Ap p e n di x G

Humidity Sample Policy

Department(s): Surgical Suites Effective Date:

Policy Title: Operating Room Humidity Review Dates:

Page 1 of 2

PURPOSE: To provide appropriate methods of monitoring and adjusting

Surgical Suite temperature and relative humidity levels.

BACKGROUND INFORMATION:

1. Although there are design criteria for operating room heating, ventilation and
air conditioning (“HVAC”) systems related to temperature and humidity, the
actual temperature and humidity within each operating room is mostly
affected by the clinical requirements of the procedure and the heat and
humidity load added by the operating team and equipment.

2. A relative humidity that is too high can result in damp or moist supplies with
added opportunity for mold growth. It can also contribute to excess
perspiration and occasional “sweat through” when combined with high
temperatures. A relative humidity that is too low can result in excessive
bacteria-carrying dust within the surgical environment. Low humidity also
contributes to static electricity charges.

3. Although humidity and temperature during operations are important,

frequent logging does not contribute to patient safety or staff comfort.

POLICY:

Preventive Maintenance of the Operating Room HVAC System: The

Engineering Department shall implement appropriate preventive maintenance
and monitoring practices to assure the HVAC system is working as designed.
Because NFPA 99 requires operating room humidity to be greater than 35%,
the Engineering Department shall routinely monitor humidity (at least weekly
checks) to assure appropriate functioning of the equipment. Other routine
monitoring of HVAC functioning will be prescribed by the Utilities
Management plan approved by the Environment of Care Committee.

Operational Monitoring: Because the temperature and humidity fluctuate

significantly throughout the day and because adjustments to temperature and
humidity must be made in real time, no routine logging within the OR is

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The Joint Commission Survey Coordinator’s Handbook, 10th Edition 211

Appendix G

Department(s): Surgical Suites Effective Date:

Policy Title: Operating Room Humidity Review Dates:

Page 2 of 2
indicated. However, staff shall consider the following guidelines to adjust
temperature and humidity as the day progresses.

a. Considerations for adjustments to temperature:

1. Comfort of the surgery team.
2. Excessive perspiration.
3. Clinical needs of the patient or the procedure.
b. Considerations for adjustments to humidity:
1. Excessive perspiration.
c. Process: The circulating nurse shall be responsible for making in-room
adjustments to temperature. Engineering shall be contacted and shall
respond promptly should these in-room adjustments prove ineffective or if
adjustments to the humidity load provided by the HVAC system be
indicated.

REFERENCES:
1. Guidelines for Construction and Equipment of Hospital and Medical
Facilities, American Institute of Architects Committee on Architecture for
Health with assistance from the US Department of Health and Human
Services (Washington, DC: Press, 2001) 70-80.
2. Hospital Special-Care Facilities: Planning for User Needs, ed H. Laufman
(New York: Academic Press, 1981) 1-258.
NOTE:
1. Perioperative Nurse Specialists in the AORN Center for Nursing Practice,
Research, and Health Policy are available for clinical practice consultation at
(303) 755-6300, ext. 265, or on the web site at www.aorn.org.

200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com

Consulting TEL 888/749-3054 FAX 781/639-0085 | Seminars TEL 800/801-6661 FAX 800/738-
1553

212 The Joint Commission Survey Coordinator’s Handbook, 10th Edition