NABH-Air Conditioning_OT

REVISED GUIDELINES FOR

AIR CONDITIONING
IN OPERATION THEATRES

Issue No. 3 Issue Date: 06/ 15 Page 1 of 6

Revised Guidelines for Air Conditioning in Operation Theatres –
NABH-Air Conditioning_OT 2015

Air Conditioning in OT

A. The air conditioning requirements for Operation Theatre in a HCO have been
deliberated at length with manufacturers, engineers, technical committee members
and other stake holders and the following guidelines have been finalized.

B. For this purpose operation theatres have been divided into groups:

1. Super specialty OT: Super specialty OT means operation theatres for

Neurosciences, Orthopaedics (Joint Replacement), Cardiothoracic and
Transplant Surgery (Renal, Liver etc.).

2. General OT: This includes operation theatres for Ophthalmology, District

hospital OTs, FRU OT and all other basic surgical disciplines.

Day care centre: Day surgery is the admission of selected patients to hospital
for a planned surgical procedure, returning home on the same day, would fall
under the category of general OT.

C. The following basic assumptions have been kept in view:

 Occupancy: Standard occupancy of 5-8 persons at any given point of time

inside the OT is considered.
 Equipment Load: Standard equipment load of 5-7 kW and lighting load of 1 kW
to be considered per OT. For super speciality OT the equipment load can be
taken as 7 – 9KW.
 Ambient temperature & humidity at each location to be considered while
designing the system.

REQUIREMENTS – Super Specialty OT

1. Air Changes Per Hour:

 Minimum total air changes should be 20 based on international guidelines although

the same will vary with biological load and the location.
 The fresh air component of the air change is required to be minimum 4 air changes
out of total minimum 20 air changes.

Issue No. 3 Issue Date: 06/ 15 Page 2 of 6

Revised Guidelines for Air Conditioning in Operation Theatres –
NABH-Air Conditioning_OT 2015

 100 % outdoor ventilation air systems are not mandatory. If HCO chooses to have
100% fresh air system than appropriate energy saving devices like heat recovery
wheel, run around pipes etc. should be installed.
 The supply & return air ducts must be of non-corrosive material.
 No internal insulation or acoustic lining must be done on ducts as they can become
breeding grounds.

2. Air Velocity: The vertical down flow of air coming out of the diffusers should be able to
carry bacteria carrying particle load away from the operating table. The airflow needs
to be unidirectional and downwards on the OT table. The air face velocity of 25-35
FPM (feet per minute) from non-aspirating unidirectional laminar flow diffuser/ceiling
array is recommended.

Positive Pressure: There is a requirement to maintain positive pressure differential

between OT and adjoining areas to prevent outside air entry into OT. Positive pressure
will be maintained in OT at all times (operational & non-operational hours)

 Laminar flow boxes/diffusers should be installed in the OT for supplying majority air
and also majority return air should be picked up 75-150 mm above floor level.

3. The minimum positive pressure recommended is 2.5 Pascal (0.01 inches of water)

4. Outdoor Air intakes: The location of outdoor air intake for an AHU must not be
located near potential contaminated sources like DG exhaust hoods, lab exhaust
vents, vehicle parking area.

5. Air handling in the OT including air Quality: Air is supplied through Terminal HEPA
(High-efficiency particulate arrestance) filters in the ceiling .The HEPA can be at AHU
level if it not feasible at terminal level inside OT. The minimum size of the filtration area
should extend one feet (i.e. 304.8 millimetres) on each side of the OT table to cover
the entire OT table and surgical team. The minimum supply air volume to the OT (in
cubic feet per minutes CFM) should be compliant with the desired minimum air
change.

Issue No. 3 Issue Date: 06/ 15 Page 3 of 6

Revised Guidelines for Air Conditioning in Operation Theatres –
NABH-Air Conditioning_OT 2015

6. Air Filtration: The AHU (i.e. air handling unit) must be an air purification unit and air
filtration unit. There must be two sets of washable flange type filters of efficiency 90%
down to 10 microns and 99% down to 5 microns with aluminium/ SS 304 frame
within the AHU. The necessary service panels to be provided for servicing the filters,
motors & blowers. HEPA filters of efficiency 99.97% down to 0.3 microns or higher
efficiency are to be provided .

