Temperature and Humdity Monitoring Surgical Services.pdf

TEMPERATURE AND HUMIDITY MONITORING SURGICAL SERVICES

SOP NUMBER Surg.Serv.OR.17 Montana VA Health Care System Fort Harrison, MT 59636

Signatory Authority:

Chief of Surgery

Responsible SOP Owner:

Nurse Manager of Surgical Services

Service Line:

Surgical Services

Effective Date:

02/25/2022

Recertification Date:

02/25/2027

1. PURPOSE AND AUTHORITY: To define responsibilities and procedures for the 24-hour monitoring of temperature and humidity within Surgical Services. Monitoring is an important factor in infection prevention. It is necessary to protect the integrity and safety of medications, solutions, sterile instruments, and sterile supplies. Temperature and humidity requirements are indicated by manufacturers for the safe operation of equipment in the surgical suite/procedural areas. Monitoring of temperature and humidity prevent loss, deterioration, and/or potential contribution to adverse outcomes.

Refrigerators designated for employee use are excluded from the scope of this SOP.

2. PROCEDURES:

a. TEMPERATURE AND HUMIDITY MONITORING

(1) The current temperature .and humidity monitoring system used at MTVAHCS is TempTrak®; troubleshooting instructions below are specific to the TempTrak® system. The monitoring system provides timely notification regarding deviations from the prescribed temperature and humidity ranges to enable prevention and/or corrective action. TempTrak® can be accessed at http://10.184.161.36/TempTrak/Login.aspx?OUID=2

(2) Each area of the surgical suite/procedural areas requiring monitoring will be equipped with a temperature and humidity monitoring sensor capable of sending an alert if temperature or humidity fall outside the established range.

(3) Areas of Surgical Services under 24-hour surveillance by department:

(a) Operating Room Suite:

1. OR A (Room 217A)

2. OR B (Room 2178)

3. Anesthesia Work Room (Room 218)

4. Implant Room (Room 208)

5. Sterile Core (Room 220) and Instrument Room (Room 229)

These two rooms have airflow communication http://10.184.161.36/TempTrak/Login.aspx?OUID=2

02/25/2022 Surg.Serv.OR.17

6. Warming Units

7. Humidors (Climate Control Chambers)

(4) The parameters for temperature and humidity are in Appendix A.

(5) During After Hours/WHEN Hours (Weekend, Holiday, Evening, Night), the

Admin Officer of the Day (AOD) will conduct monitoring of Surgical Services via TempTrak®.

a. When the AOD receives an alert, he/she will notify the Nurse on Duty

(NOD). If the cause is obvious and short duration, the NOD will take corrective action and clear the alert in TempTrak®.

b. If the cause is NOT obvious and equipment is involved (blanket warmer, fluid warmer), the NOD will:

1. Remove contents form the blanket warmer or fluid warmer,

2. Place a work order to Biomed,

3. Secure a copy of the workorder to the front of the equipment.

c. If the cause is not obvious and an OR Suite or Sterile Supply/Instrument Storage Area is involved, the NOD will:

1. Place a work order to Facilities,

2. Call the VA Police Department (7911) and state the issue.

Instruct the FH PD to notify Facility Maintenance Services at (406) 447-7393 (facilities boiler plant, who may call Facilities Chief based on urgency).

3. Conduct a risk assessment to determine the integrity of the supplies/instruments/equipment and/or the ability to use the suite/room.

(1) Based on the situation, action may be needed to protect supplies/inventory/equipment. In this situation, notify Surgical Services On-Call Staff, and the Chief of Surgery of the situation.

b. TROUBLESHOOTING

(1) See Appendix B (TempTrak Basic Training Guide)

1. Actions for deviation from required parameters.

a. Humidity Control Events

(1) When the upper Relative Humidity (RH) limit is exceeded:

a. If the RH is up to 5% above the upper RH limit for over 6 hours, the facility engineer should take corrective action and adjust the mechanical system to bring the RH down. The Surgical Leadership Team should convene if the RH is out of range for more than 12 hours. If the RH is up to 5% above the upper RH limit for more than 24 hours, the Surgical Leadership Team should consider halting operations for repairs. Traffic limiting, enhanced cleaning between cases, and perspiration controls may be added at the discretion of the Surgical Management Leadership.

