Mary Logan: Humidity in the OR and the Value of Systems Engineering

AAMI has been talking about the need for systems engineering in healthcare for several years, ever since we published an article about it in 2010 by Ray Zambuto and Stephen Grimes, followed by a BI&T cover story in 2013. This fall, AAMI will publish an issue of Horizons focused exclusively on systems engineering.

Many in the AAMI community have been intrigued by the idea, but it was difficult to make the subject real and concrete without good examples of how healthcare would be improved by a systems engineering approach. With attention these days focused on problems related to health information technology (IT), it is also challenging to find great examples outside IT departments. There definitely are people who work in those departments called systems engineers, but that is far too narrow and definitely not the same as what AAMI has been touting as systems thinking or systems engineering.

We’ve recently seen top-level affirmation as to why systems engineering is needed in healthcare. President Obama’s Council of Advisors on Science and Technology issued a comprehensive report highlighting the benefits healthcare could realize by embracing systems engineering principles.

And, now, we have a perfect, easy-to-understand, and big example of why healthcare needs a systems engineering mindset. The beauty of this example is that it doesn’t have anything to do with health IT, and you don’t have to be a genius, a systems engineer, or even a techie to understand it. The example is about humidity levels in the operating room (OR).

Facilities managers see humidity in the OR as a facilities management issue. It costs more and takes more work to keep humidity levels up in the 30-60% range as recommended for years by heating and air conditioning standards. Several years ago, facilities management leaders convinced the American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE) to change the existing humidity standard for ORs, broadening the lower limit from 30% to 20%. As part of the analysis of the request for the broadened range, ASHRAE considered the potential impact on infection control and got the OK from the Centers for Disease Control and professional societies that look at infection control issues. The National Fire Protection Association also was consulted for possible fire safety issues. The Joint Commission was supportive, and CMS in 2013 agreed the new range of 20-60% was fine.

Many individuals and organizations were involved in this process, presumably including people who work in the OR. But a crucial factor appears to have been overlooked: the need to think beyond the fact that the OR is more than one room with potential germs in it. It is a subset of a larger system that includes all of the supplies and technology used to treat patients. If a systems approach to the issue had been used before facilities managers ever requested a new standard, or before the CDC and other infection control experts signed off on it, or before the CDC or infection control experts signed off, or before The Joint Commission or CMS supported the change, then this fact might have averted some confusion and concern in the field.

Fast forward to a seemingly quiet day this summer in the OR of a California hospital being surveyed by the Centers for Medicare & Medicaid Services (CMS). The astute surveyor happened to notice that the sterile packaging for some supplies in this OR called for humidity levels of at least 30%, not 20%, and yet the relative humidity level in the room was at 20%. The hospital was cited for not following the manufacturer instructions for the humidity level on the supplies. Even this sharp surveyor did not consider whether there were humidity requirements for the medical equipment in the room. Neither, apparently, did anyone else.

Hindsight is always 20/20, and my comments are not intended to fault facilities management, ASHRAE, or anyone else. Healthcare technology management professionals can be just as narrow in how they view the OR, seeing it only as a room full of technology that needs to be calibrated and repaired, or solely through the prism of electrical safety. They can drive infection control experts bonkers when they don’t focus on infection control, but that’s a story for another day.

We now have a mess to sort through regarding humidity in the OR, and it’s easy to understand how we got here: It’s still rare for healthcare to use a systems approach to thinking through its issues. Humidity is “managed” by facilities staff, so they tend to think about it as a facilities issue.

Humidity, like everything else in healthcare, is a systems issue and has implications for all parts in the system. In the OR, that includes equipment and supplies, central sterile processing, medication management, infection control, and more. It also could have implications for other areas of the hospital where technology and supplies are used in patient care.

Systems engineering doesn’t require systems engineers running around a hospital looking for systems issues to solve. It requires a new mindset and way of thinking for all of us. It requires us to be curious about who else might need to be consulted, what else might go wrong, and whether we have considered all parts of a system that might be impacted by our decisions and actions.

If we put on our systems thinking cap in reading this blog post, we will ask:

  • “Who else should I share this with?”
  • “I wonder if our organization has lowered humidity levels in the OR without considering the technology and supplies or other potential issues.”
  • “How can I help with this even if it isn’t written into my job description?”

Each one of us can bring systems thinking into healthcare without any new credentials. Let’s start right now in our own organizations with this example that everyone can understand. And please let AAMI know if you have other examples we can flag.

Mary Logan, JD, CAE, is the president of AAMI.

2 thoughts on “Mary Logan: Humidity in the OR and the Value of Systems Engineering

  1. Excellent example of why SE is needed in healthcare.

    The facilities codes which required a minimum RH of 35% were originally developed to address the risk of static-electricity sparks triggering serious explosions in the presence of flammable anesthetics. The anesthetic gases ether, ethylene, and cyclopropane are, in fact, highly flammable, heavier-than-air, and have caused devastating explosions when sparks have ignited the vapors even at a distance from their source.

    The problem is: these explosive anesthetics have been banned from use since the 1970s. The rationale for an upper limit of RH at 60% is still valid due to its impact on microbial growth, but the lower limit of 35% has been obsolete for some 40 years!

    Even today, the codes themselves are quite durable; CMS grants “waivers” as a workaround for some state laws which still assert the 35% RH as a “standard.” If the original rationale for these requirements are no longer valid, why do these codes still exist?

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