7. Temp & RH for Super-specialty OT: It should be maintained 21 C +/- 3 C (except for
Ortho for Joints replacement as 18 C +/-2 C) with corresponding relative humidity
between 20 to 60% though the ideal RH is considered to be 55%. Appropriate devices
to monitor and display these conditions inside the OT may be installed.

REQUIREMENTS – General OT

1. Air Change Per Hour:

 Minimum total air changes should be 20 based on international guidelines
although the same will vary with biological load and the location.
 The fresh air component of the air change is required to be minimum 4 air
changes out of total minimum 20 air changes.

2. Air Velocity: should be same as per previous guide.

3. Positive Pressure: There is a requirement to maintain positive pressure differential

between OT and adjoining areas to prevent outside air entry into OT. The minimum
positive pressure recommended is 2.5 Pascal (0.01 inches of water).

4. Air handling/Filtration: It should be same as previous. When not possible, the OTs
should be well ventilated with 2 levels of filtrations with efficiencies as specified
previously (pre and micro vee filters should be in position at the AHU).

5. Temperature and Humidity: The temperature should be maintained at 21C +/- 3 Deg
C inside the OT all the time with corresponding relative humidity between 20 to 60%.
Appropriate devices to monitor and display these conditions inside the OT may be
installed.

Issue No. 3 Issue Date: 06/ 15 Page 4 of 6

Revised Guidelines for Air Conditioning in Operation Theatres –
NABH-Air Conditioning_OT 2015

Design considerations for Planning New Operation Theatres

OT Construction:

a) The AHU of each OT should be dedicated one and should not be linked to air
conditioning of any other area for all OT constructed.
b) Window & split A/c should not be used in any type of OT because they are pure re
circulating units and have convenient pockets for microbial growth which cannot be
sealed.
c) Paint- antibacterial, anti-fungal
d) OT door – automatic/ Hermitically Sealed/Touch free (preferable)
e) General Lights – Clean room lights
f) Provision of safety against static charge.
g) Separate power circuit for equipment like Laser.
h) The anti-static flooring, walls and ceiling should be non-porous, smooth, seamless
without corners (coving) and should be easily cleanable repeatedly. The material
should be chosen accordingly. Anti-static Flooring – seamless, including skirting,
should not be of porous stone as it absorbs moisture and could be a source of bio-
burden.

Maintenance of the system

 During the non-functional hours AHU blower will be operational round the clock (may
be without temperature control). Variable frequency devices (VFD) may be used to
conserve energy. Air changes can be reduced to 25% during non-operating hours thru
VFD provided positive pressure relationship is not disturbed during such period.
 Validation of system to be done as per ISO 14664 standards and should include:
 Temperature and Humidity check
 Air particulate count
 Air Change Rate Calculation
 Air velocity at outlet of terminal filtration unit /filters
 Pressure Differential levels of the OT wrto ambient / adjoining areas
 Validation of HEPA Filters by appropriate tests like DOP (Dispersed Oil
Particulate) /POA (Poly Alpha Olefin) etc.; repeat after 6 month in case HEPA
found healthy.

Issue No. 3 Issue Date: 06/ 15 Page 5 of 6

Revised Guidelines for Air Conditioning in Operation Theatres –
NABH-Air Conditioning_OT 2015

 Preventive Maintenance of the system: It is recommended that periodic preventive

maintenance be carried out in terms of cleaning of pre filters, micro vee at the interval
of 15 days. Preventive maintenance of all the parts of AHU is carried out as per
manufacturer recommendations.

References
1. American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)
Standards. Ventilation for Indoor Air Quality. 2013
2. Previous NABH guidelines for air conditioning in operation theatre
3. Discussion by NABH TC & AC team on 25th April 2015.

Assessors Checklist during NABH Audit

1. To check the temperature, humidity inside OT.
2. The differential pressure inside & outside OT.
3. Maintenance record of AHU & filter cleaning frequency.
4. Last HEPA filtration report & HEPA validation report.
5. Is Air-conditioning done through split AC or AHU?

Issue No. 3 Issue Date: 06/ 15 Page 6 of 6