The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
#109 How Clean is the Air in Your Office?
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On 5/11/23 the CDC released updated guidance on ventilation in buildings, including healthcare facilities. This episode discusses these guidelines and how they apply to dental practice settings, including such topics as air exchanges per hour (ACH), HVAC settings and filtration and the use of HEPA air purification devices.
Recources:
- CDC Improving Ventilation in Buildings https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/improving-ventilation-in-buildings.html
- ASHRAE Coronavirus (COVID-19) Response Resources https://www.ashrae.org/technical-resources/resources
- ASHRAE Core Recommendations for Reducing Airborne Infectious Aerosol Exposure https://www.ashrae.org/file%20library/technical%20resources/covid-19/core-recommendations-for-reducing-airborne-infectious-aerosol-exposure.pdf
Welcome.
SPEAKER_03I'm Leslie Cannon. I'm Mary Gavoni.
SPEAKER_02I'm Linda Harvey. I'm Olivia Long, and together we are the Compliance Divas.
SPEAKER_03Welcome to the Compliance Divas podcast. I'm Mary Gavoni and I'll be the moderator for this episode on the new CDC ventilation guidelines for buildings. The compliance divas bring clarity and simplicity to regulatory compliance by navigating the regulatory world to keep you on course. You can subscribe to the Compliance Divas podcast through your favorite podcast channel or on our website, thecompliancedevas.com. The resources that we mentioned during this episode will be included in the show notes on your podcast app and also on our website, thecompliancedeevas.com. You may submit questions at any time to support at thecompliancedivas.com, and we will answer those questions via email. So not only did the CDC update their interim infection control guidelines for healthcare workers on May 8th, on May 11th, they published updated guidance on ventilation in buildings. And this is interrelated with the infection control guidelines. As many of our listeners will remember that during the pandemic, especially the height of the pandemic, we had all kinds of recommendations for the number of air exchanges we should have in our facilities and that we should have air purification and any number of things. And so those now are still in the guidelines for healthcare providers or healthcare professionals, but they also have been included in a separate set of guidelines just on ventilation. So there's a lot of information here. Again, we will have all these resources in the show notes and on the on our website. But what we're going to do is give you sort of a summary version of what these are and hope that it spurs our listeners to want to just double-check. The bottom line here is that we don't want to get rid of the good ventilation that we had during the pandemic because the aerosols and COVID haven't gone away. So, Linda, how does the CDC actually define ventilation? And can you talk about what an air exchange is in a building and what's the recommendation for that?
SPEAKER_01Sure, Mary. When I think about ventilation, I maybe just have a little chuckle because I think the only time we typically think about ventilation is when we're too hot or too cold and we want to go mess with a thermostat and fix it, which is not always easy in an office because everybody's personal thermostat's different. Or perhaps we think of ventilation when someone in the break room burns the popcorn. But there's a much more serious aspect to ventilation, and that's just the air that we breathe, and the quality of the air just has so much impact on our total body health. And we know that from the realm of secondhand smoke over the years and many other things and pollutants. So essentially, the CDC website does talk about the definition of ventilation. And this term can mean different things to different people. And I'll give you three aspects of what the CDC includes on their website. So really I think this will resonate with our listeners. First, it's considered indoor air movement and the dilution of viral particles through mechanical or non-mechanical means. And so non-mechanical means, those are natural sources. Can we open the windows, which we know is not typically the case in a dental setting? We might be doing that at home or other, you know, other locations. Mechanical is the ventilation systems that we have, the air, um, air ducts and the units and so forth. Ventilation is also the filtration through the heating, central heating lights and central ventilation and the air conditioning, known as the HVAC system, or in-room air cleaners, whether it's a portable or permanently mounted. And we'll talk about, I'll make a couple of comments about the air purifiers in just a minute. And third, the CDC lists air treatment with ultraviolet germicidal radiation, the UVGI systems that we offices have installed and some buildings have in place. So