b. If the RH is more than 5% above the upper RH limit for over 2 hours, the facility engineer should take corrective action and convene the Surgical Leadership Team. If the RH is more than 10% above the upper RH limit for more than 8 hours, it is very likely that the mechanical system needs repair. The Surgical Leadership Team should consider halting operations until the issue is resolved. Traffic limiting, enhanced cleaning between cases, and perspiration controls should be added where appropriate.

(2) When the lower RH limit is exceeded:

a. If the RH is up to 5% below the lower RH limit for over 6 hours, the facility engineer should take corrective action and adjust the mechanical system to bring the RH up. The Surgical Leadership Team should convene if the RH is out of range for more than 12 hours. If the RH is up to 5% below the lower RH limit for more than 24 hours, the Surgical Leadership Team should consider halting operations for repairs.

b. If the RH is more than 5% below the lower RH limit for more than 2 hours, the facility engineer should take corrective action and convene the Surgical Management Leadership. If the RH is more than 5% below the lower RH limit for more than 8 hours, it is very likely that the mechanical system needs repair. The Surgical Leadership Team should consider halting operations until the issue is resolved.

b. Per AORN (2021), the temperature in an OR, "may be intentionally adjusted up or down based on the occupant comfort and individual needs of the patient."

c. Per AORN (2021), "There are no predetermined guidelines on when to close an

OR, but generally it is not necessary. The steps to be completed prior to making this decision include:

(1) Perform an assessment in collaboration with a representative from plant operations and the infection preventionist.

(2) Determine how long and how far out of range the temperature or humidity is.

(3) Determine if you can see any visible evidence of contamination of the suite

(e.g. condensation on the walls or on other surfaces):

(4) Based on the assessment, measure to be taken immediately may include:

a. Rescheduling or redirecting procedures to areas of the surgical suite where the temperature and humidity are functioning within accepted parameters,

b. Delaying elective procedures,

c. Limiting surgical procedures to emergency procedures only,

d. Closing the affected OR(s), or

e. Taking no action."

2. ASSIGNMENT OF RESPONSIBILITIES:

a. Nurse Manager/Assistant Nurse Manager/Designated Staff of Surgical Services (Charge Nurse OR, Endoscopy Staff, others as directed) will be responsible for responding to alerts from TempTrak® during business hours.

b. During WHEN Hours, the AOD will respond to alerts from TempTrak® to provide 24/7 coverage.

c. During WHEN Hours with procedural care, the On-Call OR RN will monitor temperature and humidity of the Surgical Suite as described above.

d. Staff will:

(1) Ensure temperature monitoring equipment is physically present in each area where sterile procedures are performed and/or where sterile supplies are stored.

(2) Ensure monitors are not obstructed from air flow.

(3) Close door to maintain temperature/humidity within range. When doors are opened, open doors as short amount of time as possible.

(4) Report temperature and/or humidity concerns or equipment damage or malfunction to the manager or next in command as soon as possible.

d. Engineering Services or the Building Manager will:

(1) Coordinate and assist with installation and mechanical maintenance of the electronic monitoring system.

(2) Repair HVAC and equipment units that are determined to need repair.

3. DEFINITIONS: NONE

4. REFERENCES

a. ASHRAE Technical Committee 9.6, Healthcare Facilities, “Humidity Control Events in Perioperative Care Areas”, 2019; Humidity Control Events in Perioperative Care Areas (ashrae.org).

b. VHA Directive 1761, 2020; Supply Chain Management Operations.

c. AORN, 2021; Guidelines for Perioperative Practice.

https://www.ashrae.org/file%20library/technical%20resources/bookstore/whitepaper_tc0906-humidcontroleventsinperiopcareareas.pdf

d. U.S. Department of Veterans Affairs Office of Construction & Facilities Management, 2021;

“HVAC Design Manual”.

