2002 Update1 Construction Risk Assessment An Overview of Environmental Infection Control and Construction Related Activities

2002 Update 1

Construction Risk Assessment

An Overview of Environmental Infection Control and Construction

Related Activities

2002 Update 2

2002 Update 3

2002 Update 4

“Indoor-air-quality (IAQ) challenges out number all others in the health-care industry. Unfortunately, the cost-conscious powers that be have failed to make the management of critical infection-control systems a top priority.”

Andy Streifel, MPH, REHS

2002 Update 5

Commercial Airline Analogy

A typical commercial airliner transports approximately 100 passengers and if the same number of deaths occurred in the aviation industry as a result of airline crashes it would equate to 17 commercial airliner crashes a week. Of which approximately 4 per month would have to do with construction/maintenance related activities.

2002 Update 6

Here’s Our Problem!

Annual Passenger DeparturesAnnual Hospital Admissions

Deaths per year/Nosocomial Deaths per year

Deaths per Scheduled Activity

Airline Industry 1,009,971,000 525

1death/1,923,750passenger departures

Hospital Industry 34,890,76888,000 (all nosocomial)

1 death/396

admissions

Hospital Industry 34,890,7684,400 (airborne)

1 death/7,930

admissions

2002 Update 7

Current Regulations and Guidelines

Joint Commission on Accreditation of Healthcare Organizations

Guidelines for the Design and Construction of Hospital and Health Care Facilities (mandated by state law)

CDC – Guidelines on Environmental Infection Control

State Licensure (in many states)

2002 Update 8

JCAHO

Environment of Care Standards EC.3.2.1

Patient Safety Standard

2002 Update 9

EC.3.2.1 – effective 1/1/02

Demolition, Construction or Renovation

Proactive Risk Assessment Identify hazards that could

potentially compromise patient care Address impact on:

air quality requirements, infection control, utility requirements, noise, vibration, and emergency procedures.

2002 Update 10

Construction & Renovation

Disruption of settled dust Disruption of ceiling tiles Repair/renovation of elevator shafts Repair of under sink cabinets Pulling up carpeting Disturb “environmental reservoirs”

2002 Update 11

Construction, Demolition, and Repair

Multi-disciplinary team approach to review:

design and function of new area risk assessment in preventing airborne

nosocomial disease dust and moisture containment

barrier walls negative pressure differential

2002 Update 12

Air Water Environmental Services Laundry and Bedding Animals in Healthcare Facilities Regulated Medical Waste

CDC Guidelines for Environmental …What it Covers

2002 Update 13

HVAC System Design

Temperature Humidity ACH Mixing of air in the room

Filtration Filter Types and Efficiencies HEPA

Where they are required Portable units

Maintenance

CDC Guidelines for Environmental Infection Control - Air

2002 Update 14

Infection control impact of system maintenance and repair Duct cleaning System shutdowns Moisture in the system Backup emergency electrical power


2002 Update 15

Construction, Renovation, Remediation, Repair and Demolition ICRA (Infection Control Risk

Assessment) Multidisciplinary team Risk assessment of project P&P to protect patients Procedure to Correct Problems Rapidly


2002 Update 16

Construction, Renovation, Remediation, Repair and Demolition Preliminary considerations

Resources for education of internal staff and contractors

Penalties for non-compliance with contract documents

Contingency Plans for Utility Disruption


2002 Update 17

Construction, Renovation, Remediation, Repair and Demolition Air sampling External and internal demolition (Barriers

Required?) Working with plumbing in sensitive areas Exposure of ceiling spaces Crawling into ceiling spaces Work on elevator shafts Demo of wallboard, plaster, ceramic tile, ceiling

tile Removal of flooring Removal of windows and doors Removal of casework


2002 Update 18

2001 Guidelines for Design and Construction of Hospitals and Health Care Facilities – Chapter 5

AIA Guidelines

2002 Update 19

Chapter 5 – Planning and Design

All new and existing construction Due to the hazards of construction

consultation from: Infection control professionals Safety professionals

Development of an Infection Control Risk Assessment (ICRA)