those are all the kind of different ways that we can look at the term ventilation. And then it brings us to the question well, how much ventilation is enough? And I'll chuckle again, Mary, because okay, how much do we need to breathe? How much air do we need, right? So, but seriously, how much ventilation is enough to have safe air in the environment that we're breathing? So when we think about the aerosol-generated procedures and a dental setting, what's a safe ventilation for us so that we're not inhaling the aerosols that might still be suspended in a treatment room after the patient has walked out, and now we're ready to come back in and clean a disinfect for the next patient. So the CDC recommends that we shoot for having five air exchanges per hour. And and I want to uh mention to our listeners that air exchanges per hour is oftentimes abbreviated ACH air exchanges per hour. So we want to, and possible, you want to have five or more per hour of clean air to help reduce the number of germs in any different given setting or office or operatory, wherever you are, and even in our homes. So this can be achieved through some combination again of central ventilation system, natural ventilation, or additional devices that can help provide that equivalent of those air exchanges per hour to the existing ventilation system. So let's just talk about portable devices for a minute. We know that the majority of dental practices purchased some type of air purification device during the peak of the pandemic, whether they actually bought a medical grade quality device or whether they got something from an office supply center or online, but wherever it was, we know offices bought something. And I find that more times over, not everybody understood where that needs to be placed in an operatory. And frequently it gets placed on the side of one of the counters because they're not too tall. Sometimes they can sit on the counter based on where the outlets are, which is totally logical because that's the convenient place where you're going to plug it in. However, that's not the best place to help with the ventilation and air purification in an operatory, for example. You really want to have that air purification device down near the foot of the chair so that way it's drawing away contamination and it's not taking it over your head and neck, you know, behind you where the device might be sitting on a countertop and it's not heading out to the hallways. It is going down in that direction. And that's not where usually an outlet exists. So oftentimes I will tell offices to look at the outlet that's underneath the junction box at their chair. Is that an opportunity they can use for that? So then another thing that offices can do is just talk to their HVAC company that comes in every year to do the maintenance. And I know we're going to talk about different levels of certification and take this further, you know, in a conversation in a minute, but just talking to your current HVAC system company, you know, finding out just some basics about your own system. How old is the system? Um, can it be retrofitted to have a HEPA filter or UVC? Or do you already have that on your system because it's a new system? And Mary, I'll share one quick story here and then I'll turn the mic over to you. Is I have a client that's in an older building, and I've used this example several times in the past. The building is probably about 50 years old. They are the only dental practice in this building. There's insurance companies, real estate companies, and so forth. And come to find out in talking to their HVAC specialist, you know, the air conditioning unit is old and their their rating, their MERV rating um is was only eight. So I'll come back and explain MERV rating in just a moment. But they and they had no air purification devices. So they really didn't have a good system for maintaining clean air. And I'll go into the MERV later, Mary, but I want to turn the mic over to you so we can keep flowing because I think there's a lot of good information to talk about. Thanks, Linda.
SPEAKER_03And and you're so right. The air purification devices that a lot of practices purchased and installed, either correctly or not correctly, in their treatment rooms, are great things to have whether there is COVID in the air or not, because there's other respiratory diseases. We also have chemicals. Um, you know, many of us remember the days of using a lot of methyl methacrylate and um eugenol and other compounds that create lots of odors in the office. And you walk in like, oh yeah, it's that dental office smell. So if we're breathing that in all day, that may not be good necessarily for our health, but it's not exactly welcoming to patients either. So these actually serve a dual purpose. So, Olivia, in the new guidelines from the CDC, they talk a lot about important considerations for improving ventilation in the facility. Can you elaborate on those for us?
