What’s in the Air? Rethinking Airflow and Infection Risk in Health Care

For nurses, environmental infection prevention is often framed around visible conditions such as high-touch surfaces, shared equipment, and visible dirt. In my experience, airflow and ventilation are not topics that receive significant emphasis in nursing education or orientation. While this may vary by setting, many nurses are left to learn these concepts in practice rather than through formal training.

With the recent COVID-19 and measles outbreaks, there has been more focused attention placed on contaminated air as a risk to patient safety. In my work with health care teams across settings, I’ve found that while nurses are highly attuned to cleaning and disinfection practices, airflow and ventilation are often assumed to be “handled” by the facility operations staff. In reality, these systems depend heavily on how the environment is used at the bedside. Small, routine actions—like leaving a door open or introducing a fan—can unintentionally disrupt carefully designed controls.

This gap in awareness among clinical staff matters. While the Centers for Disease Control and Prevention continues to report progress in reducing health care-associated infections (HAIs), these infections remain at a persistent risk for patients. Expanding the nurse’s focus on the environment to include airflow is a necessary next step in strengthening prevention efforts.

When the environment works against us

Air in health care settings is not passive. It is carefully engineered through ventilation systems, filtration, and pressure relationships designed to reduce the spread of airborne pathogens. Regulations (OSHA) and standards (AIA) are used when building, maintaining, and remodeling health care facilities to ensure proper air handling. These are often reviewed by agencies such as The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) when they conduct inspections for compliance.

Ventilation systems are highly effective when functioning properly. However, when they are disrupted by either equipment issues or everyday practices, the risk of transmission increases. Similar to other environmental control elements, airflow depends on both system performance and human behavior. While the facility operations staff are responsible for overseeing the ventilation system, they rely on nurses and other clinical staff to report problems and maintain the intended airflow.

Airborne infection isolation rooms: high-reliability, but not fail-proof

Airborne infection isolation rooms (AIIRs), formerly known as negative pressure rooms, are designed to contain airborne contaminants and prevent them from spreading beyond the room. These spaces are a critical component of infection prevention for diseases such as tuberculosis, measles, varicella, and other airborne pathogens.

Their effectiveness depends on consistent performance and proper use. In observations across facilities, common issues include when pressure relationships are not routinely verified, doors are left open for convenience or safety concerns, nursing staff are unsure how to respond to alarms or equipment failures, and facilities operations staff are assumed to be solely responsible for monitoring room function.

These are not knowledge gaps alone. They are workflow and communication gaps between clinical staff and facility operations staff that can undermine even the most well-designed systems.

When AIIRs aren’t available

Not all health care settings have access to AIIRs, particularly in long-term care or smaller facilities. In these situations, nurses often must think beyond standard protocols such as using portable HEPA filtration units, cohorting patients, ensuring doors remain closed, and reinforcing masking practices. These adjustments highlight an important reality: nurses are often the ones operationalizing infection prevention in real time, even when ideal infrastructure is not available.

These are not permanent solutions, but they reflect the importance of adapting infection prevention practices to real-world constraints. Even small lapses in control measures can lead to an outbreak of an airborne illness.

Personal fans: A small detail with bigger implications

Something as simple as a personal fan can introduce unintended risk. While fans may provide comfort for patients with chronic obstructive pulmonary disease (COPD) and other respiratory conditions, they also disrupt carefully designed airflow patterns, circulate dust and microorganisms, and complicate environmental cleaning efforts. Additionally, fans can blow contaminated air particles from a sick patient to their roommate or the hallway if not carefully placed.

In spaces where airflow is engineered to contain or direct contaminants, even small disruptions can have an impact. This is a good example of how small, well-intentioned decisions at the bedside can conflict with larger infection prevention strategies.

The role of the nurse: awareness and action

Nurses are not responsible for managing ventilation systems, but they play a critical role in recognizing and mitigating risk at the point of care. Like other core nursing practices, such as medication administration and wound care, managing the patient’s environment plays an important role in overall well-being.

Maintaining appropriate room conditions is a critical nursing responsibility, including keeping doors closed in AIIRs and ensuring staff and visitors understand the importance of doing the same. Nurses must also avoid practices that disrupt airflow, provide patient and visitor education, and recognize when ventilation systems are not functioning as intended. Because they are consistently at the bedside, nurses are often the first to identify disruptions and escalate concerns accordingly.

Another lesson from the pandemic was how often care is delivered in spaces with suboptimal ventilation. In older facilities or resource-limited settings, nurses must rely on critical thinking and an understanding of airborne transmission to reduce infection risk.

A necessary shift in perspective

Environmental hygiene is often defined by what we can see. Air challenges that perspective. It is dynamic, invisible, and influenced by both system design and human behavior.

Missy Travis, RN, MSN, CIC, FAPIC, is the founder of IP&C Consulting, LLC, a consulting business that supports infection preventionists, health care organizations, business owners, and professional sports teams in developing and sustaining effective infection prevention programs.