e. Baxter, 2021; “Warming parameters for Injection Solutions in VIAFLEX Container (4.4)” https://baxter-usmpprd.irmscare.com/.

f. ECRI, 2020; “Warming Cabinets”, Health System Risk Management, https://www.ecri.org/search-results/member-preview/hrc/pages/surgan23.

g. Eagle Pharmaceuticals (2018): Ryanodex (Dantrolene sodium) for injection suspension.

https://www.ryanodex.com/frequently-asked-questions/.

h. MHAUS, 2021; “What evidence-based interventions are recommended to alleviate hyperthermia associated with Malignant Hyperthermia?” https://www.mhaus.org/healthcare-professionals/mhaus-recommendations/what-evidence-based-interventions-are-recommended-to-alleviate-hyperthermia-associated-with-malignant-hyperthermia/#:~:text=Cold%20intravenous%20fluid%20is%20effective,%C2%B1%200.2%C2%B0 C%2C%20respectively.

i. U.S. Food and Drug Administration, 2017; “Information Regarding Insulin Storage and Switching Between Products in an Emergency”, https://www.fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency.

j. Fort Harrison VA Policy MCM Number: 11-21-108 “Drug Policy and Procedure”.

8. REVIEW

a. At a minimum at recertification; when there are changes to manufacturer guidelines; when there are changes/creation of a governing document (for example, national policy or a healthcare accreditation body mandate), and any regulatory requirement for more frequent review.

9. RECERTIFICATION

a. Surgical Services/Operating Room Nurse Manager is responsible for the contents of this SOP. Employees of the Surgical Services/Operating Room are required to adhere and abide by the contents of the SOP until expiration date or updated SOP and process change.

b. This SOP is scheduled for recertification on or before 02/25/2027. In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATORY AUTHORITY

Jason Nelson Operating Room/Endoscopy Nurse Manager https://baxter-usmpprd.irmscare.com/ https://www.ecri.org/search-results/member-preview/hrc/pages/surgan23 https://www.ryanodex.com/frequently-asked-questions/ https://www.mhaus.org/healthcare-professionals/mhaus-recommendations/what-evidence-based-interventions-are-recommended-to-alleviate-hyperthermia-associated-with-malignant-hyperthermia/#:%7E:text=Cold%20intravenous%20fluid%20is%20effective,%C2%B1%200.2%C2%B0C%2C%20respectively https://www.mhaus.org/healthcare-professionals/mhaus-recommendations/what-evidence-based-interventions-are-recommended-to-alleviate-hyperthermia-associated-with-malignant-hyperthermia/#:%7E:text=Cold%20intravenous%20fluid%20is%20effective,%C2%B1%200.2%C2%B0C%2C%20respectively https://www.mhaus.org/healthcare-professionals/mhaus-recommendations/what-evidence-based-interventions-are-recommended-to-alleviate-hyperthermia-associated-with-malignant-hyperthermia/#:%7E:text=Cold%20intravenous%20fluid%20is%20effective,%C2%B1%200.2%C2%B0C%2C%20respectively https://www.mhaus.org/healthcare-professionals/mhaus-recommendations/what-evidence-based-interventions-are-recommended-to-alleviate-hyperthermia-associated-with-malignant-hyperthermia/#:%7E:text=Cold%20intravenous%20fluid%20is%20effective,%C2%B1%200.2%C2%B0C%2C%20respectively https://www.mhaus.org/healthcare-professionals/mhaus-recommendations/what-evidence-based-interventions-are-recommended-to-alleviate-hyperthermia-associated-with-malignant-hyperthermia/#:%7E:text=Cold%20intravenous%20fluid%20is%20effective,%C2%B1%200.2%C2%B0C%2C%20respectively https://www.fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency https://www.fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency https://www.fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency

Renee Vulk Outpatient Surgical/Infusion Clinic Nurse Manager

Jose L. Rivera Henandez Chief Engineering & Facility Management

Dr Philip Alford Chief of Surgical Services

NOTE: The signature remains valid until rescinded by an appropriate administrative action. In this case, by a new SOP or an email to appropriate staff then removal of SOP from SOP Folder below.