SPEAKER_02Well, one, Mary, the point is made first do no harm. If the dental office is owned by the dentist, the building itself, then these would be considerations for them to be very proactive in. But let's say the dentist is leasing space from a building owner. Well, that's also true. First do no harm. So this is a good discussion for the dentist to have with the building owner to find out what types of strategies are being considered to improve indoor air quality. Because the fact is, airborne viral product uh particles spread between people more readily when they're inside rather than being in the outdoors. And so the concentration of these viral particles is often much higher when you are inside a building. So I was looking at some information that was published that, and I remember this having grown up in the 70s and early 80s, you know, in the 70s we had the energy crisis. And by the time the 80s rolled around, buildings were being constructed which with a much tighter seal. And so, although that was saving money on air conditioning and heat, it was actually contributing to a decreased quality of air that we were inhaling. I mean, I could remember as a kid helping my grandmother tape plastic on the windows so that there was no draft, when reality, it's healthier to have that outdoor air circulating into the building. And we could remember during the COVID pandemic that that was actually something that was brought up in the guidelines. How, if it was possible to have a window that was open, well, that's not always possible. And so, in the effort to increase the quality of the uh ventilation, we may be looking at system upgrades, upgrading the HVAC system or some other improvement that can increase the delivery of clean air and dilute potential contaminants. And I think you both pointed that out, Leslie, uh, Mary, and Linda, on not only the uh airborne contaminants from people that you can get an infection from, but also from the chemicals. And so these are different types of mitigation strategies that could be employed for indoor environments, taking into consideration that there's different types of buildings. And so these are something that the building owner should carefully consider. And it does take a combined approach. Uh, as I mentioned, it may be that the dental office is just renting space. And so we really encourage them if you're working with a building owner, uh, maybe provide them the link for the clean air in building challenge, or even print off a copy to say, I thought this might be of something of interest uh to be published. So I think these are important things that we're going to talk about in improving air quality, uh, especially in the near future.
SPEAKER_03I'm so glad you brought up the idea of the um issue of the buildings being more airtight and decreasing air quality. They actually, the I believe it was the Environmental Protection Agency actually coined a term that they called sick building syndrome because people were getting sick from the um volatile organic compounds and other things that were in the in the air that didn't get um ventilated out. So, Leslie, let's continue this discussion with you. And can you give us some suggestions from these guidelines what dental practices specifically can do to improve the cleanliness of their air?
SPEAKER_00Well, Mary, the CDCA gives us four very simple steps. They tell us to upgrade our HVAC filters, they tell us to inspect our HVAC systems, to use portable or built-in high-efficiency particulate air filters or filtration systems or air cleaners. And then we may even consider using UVGI or GUV. And I will talk about what each one of these acronyms means. So the first recommendation is what so what Livia had alluded to is you may have to upgrade your central HVAC, which means heating, ventilation, air conditioning filter efficiency to what's called minimum efficiency reporting value. Many of us heard the term MERV 13 during COVID. That was the recommended filter that we should have. And so the recommendation is to have at least a MERV 13 or better filter. And something that's, of course, compatible with your HVAC system. Increased filtration efficiency is especially helpful, again, when enhanced air door outdoor air delivery options are limited. Now, inspecting HVAC systems, I want to also point out before I go into what that means, is that um OSHA may ask for records about the HVAC systems. If the uh employer is also the owner of the building, they're going to want to see that that system has been kept up to date and maintained so that it is safe for employees. So inspecting the systems means ensuring ventilation systems operate properly and are up to date on maintenance, making sure the air filters are properly sized and within their recommended service life, inspecting filter housing and racks to assure appropriate filter fit and minimize the air that flows around instead of through the filter. And then the third recommendation was the HEPA filters. Now, HEPA stands for high-efficiency particulate air. So this is a system that it can also be called an air cleaner or an air purifier. Well, CDC recommends that we use HEPA systems to enhance air cleaning, especially in higher-risk areas such as a medical office or frequently areas that are frequently inhabited by people with a higher likelihood of having COVID-19 andor at increased risk of getting COVID-19. So we may not be in an area where there's high transmission, but we certainly do sometimes have patients who are fragile or at risk or elderly or have other underlying conditions that would make them be a poor candidate to be infected with COVID-19. And you know, when you have dental practices that have in-room air cleaners that use filters that are less efficient than HEPA filters, um, they should actually be clearly labeled as non-HEPA units. So if you have air filters or air purifiers or air cleaners, you may want to look and see if they're actually HEPA filtration systems or non-HEPA units. Some air cleaners or air purifiers use technology other than filtration. And so that brings me to another area that uh I'd like to talk about, which is called UVGI, which stands for ultraviolet germicide irradiation. And some medical facilities and even some dental facilities has used that as supplemental treatment to inactivate airborne viruses such as SARS-CoV-2. UVGI can be effective in many spaces, but it's especially useful as an added layer of protection to reduce infectious particles in indoor spaces that host large gatherings or where the risk of disease transmission is high. It's also helpful when options for increasing room ventilation and filtration beyond code requirements are limited. So, this is something that may be a consideration for dental practices. I think the first three are probably easier to upgrade your air conditioning ventilation system to the MERV 13 or better, inspect regularly your HVAC system, and use uh portable HEPA filters. And in addition to what we talked about with reducing viruses, viral transfer, and improving indoor air quality, reducing dental office odors as we sometimes know them. It's also important to recognize that we can reduce allergens that may be in the air. And that's always healthier for dental team members who work in the premises ongoing regularly, as well as patients who are just there for a short period of time. Mary? Thanks, Leslie.
