms Required?

The Centers for Disease Control and Prevention (CDC) TB Guidelines (1994), OSHA TB
Enforcement Policy (1996) and proposed TB rule (1997) provide the federal guidelines
and regulations for isolation rooms. In April of 2001, the American Institute of
Architects (AIA) have called for more stringent practices in the new revision to their
Guidelines for Design and Construction of Hospital & Health - Care Facilities. These
guidelines require isolation rooms for a number of areas in the health care facility if
determined by an infection control risk assessment. These areas include medical and
surgical nursing units, critical care units, pediatric care units, newborn intensive care
units, emergency service areas, nurseries and also other areas such as renal dialysis, if
they require isolation rooms.

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[top]

Table 1 : Functional classification of isolation rooms

Class S

Class N

Class P

Class A

(Standard)

(Negativ e)

(Positiv e)

(Alternating)

Key

No air pressure

Lower air

Greater air

V entilation

V entilation

difference

pressure in the

pressure in the

controlled to

Criteria

between the

room than in

room than in the

achiev e either

room and the

adjacent

adjacent corridor positiv e or

adjacent

corridor

negativ e pressure

corridor

in the room

Transmission To prev ent

To prev ent

To prev ent

Not

based

contact or

airborne

transmission of

recommended

precautions

droplet

transmission

pathogens from

transmission

outside
env ironment to
immunosupressed
patients

Ex amples

Hepatitis A,

Measles,

Prev ention of

meningococcal

chicken pox ,

infection in bone

infection

tuberculosis

marrow or organ

Not recommeded

transplant
recipients

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Classification of Isolation Rooms

Table 1 gives a functional classification of isolation rooms. The classification is based on
the basic design principle for pressure control of isolation room as illustrated in the
isometric view shown in Figure 3.
It includes an anteroom or airlock which has three functions:
To provide a barrier against loss of pressurisation, and against entry / exit of
contaminated air into / out of the isolation room when the door to the airlock is
opened.
To provide a controlled environment in which protective garments can be donned
without contamination before entry into the isolation room.
To provide a controlled environment in which equipment and supplies can be
transferred from the isolation room without contaminating the surrounding areas.

[top]
In this diagram, air is supplied to the isolation room and exhausted from both the
isolation room and the anteroom. The balance of airflow, or the difference exhausted will
dictate whether the room experiences positive or negative pressure with respect to
ambient. There are different possible airflow configurations for pressure control which
are discussed later in this article.
Table 2 : Air change rates and removal
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efficiencies of airborne contaminants

Minutes Required for :
Air

90%

99%

99.9%

Changes Rem ov al Rem ov al Rem ov al

Per
Hour
1

1 38

27 6

41 4

69

1 38

207

46

92

1 38

35

69

1 04

28

55

83

23

46

69

20

39

59

17

35

52

15

31

46

10

14

28

41

12

12

23

35

14

10

20

30

16

17

26

18

15

23

25

11

17

30

14

40

10

50

Design Guidelines
The CDC* acknowledges as the second level of importance, the use of engineering
controls to prevent the spread and reduce the concentration of infectious droplet nuclei.
This includes source control, directional airflow, general ventilation for dilution, removal
of contaminated room air and air cleaning through HEPA filteration. The engineering
controls also refer to the ultraviolet germicidal irradiation (UVGI) and personal
respirators which are not covered in this article.

Source Control
The use of local exhaust ventilation to remove airborne contaminants at or near their
source is an effective infection control measure. There are two types of source control
ventilation devices that are commonly used. These are capture type and enclosing type.
Figure 4a shows a capture type enclosure that is designed to capture infectious
l i
ll d f
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i f t d

dt

Fi

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nuclei expelled from an infected person in procedure and treatment rooms. Figure 4b
shows a hood device used in clinical laboratories when working with highly infectious
materials such as Mycobacterium tuberculosis. Figure 4c shows an isolation tent that
is used around the patients bed or other areas during high risk procedures.

[top]
Additionally enclosing type devices such as sputum induction chambers (Figure 5a
& 5b) are available. These enclosures are maintained at a negative pressure with
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respect to surrounding areas at all times. The exhaust air is passed through HEPA filters
and thereafter can be discharged into the room or outside the building. The CDC and
OSHA standards recommend 99.9% removal efficiency of the airborne particle during
the interval between the departure of one patient and the arrival of the next without
respiratory protection.

