Ventilation Requirements for Healthy Hospitals

Posted by Jason Di Marco on November 03, 2016
Jason Di Marco


The Joint Commission and NFPA have stringent requirements in place to keep your patients, employees and visitors safe. One of those requirements and concerns as a healthcare manager is the ventilation in your care areas and hazardous areas.

Room pressurization should be either positive or negative with respect to neighboring areas. 

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What is Ventilation in a Healthcare Facility

When we think of ventilation in general it is simply moving air from one location to another through duct work. Air is cleaned by filters and released into the space intended. When it comes to hospitals, we go a level deeper with specific rooms needing to be either positively or negatively pressurized with respect to adjacent areas.

The purpose of positive pressure is to ensure airborne pathogens do not contaminate a patient or equipment and supplies in that room. So extra air is pumped into these rooms to push contaminates away from entering. Negative pressure, sucking air out of the room, is used to pull any potential contaminants out of an area and exhaust them to the outside air, usually out the roof.

The opposite of releasing air into a room is removing air from its space through the exhaust system.

According to George Mills, Director of Engineering - The Joint Commission, based on "how much air is exhausted and how much air is supplied, the area is considered either negative, neutral or positive."

  • more air out, negative pressure
  • same air in and out, neutral
  • more air in, positive pressure

TJC Performs Ventilation Pre-Screen Test

As part of The Joint Commission’s requirement, rooms must be tested and documented to confirm they meet their rating as negative or positive pressurized. A simple pre-screening test known as the “tissue test” is used as a tool to evaluate if any investigation is further needed.

A room is positive if the tissue is blowing away from the room and negative if the tissue is drawn into the room. Professional inspectors and HVAC specialists have equipment to measure relative pressures, volumes and air exchanges.

An example of a negative pressure room would be a patient with active Tuberculosis. The germs are "sucked out" of the room and exhausted, not spread around the hospital. Conversely a patient with burns or open wounds would be in a positively pressurized room to discourage pathogens in the hospital from getting to the patient.

A life safety surveyor will note the deficiency if a marked room is not in compliance with TJC's standard (EC.02.05.01). With the standard in place, ventilation requirements can become an issue with a 46% findings for healthcare facilities. An issue could be air pressure, filtration and air changes in critical areas such as the OR.

Positively pressured rooms are typically considered the cleanest rooms in the hospital. Think of an OR that needs to protect the patient and all the sterile surgical supplies.


Controlling your air flow will benefit your patients, employees and visitors. It will also keep you compliant with The Joint Commission. There are safety measures to be taken in order to provide a safe environment.

CHT can provide pressure and air flow tests with documentation as part of your CHx program profile that satisfies the code and statute. CHT inspectors and verifiers speak TJC, CMS, NFPA99-2102, ASSE, OSHA, FGI and several other languages to help everyone breath easier.

They can assist in making sure your rooms are appropriately pressurized and you will not get cited for EC.02.05.01.[EP 15]

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photo credit: Health

Topics: Medical Gas Compliance

Jason Di Marco

Jason Di Marco

President at Compliant Healthcare Technologies, LLC
Jason Di Marco has been intimately involved with helping hospitals protect and improve their medical piped gas systems from CHT's beginnings. He is certified by ASSE, NITC, and NFPA as an inspector and installer and has worked with major institutions from construction to risk assessment planning.