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2009 Advisories and Alerts

Proposed Change to Reduce Minimum Humidity Levels to 20% for Short-Term Patient Treatment Stay Areas (Including Operating Rooms) (December 8, 2009)

ASHRAE Standing Standard Project Committee (SSPC)-170 has issued a public notice for a proposed addendum "d" that would lower the minimum design humidity levels for short-term patient treatment stays from 30% to 20% RH in ASHRAE Standard 170-2008: Ventilation of Health Care Facilities. This standard, and all approved addenda, have been fully incorporated into the 2010 edition of the FGI Guidelines for Design and Construction of Health Care Facilities; therefore, if this proposed addendum is approved, the 2010 Guidelines will officially have been modified.

Request of ASHE Membership:

We need your input on this proposed change by the deadline of January 4, 2010.

CMS Issues Survey and Certification Letter on Damper Testing (October 30, 2009)

On October 30, 2009, the Centers for Medicare & Medicaid Services (CMS) issued a categorical waiver to permit hospitals to operate under the damper testing cycle of the 2007 editions of NFPA 80 and NFPA 105 without special application to CMS. ASHE appreciates this proactive action by CMS, which brings it in line with the Joint Commission and state agencies. The letter, issued by the Survey and Certification Group to state agencies under contract with CMS, directs the state to disseminate this information within 30 days of the date of the memorandum.

AHA Special Bulletin: Sen. Max Baucus (D-MT) Releases Statement on "America's Healthy Future Act of 2009" (September 16, 2009)

Baucus, chair of the Senate Finance Committee, today released the chair’s mark of the “America’s Healthy Future Act of 2009.” The health care reform bill expands coverage, introduces new delivery system reforms, reduces Medicare and Medicaid payments, and includes key provisions agreed to by the AHA, Catholic Health Association, and Federation of American Hospitals.

Regulatory Advisory: The Joint Commission Continues to Accept Six-Year Fire and Smoke Damper Testing in Hospitals (September 9, 2009)

In the June 2009 print version of its accreditation manuals, the Joint Commission published erroneous time-frame requirements for testing fire and smoke dampers in hospitals and critical access hospitals, calling for testing every four years instead of every six years. This error also appears in the electronic version (E-dition) of the manuals dated July 1, 2009. This four-year testing frequency for hospitals is a misprint. To alert users to the error, the Joint Commission published the following correction for the 2009 accreditation manuals in the August edition of Joint Commission Perspectives:

Applicable to hospitals and critical access hospitals
EC.02.03.05, EP 18
The [organization] operates fire and smoke dampers 1 year after installation and then at least every 6 years to verify that they fully close. The completion date of the tests is documented.
Note 1: The initial test that must occur 1 year after installation applies only to dampers installed on and after January 1, 2008.
Note 2: For additional guidance, see NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2007 edition ( and NFPA 105, 2007 edition (6.5.2).

Read the full text of this advisory on damper testing Members Only Adobe PDF on the ASHE Web site.

Regulatory Advisory: UpdateNFPA 99: Standard for Health Care Facilities (August 24, 2009)

Over the past five years, the draft 2010 edition of NFPA 99 has undergone major revisions that will affect how its requirements are applied to the health care field. As we earlier reported to the ASHE membership, the revised standard was presented to the NFPA membership for approval in June 2009. The members voted to "return the document to committee," which means it must undergo further review by the NFPA 99 Project Technical Committees and the public before it can be issued. The decision to return the document for further review may appear harsh; however, in reality this rewritten standard—essentially a brand-new document—needs additional analysis.

In August 2009 the NFPA Standards Council issued a decision stating that, once the process of further review is complete, the revised NFPA 99 document will be presented for approval at the 2011 NFPA annual conference, which will be held June 12–15, 2011, in Boston. If there ever was an opportunity to get NFPA 99 right, now is that time.