Air Change Rates

Just one airchange with fresh air can remove 63% of suspended particles from the room
air. If a ventilation system can perform 10 airchanges per hour (ACHs), it takes 14
minutes to remove 90% of airborne contaminants in a room and 28 minutes to remove
99%. Thus increased number of fresh air changes per hour is effective for cleaning
airborne contaminants. However, the higher air change rate may cause turbulence and
the cost for ventilation itself will be too high. Therefore, a recommended compromise of
12 ACHs or more is proposed which should be achievable when the filters have reached
their maximum pressure drop.

Table 3 : Ventilation air change rates for isolation rooms

CDC

Pressure

Guidelines

Relationship Air

T otal Air

Ex hausted of Air Within

to Adjacent

Changes

Changes

Directly to Room s

or

Per Hour

Outdoors? Allowed?

Spaces

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Minim um Minim um All Air

O td

Recirculation

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Outdoor
Air Per
Hour
Infectious

Y es

OPTA

12

Y es

OPTA

6B

Y es

No

15

Y es

OPTA

10

Y es

No

12

No

12

No

10

Y es

No

Isolation Room
(in ex isting
facilities)
Infectious
Isolation Room
(in new
facilities)
ASHRAE 99 Appl. Hbk
Infectious
Isolation Room
Protectiv e
Isolation Room
Isolation Room
A nteroom
AIA Guidelines 1996-97
Infectious
Isolation
Room A
Protectiv e
Isolation
Room A
Isolation Room
A nteroom

[top]

General Ventilation
The purpose of general ventilation is to dilute and remove contaminants generated in the
space. Recommended ventilation rates and pressure relationships for hospital isolation
rooms as available in various guidelines is shown in Table-3

Directional Airflow
This technique is used to isolate an entire area that can be a group of isolation rooms or a
ward for infectious patients. The directional airflow is achieved by pressurisation control
by supplying air to areas of least contamination (greatest cleanliness) and stage this air
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to areas of progressively greater contamination potential. Figure 6 illustrates the basic

principle of cascading airflows from clean areas to relatively contaminated areas.
In the above diagram, a facility is depicted which has offices and isolation rooms,
separated by corridors and other areas (storage rooms, labs). Air is supplied to the
areas, usually offices, maintained at the greatest positive pressure (marked with a ++),
and exhausted from the areas maintained at the greatest negative pressure (marked
with a ). Transfer air (exfiltration/infiltration) is identified with purple arrows. The
unlabeled rooms in the diagram above could be laboratories, which usually have
independently operating exhaust hoods or separate ventilation systems. If not, they
would be generally designed as double negative pressurization areas.

Air Filtration
For infectious isolation rooms, where recirculation of room air is allowed, the return air
should be HEPA filtered. For protective isolation, the supply air should also be HEPA
filtered. HEPA filtration can be used as a method of air cleaning that supplements other
recommended ventilation measures. HEPA filters should be used:When the HVAC system configuration dictates recirculation of air from the
isolation room to other parts of the facility.
when it is impossible for air from an infectious isolation room and /or local
exhaust devices to be exhausted directly outdoors.
when air is being recirculated into the same infectious isolation room.
The guidelines do not mandate the exhaust air from an infectious isolation room to
be HEPA filtered before being discharged outdoors unless there is any chance that the
exhaust air could reenter the system. However, there is always a possibility of exhaust
re-entry under certain wind and climatological conditions. It is, therefore, preferable to
filter all exhaust air.
HEPA filters have an efficiency to capture at least 99.9% particles of all sizes greater
than or equal to 0.3 mm. For droplet nuclei, which are considerably larger, the capture
efficiency is virtually 100%. HEPA filters should be prefiltered to increase their life and
reduce costs. While designing airflow rates, special attention should be given for volume
control to compensate for increasing pressure drop over the life of the filters. Filter
replacements require bag-in / bag-out procedures to minimise risk of exposure of the
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maintenance personnel to the infectious material.

Measurement of filter pressure drop and regular monitoring is also recommended.

[top]

Room Air Distribution

Figure 7 shows two possible room air distribution methods as stated in the CDC
guidelines. Laminar (horizontal or vertical) flow distribution is preferable. Introduction
of low velocity air near the ceiling at the entrance of the room, flowing past the patient,
and exhausted or returned close to the floor at the head of the patient bed. An airflow
pattern is thus established which helps to move microorganisms from the point of
patients expulsion to the exhaust / return air terminal to prevent health care workers
or visitors from inhaling the bacteria. Air should be supplied through non-aspirating
diffusers (typically perforated face) to prevent updrafts and to provide a laminar flow of
air which will flush the isolation room of unwanted airborne particles. The diffuser should
be placed away from patient bed, preferably near the point where a health care worker
or visitor would enter the room. The placement of the diffuser immediately over the
patient bed would result in uncomfortable drafts being projected directly at the patient.
Room air temperature should be 24C and humidity should be designed in the range of
30-60 percent.