DISTRIBUTION:

Updated SOP in S Drive: S: Surgical Folder:2019.2020 OR SOP’s Cross-Service SOPs are available at: W: STANDARD OPERATING PROCEDURES folder in the appropriate sub-folder.

Appendix A Location Description Unit Room Temperature Humidity Reference

OR OR Core IV Warmer IV Warmer 220 Not > 104F for 14 days

NIA Baxter & MCM Number: 11-21-108

OR ORA (RM 217A) OR 4 of 8 217 A 68- 75** 20 - 60 AORN, Table 3

OR ORB (RM 217B) OR 1 of 8 217 B 68- 75** 20 - 60 AORN, Table 3

OR OR Anesthesia Workroom

OR 6 of 8 218 66 - 75 20-60 VHA Directive 1761 Appendix F

OR

Clinic

OR Sterile Core Humidor

OR Sterile Core/Humidor

Humidor

66 - 75 20-60 VHA Directive 1761 Appendix F

OR OR MH

Refrigerator

OR MH

Refrigerator

220 36-46 NIA U.S. FDA

Clinic Procedure Room All 93 70 - 75 20 - 60 AORN, Table 3

Endo

Endo Rm 363D Clean Storage

ENDOSCOPY 363D <75 Max 60 AORN, Table 1 (Flexible Endoscopes)

Endo ENDO RM 363A/E Procedure Room

ENDO RM 363A/E 363A 68- 73 Max 60 AORN, Table 1 (Flexible Endoscopes)

Confidential Information © 2014 Cooper-Atkins Corporation

TempTrak Basic Training Guide

Revision A August 2014

Appendix B

TempTrak Basic Training Guide Topics Covered

• Logging in TempTrak

• TempTrak’s Dashboard

• Basic Navigation

• Transmitter Reading Examples

• Transmitter Information Detail o Sensor Conditions o Unit Currently in Alert o Unit Alert Acknowledged o Unit out of Range but Not Alarming o Sensor Alarms/Condition Icons

• Identifying Alert Types o Sensor Alarms o Battery Alarms o Communication Alarms

• Responding to Sensor Temperature Alarms (Clearing Alarms) o Acknowledge an Alarm o Clear an Alarm

Logging in to TempTrak

To log into TempTrak, double click on the TempTrak icon or open your web browser and type in the URL address provided by your facility to access TempTrak System Login page.

Each user is provided their own Login ID and Password assigned by the TempTrak administrator.

TempTrak Basic Training Guide

Revision A

TempTrak Dashboard

TempTrak uses a dashboard layout for the default home page. The dashboard is configurable allowing users to customize their experience depending on what information they need to monitor.

T a b s

Dashboard Display Region

Outstanding Alerts Menu Bar

TempTrak Basic Training Guide

Revision A

Basic Navigation Navigating through TempTrak is simple and easy.

TempTrak Logo Clicking on TempTrak logo takes you to Dashboard home page.

Outstanding Alerts Clicking on one of the blinking Alerts will take you to the corresponding alarm page (Alerts, Battery, and Communication).

Menu Bar The top menu provides the ability to change your password, modify user settings, obtain page help, and search for a sensor or group, and logout of TempTrak.

Tabs The Sensors and Reports tabs on the left open a scrolling menu with additional options corresponding to the tab name. Depending on user security and access rights, one or more tabs may not appear.

TempTrak Basic Training Guide

Revision A

Transmitter Reading Examples TempTrak can monitor a wide variety of equipment, with each piece of equipment characterized by a color-coded box: green, red, or blue. Each box displays information about how the equipment is currently running and configured in TempTrak.

Transmitter Information Detail Each transmitter contains a wealth of detail information allowing the user to quickly identify and understand the current state of the equipment being monitored.

Transmitter Name

Reading Type

Valid Reading Range

Sensor ID

Description

Current Reading

Last Recorded Date/Time

Alarms/Conditions

TempTrak Basic Training Guide

Revision A

To quickly identify a piece of equipment’s current condition, TempTrak uses a coloring system based on three colors: green, red, and blue.