To learn what this means to you as an ASHE member, read more about updates to NFPA 99. Members Only Adobe PDF

Guidance Statement to Membership: UpdateCMS Waiver Requirement for Extending Damper Testing to Six Years (August 24, 2009)

As many of you know, what at first seemed to be cut-and-dried instructions from CMS to the ASHE membership for extending the damper-testing requirements turned out to be a real challenge to the CMS waiver process. After years of discussion and negotiation to gain CMS approval for use of a later edition of NFPA 90A (the damper-testing requirements are actually contained in NFPA 80 and 105), we were instructed to proceed with requests for waivers as explained in the ASHE Guidance Statement to Membership issued in July 2009. When ASHE members began requesting the waivers, the CMS system came to a screeching halt as there is no mechanism for the CMS state authorities or regional offices to process a waiver for something that has not been cited during a survey.

ASHE staff has been working with CMS and the director of its Survey and Certification Group to find a resolution to this dilemma. To learn more about this effort and how you can help, please read the full text of this Guidance Statement Members Only Adobe PDF on the ASHE Web site.

Advocacy Alert: Hospira Recalls AC Power Cords Used for Infusion Pumps, Cardiac Monitoring Systems, Etc. (August 18, 2009)

Hospira Inc. has recalled certain Hospira devices with defective AC power cords made by Electri-Cord Manufacturing Corp. Hospira said the cords could cause the devices to fail or result in an electrical shock or fire. The company advised customers to immediately stop using devices with cords that have bent or cracked prongs, burned plastic, or excessive wear and tear. Regular monitoring of affected power cords without these characteristics is advised until the cords can be replaced. Customers should contact the company for instructions on receiving replacement parts or devices. For the company’s press release, visit

For further information, contact John Collins at

Guidance Statement to Membership: CMS Waiver Requirement for Extending Damper Testing to Six Years

As many of you are aware, the NFPA codes have been changed to permit a six-year testing frequency for fire and smoke dampers in hospitals. In its standards, the Joint Commission has recognized these new requirements as an enhancement to the overall safety of health care environments. Compliance with the six-year testing frequency will reduce necessary shutdowns of hospital ventilation systems as well as the number of times dampers in patient-occupied environments will need to be accessed. The new requirements will also result in significant cost savings.

Advocacy Alert: House Reform Bill Cuts Billions From Payments for Hospital Services

Urge your representative to reject proposed cuts.

The hospital field supports true health care reform, but we must band together to fight cuts contained in the draft reform bill released by House leaders Friday. The cuts come in two major areas:

Permanent update cut: The draft bill proposes a permanent cut to Medicare's annual hospital Market Basket updates that we estimate could cut payments for hospital-based services by an estimated $150 billion or more over 10 years. The bill also includes an aggressive readmissions policy that would cut billions more.

Public plan paying Medicare rates: The draft proposes a public insurance plan that would pay Medicare rates for hospitals for the first two years. After that, the rates would be set by the HHS secretary . . . and we have no reason to believe those rates would surpass Medicare rates. With a fairly rapid phase-in, the public plan would eventually be available to all, potentially attracting millions more patients to a plan that continues to underpay for hospital services. An estimate by the Lewin Group, a private consulting firm, shows that if rates continued at Medicare levels, the plan could result in as much as $36 billion in annual lost revenues to hospitals.

Please see the fact sheets (below) for more information on these two issues, and please contact your representative today. Also, take advantage of the upcoming June 29 July 3 congressional recess to help your representative understand that hospitals are for true reform, but arbitrarily cutting hospital payments does not help patients or communities.

Proposed Rule for National Emission Standards for Hazardous Air Pollutants for Reciprocating Internal Combustion Engines (May 6, 2009)

The EPA is soliciting comments for the above proposal. The proposal will potentially affect all hospital emergency generators but will not require hospital engineers and facility managers to change what they typically already do.