Supply and Exhaust Air Duct Design

The duct work of a negative pressure isolation room must not communicate with the
duct work of the rest of the hospital. Duct work should be designed to reduce the
possibility of cross-contamination in the event of fan failure. This can be accomplished by
ducting each negative pressure isolation room separately from the air-handling unit.
Separate long duct work runs from the air-handling unit increase static pressure and
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reduce the contaminated airflow in the event of a failure.

Supply and exhaust systems should be designed as failsafe (for example, using
duplex fans) to prevent contamination of any area within the facility in the event of fan
failure. The exhaust fan should be located at a point in the duct system that will ensure
that the entire duct is under negative pressure within the building.

Negative Pressure Isolation Rooms

Negative pressure isolation rooms (Figure 8 ) maintain a flow of air into the room, thus
preventing contaminants and pathogens from reaching surrounding areas.
The air pressure differential which is required to be maintained is 0.001" wg. This is
generally accomplished by maintaining an inward velocity of 100 fpm, or exhausting
10% of the airflow, or exhausting 50 cfm more than the supply. There are three possible
airflow / control designs which differ in pressure relationship of anteroom to isolation
room and the corridor. Refer Table 4.
Table 4 : Alternate designs for infectious isolation room airflow
Design #1I

Design #2I

Design #3I

RELAT IVE

Anteroom

Anteroom

Anteroom Net

PRESSURE

Negativ e to

Positiv e to

Neutral; Negativ e to

RELAT ION-

Isolation Room

Isolation Room

Room , Positiv e to

SHIPS

and Corridor

and Corridor

Corridor

Isolation Room to
Corridor
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Corridor
A nteroom to
Corridor
Toilet Room to
Corridor

[top]
Design # 1 I : Anteroom negative to isolation room and corridor
This design has two advantages: There is no need to supply air to and delicately balance
the anteroom, and if the anteroom becomes contaminated there is still a pressure buffer
between the anteroom and the corridor. The disadvantage is; since the anteroom is
negative with respect to the isolation room, the chance of contaminating the anteroom is
higher.
Design # 2 I : Anteroom positive to isolation room and corridor
This design also has two advantages. There is no need to exhaust air from and delicately
balance the anteroom, and since the anteroom is positive with respect to the isolation
room, the change of contaminating the anteroom is lower. The disadvantage is: If the
anteroom does become contaminated, it is likely that the corridor will become
contaminated as well. So, this design is not recommended.
Design # 3 I : Anteroom net neutral; positive to isolation room and negative to
corridor
This design incorporates the best features of the other two designs. The advantages are:
Since the anteroom is positive with respect to the isolation room, the chance of
contaminating the anteroom is lower, and if the anteroom becomes contaminated, there
is still a pressure buffer between the anteroom and the corridor. The disadvantage is
increased cost and complexity of the controls and balancing.

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Positive Pressure Isolation Rooms

Positive pressure isolation rooms (Figure 9) maintain a flow of air out of the room thus
protecting the patient from possible contaminants and pathogens which may otherwise
enter. The application of these rooms is for immuno-suppressed patients. The design
criteria for positive pressure isolation rooms are similar to the negative pressure
isolation rooms with the only difference that the supply air is filtered through HEPA
filters. There are three possible airflow / control designs for positive pressure isolation
rooms which differ in pressure relationship of anteroom to the isolation room and the
corridor. Refer Table 5.
Table 5: Alternate designs for positive isolation room airflow
Design #1P

Design #2P

Design #3P

RELAT IVE

Anteroom

Anteroom

Anteroom Net

PRESSURE

Negativ e to

Positiv e to

Neutral; Negativ e to

RELAT ION-

Isolation Room

Isolation Room

Room , Positiv e to

SHIPS

and Corridor

and Corridor

Corridor

Isolation Room to
Corridor
A nteroom to
Corridor
Toilet Room to
Corridor

[top]
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Design # 1 P : Anteroom negative to both isolation room and corridor