Sensor Conditions

• Green = Unit is reading in range

• Red = Unit is reading out of range and exceeding maximum range setting or too warm

• Blue = Unit is reading out of range and exceeding minimum range settings or too cold

Equipment in an alert state will be either blue (too cold) or red (too warm). A small bell will appear in the lower right corner of the colored box.

Unit Currently in Alert

The unit has been out of range longer than the predefined time limit set for the transmitter. It is in alert mode and generated a notification to alert. An alarm bell will appear in the lower right corner.

• Red = Unit’s reading exceeding maximum range setting

• Blue = Unit’s reading exceeding minimum range setting

TempTrak Basic Training Guide

Revision A

Unit Alert Acknowledged

The unit is currently out of range and the generated alert has been acknowledged, but not cleared. A bell with a check mark will appear in the lower right corner.

The checked bell will disappear once the alert has been cleared.

Unit Out of Range but Not Alarming

The unit is currently out of range but has not generated an alert due to the unit not exceeding the assigned Alarm delay.

The Alarm delay establishes a time delay where an alarm has not been generated, but the unit has exceeded its valid operating range. Once the time delay has been exceeded, an alarm will be generated.

Sensor Alarms/Conditions Icons

There are three alarm conditions that can affect equipment: Exception (out of valid range – too hot/high or too cold/low), Low Battery, and Communication. These icons will display in the lower right corner of the colored box.

Each transmitter can have three alarms associated with it at any given time. When one of the icons is selected, it will open the corresponding alert page. This information will be covered in a subsequent document.

Exception Alarm

Low Battery Alert

Communication Alert

TempTrak Basic Training Guide

Revision A

Identifying Alert Types There are three alert types in TempTrak: Sensor Alarm, Battery Alarm, and Communication Alarm. Anytime an alarm is generated by one of the three alert types, a red blinking alert indicator appears at the top of the screen.

Sensor Alarms

Sensor Alarms provide current information on outstanding alarms and recently cleared alarms. This provides a quick overview of any immediate alert issues that need to be addressed as well as those alarms that have recently been cleared.

Battery Alarms

Battery Alarms appear when the battery on a transmitter is close to being drained. If a battery alert is generated for a 900 MHz or Wi-Fi transmitter, you will have roughly two weeks before the battery is drained. When the batteries are replaced, the sensor’s battery alarm will be automatically cleared.

Communication Alarms

Communication Alarms are indicated by a wireless symbol and appear when sensor is not communicating with the TempTrak application for roughly 60 minutes. When a sensor starts communicating again, the sensor’s communication alarm will automatically be cleared.

TempTrak Basic Training Guide

Revision A

Responding to Sensor Temperature Alarms (Clearing Alarms) After having logged into TempTrak, if you see the following blinking alarm indicator, there are one or more sensors that have triggered an excursion alarm.

Click on the blinking sensor alarm indicator to bring up the Alarms page displaying all outstanding alarms and any recently cleared alarms.

Locate the sensor you want to address from the list of sensors that are in an alarm status. Click “Clear / Acknowledge”. The Clear/Acknowledge Alarm page will appear.

Here you will be able to document the corrective action (standard actions or custom entered text) to resolve the alarm.

TempTrak Basic Training Guide

Revision A

There are two sections: Alarm Details and Comments. At the top of the alarm window is the alarm details, providing information about what sensor is in an alarm status to whether it was above or below range to when the alarm finally ended (returned to a valid reading).

The bottom section is where you add any comments or standard actions (actions set up by your administrator). Each standard action has a green arrow to the right. Clicking on the green arrow places that standard action in the comment field to the right. If you need to add additional notes, you can click inside the comment field and type the additional information.

At this point, you are presented with two options, acknowledging an alarm or clearing an alarm.

TempTrak Basic Training Guide

Revision A

Clearing an Alarm

If you can address the alarm yourself, you should clear the alarm. Clearing the alarm states that the issue has been addressed and everything is working correctly. If the sensor goes out of range, then a new alarm will be generated.