SPEAKER_03That's such great information. And I just wanted to make one sort of um important point here that what we've been discussing are mitigation strategies to help control the spread of airborne infectious diseases. But no matter how good those are, they don't take the place of personal protective equipment. So we still have to be very well aware of what the PPE guidelines are and what the possibility is that you have a high number of either COVID-19 or other respiratory viruses in your area. So I'd like to now just have again our round robin um kind of discussion and talk about some particular um tips for dental practices beyond the HVAC system. What else do we need to know? And Leslie, we're gonna start with you.
SPEAKER_00Well, I'd like to go back to that HVAC system before we leave that all together and remind our listeners that consulting with a professional that's experienced with the proper selection and implementation and commissioning of HVAC systems and improvements is strongly encouraged by CDC. So for the do-it yourself, uh, you may not be doing uh yourself a favor if you're missing very important parts of uh installation of either filters or upgrade or maintenance of your system. So uh it's important to contact a professional who has the experience and not try to go it alone.
SPEAKER_03Great, Leslie. Linda, what about the settings for your HVAC system? Should we use the energy control settings or how should we have them set? What's the recommendation?
SPEAKER_01Well, Mary, this is one thing that CDC came out and talked about during the height of the pandemic and said that we really should set our system to auto and leave it there because if we're constantly adjusting the thermostat and changing it, we're not getting the airflow that we need. And we have good airflow during the day, not at night when it's not on or on the weekends. And I understand the need to be budget conscious, but we want to also be careful that when we do these things, we're not um not we're losing out on the opportunity to have better air exchanges and keep the office as clean as we'd like it to be, considering how well we're taking time to clean and disinfect all the clinical contact surfaces and and housekeeping surfaces. And then I would also like to say that it's important that you continue to use the portable air cleaners that we use, or the purifiers rather, that we used during the pandemic. Please don't put those away. It's important to keep those. I know we're no longer under the public health emergency, but that doesn't mean that COVID's gone. It doesn't mean that the good practices that we put in place previously don't still have meaning and aren't important now because there are other airborne transmitted diseases, Mary.
SPEAKER_03Absolutely, Linda. And I think if we've learned nothing else during the pandemic about healthy um environments, is that we really do need to pay attention to the ventilation and the air purification. Um, there have been um cases of dentists who have been diagnosed with idiopathic pulmonary fibrosis, where they've been exposed to silica and other types of dust in the offices that probably should have, could have been filtered out. And so I think that going forward, because the pandemic just really put everything under a microscope, I think going forward, we are going to have healthier environments in the dental office from screening out patients with the respiratory diseases and telling them not to come in when they're sick and filtering the air, keeping our HVAC system up to date. So I don't believe that as a result of these um guidelines being um released, that there will be major changes that our practices need to do in their um or listeners need to do in their facilities. But again, just keeping in mind that we're certainly not all the way done with COVID. And going forward, we need to, again, be more cognizant of what are the health hazards to all of us in the practice. So we thank you for listening. We hope that you'll join us for our next episode. The compliance divas bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. If you have questions, please submit them by email to support at the compliancedeevas.com. And all the resources that we've talked about today will be included in the show notes and will be on our podcast website, the compliancedeevas.com. Again, thanks for listening. We'll see you next time.