Interim Guidance Document on Swine Flu from the Centers for Disease Control (CDC) (April 30, 2009)

The CDC's Interim Guidance Adobe PDF document on swine flu gives some very good direction on how to prepare for an influx of patients with flu-like symptoms. The document emphasizes that swine flu is not a small-particle airborne virus; therefore, there is no need to modify standard ventilation practices, convert additional rooms to provide airborne infection isolation protection, or place HEPA filtration devices in waiting rooms or lobbies.

The document does include some facility-related recommendations, however:

  • Set up screening areas at entrance points into the facility.
  • As the need increases, designate additional waiting spaces for patients who need to be isolated. (This does not require turning that space into a negative environment.)
  • Continue to review your pandemic plan for an increase in patient volume and potential staffing limitations. Remember, this is not an airborne virus
  • Perform procedures that are likely to generate aerosols (e.g., bronchoscopy, elective intubation, suctioning, administration of nebulized medications) in a location with negative pressure air handling whenever feasible. Patients with swine flu do not need to be placed in an airborne infection isolation (AII) room or environment.
  • Monitor rooms used for procedures generating aerosols and document the negative airflow and air exchanges.
  • Schedule and control visits to allow for appropriate screening for acute respiratory illness before visitors enter the hospital, and provide visitors with appropriate instruction on use of personal protective equipment and other precautions (e.g., hand hygiene, limiting surfaces touched) while in the patient's room. Visitors should also be instructed to limit their movement within the facility.
  • Post signage at entry points instructing patients and visitors about hospital policies, including the need to notify staff immediately if they have signs and symptoms of febrile respiratory illness. Facilities in communities where swine influenza transmission is occurring should limit points of entry to the facility.
  • Facility staff working in and around patients with swine flu should be medically cleared, fit-tested, and trained for respirator use, including proper fit-testing and use of respirators, safe removal and disposal, and medical contraindications to respirator use.

Contact Douglas Erickson by e-mail for further information.

Regulatory Advisory: CDC Guidance on Swine Flu (April 27, 2009)

As of Monday afternoon April 27, 2009, 40 cases of swine flu have been confirmed in 5 states. In response to this rapidly evolving issue, ASHE has prepared an advisory based on information posted on the Centers for Disease Control and Prevention (CDC) Web site.

Regulatory Advisory: Revised 2009 Joint Commission Hospital Accreditation Standards (March 26, 2009)

On March 26, 2009, the Joint Commission issued revised requirements for the Hospital Accreditation Program. These revisions replace the draft revised requirements issued on January 5. In the new revisions, the number of new or modified elements of performance (EPs) has been reduced from 165 to 87.

Statement from ASHE: American Recovery and Reinvestment Act Update (March 19, 2009)

The recently passed American Recovery and Reinvestment Act of 2009 includes funds that affect the health care sector of the economy.

Regulatory Advisory: Joint Commission Publication of Standards Errata (February 12, 2009)

The Joint Commission published errata to the 2009 Joint Commission standards in the February 2009 issue of Joint Commission Perspectives ®, (vol. 29, no. 2). [More ...] Members Only

Regulatory Alert: The Joint Commission New and Revised 2009 Accreditation Requirements (January 8, 2009)

On January 5, 2009, the Joint Commission posted a 46-page document titled "New and Revised 2009 Accreditation Requirements, Hospital Accreditation Program" on its Web site. It appears these new and revised requirements, which are in addition to the revisions included in the 2009 Comprehensive Hospital Accreditation Manual, have not been released or published through any Joint Commission sources other than its Web site. This has led to confusion about compliance requirements among accredited hospitals and health care organizations.

Advocacy Alert: Signatures needed on House Letter Urging President-Elect to Include Hospital Issues in Economic Recovery Package (January 7, 2009)

The first priority of the Obama administration will be to enact an economic recovery package. Reps. Robert Brady (D-PA) and Joe Wilson (R-SC) have asked their House colleagues to sign a letter urging the president-elect to include relief for hospitals in the plan. Has your representative signed? The letter cites the "necessity of maintaining the economic health of our nation's hospitals" and notes that hospitals are among the nation's largest employers—five million jobs nationwide.