This design has two advantages: There is no need to supply air to and delicately balance
the anteroom, and if the anteroom becomes contaminated there is still a pressure buffer
between the anteroom and the corridor. The disadvantage is: Since the anteroom is
negative with respect to the corridor, the chance of contaminating the anteroom is
higher.
Design # 2 P : Anteroom positive to both isolation room and corridor
This design also has two advantages. There is no need to exhaust air from and delicately
balance the anteroom, and since the anteroom is positive with respect to the corridor,
the change of contaminating the anteroom is lower. The disadvantage is: If the anteroom
does become contaminated, it is likely that the isolation room will become contaminated
as well. So, this design is not recommended.
Design # 3 P : Anteroom net neutral; negative to isolation room and positive to
corridor
This design incorporates the best features of the other two designs. The advantages are:
Since the anteroom is positive with respect to the corridor, the chance of contaminating
the anteroom is lower, and if the anteroom becomes contaminated, there is still a
pressure buffer between the anteroom and the isolation room. The disadvantage is
increased cost and complexity of the controls and balancing

Energy Conservation
The use of 100% outside air in Class N isolation room is relatively energy-intensive.
However, the use of heat recovery wheels is not recommended (unless incoming air is
also HEPA filtered) due to possible cross-contamination of incoming clean side air.
Devices such as run around coils are more appropriate.

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[top]

Renovations
During renovations of existing patient rooms, there may not be enough space available to
create an anteroom. A possible solution is to create two isolation rooms and a common
anteroom from three existing patient rooms. Figure 10 shows a possible layout for such
conversion.
The isolation rooms should be airtight and well-sealed from the surroundings to help
maintain the pressure differential. All utility penetrations through walls / ceilings must
be properly sealed.

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Room Pressure Controls

The two common methods of isolation rooms differential pressure control are Flow
Tracking measurement & control and Differential Pressure measurement & control
(Figure 11). In flow tracking system, the exhaust and supply flow rates from and to
space are measured and controlled to produce a desired infiltration or exfiltration.
In differential pressure system, the actual differential pressure between the isolation
room and the corridor is taken by measuring the velocity of air induced through a hole in
the envelope between the isolation rooms and corridor created by the differential
pressure.
However, the magnitude of this differential pressure being too small, it is affected by
other factors like building stack effects, elevator effects, wind etc., and as such it is
difficult to measure. There are accurate ultra-low-differential pressure transducers
available, but their cost is very high.
Neither OSHA, nor CDC require the use of room differential pressure monitors but
both agencies accept their use, provided that they measure down to 0.001 wg.
As a minimum, air pressure relationships from the isolation room to the adjacent
anteroom or corridor should be indicated with a mechanical gauge. Air pressure drop
across filters should be indicated with a mechanical gauge or manometer.
Programmable microprocessors with features like temperature and humidity
control, system status, continuous data logging, malfunction display, visual alarms, air
changes per hour, display and monitoring, pressure indication and remote monitoring
and alarm are also available nowadays.

Emergency Rooms & Reception Areas

In public areas of a health care facility such as an emergency room, reception and waiting
areas, persons with undiagnosed active infection can come in contact with and infect
others prior to examination and treatments. As such, these areas should be maintained
at negative pressure to prevent contaminated air from reaching sensitive areas. Return
air from these areas should be either HEPA filtered or to a minimum 95% filtered. This
will remove all or most of the infectious droplet nuclei.
TB is posing an ever-increasing threat in health care facilities. Patients get admitted
in hospitals for getting healthy but can contract TB infection during their stay for
treatment in the hospitals. Preventing the transmission of TB and other infectious

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treatment in the hospitals. Preventing the transmission of TB and other infectious

diseases, requires the use of both old proven methods as well as new technology in
HVAC system design.
This article touched upon new guidelines, practices, techniques and technologies in
HVAC system design for isolation rooms, addressing the need to upgrade infection
control. When these are applied prudently and correctly, the risk of infection
transmission can be significantly controlled.
Bibliography
1. Centers for Disease Control, Guidelines for Preventing the Transmission of
Tuberculosis in Health Care Settings - with special focus on HIV Related Issues.
2. Centers for Disease Control, Guidelines for Preventing the Transmission of
Mycobacterium Tuberculosis in Health Care Facilities, 1994.
3. American Institute of Architects : Guidelines for Construction and Equipment of
Hospital and Medical Facilities, 1996-1997.
4. ASHRAE Chapter 7, Health Facilities, 1999 ASHRAE Handbook : HVAC
Applications, American Society of Heating, Refrigerating and Air-conditioning
Engineers.
5. ANSI / ASHRAE, Ventilation for Acceptable Indoor Air Quality, American Society
of Heating, Refrigerating and Air-conditioning Engineers. Standard 62-1999.
6. Gill Kenneth E., HVAC Design for Isolation Rooms, HPAC February 1994
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