2002 Update 20

Chapter 5 – Elements of an ICRA

Continuous process Component of the facility functional

program or master program Initiated in planning and design and

continued through construction/renovation

Performed by a multidisciplinary panel Documented

2002 Update 21


Key Elements

Impact of disrupting essential services Patient placement or relocation Placement of barriers Evaluation of ventilation needs in

existing sensitive areas Number of AII and PE rooms

2002 Update 22


Key ElementsPatient protection from:

DemolitionUnplanned power outages effect

on ventilation and waterMovement of debrisPatient flow through the building

2002 Update 23

Chapter 5 – Bid Documents

Project bid documents shall include:

Control of airflow (clean to dirty)

Interruption of utility and/or building service equipment

Communications of the construction process manager and the facility staff

2002 Update 24

Role of the ICP. . . Overview

Help identify those effected by project Know your facility Facilitate teams & communication

Populations at risk Decreased immunity Allergies, asthma, COPD Noise and vibration

Assist w/ education, P&P, documentation

2002 Update 25

Know Your Facility

Types of patients based upon services Layout of services

3-D considerations Location of inpatient units Venues for outpatient specialties Ancillary support functions

TB risk in community - OSHA/CDC Long & short term planning Applicable regulations & guidelines

2002 Update 26

2002 Update 27

Facilitate Teamwork

Existing committees Reporting structure Responsibilities & authority Ownership - P&P (CRP)

Ad hoc team projects Key & ancillary members

Communication Internal & external Documentation

Epidemiology

2002 Update 28

Noise and Vibration

Patients and/or employeesRecent myocardial

infarctionPremature neonatesRecent ICH or strokeNeurological/psychiatric

disorders

2002 Update 29

Noise and Vibration

Procedures or testingEEG or EKGHearing assessmentsNeurological studiesFine motor skill procedures,

such as microsurgeryCertain laboratory proceduresSleep studies

2002 Update 30

Developing ICRA (1 of 3)

Determine potential spread of infectious agents in the healthcare environment

Provided by facility “owner” Continuous; essential part of

facility’s master program to provide a safe environment of care

Initiate at design & planning phase

2002 Update 31

Continue during renovation/construction through commissioning

ICRA limited to only affected areas Multidisciplinary team / expertise in:

IC, risk, facility design, construction, ventilation, safety and epidemiology

Team provides documentation of the risk assessment during PDC


2002 Update 32

Design professional incorporates specific construction-related requirements of ICRA into contract documents

Contract documents require contractor to implement these specifics into renovation/construction activities

Consistent with JCAHO-EC and OSHA


2002 Update 33

Regulations & guidelines Infectious agents & hazards change Microbiological ecology influenced by

patients & HCWs Physical surroundings Documents & reports Use as QI/PI activity?

ICRA Considerations

2002 Update 34

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2002 Update 36

2002 Update 37

Physical Surroundings

Structure: HVAC, air flow, plumbing Fixtures: Handwashing sinks, “hoppers”,

showers, toilets Maintenance: Reservoirs and wet, porous

surfaces may support microbial growth Equipment: Location, fixed vs. moveable,

storage, prevent contamination Design: Flow; form follows function

2002 Update 38

ICRA Matrix

PATIENT Risk Group TYPE ATYPE A TYPE BTYPE B TYPE CTYPE C TYPE DTYPE D

LOWLOW Risk Group II II II III / IV

MEDIUMMEDIUM Risk Group

I II III IV

HIGHHIGH Risk Group

I II III / IV IV

HIGHESTHIGHEST Risk Group

II III / IV III / IV IV

2002 Update 39

IC Construction Permit

Suggest use based upon IC precautions

Some require for Classes III & IV Outlines steps required Assists in documentation

Project parameters Sign-off

Customize to your organization by ICRA team consensus

2002 Update 40

Effective Program Elements

Traffic patterns & patient relocation People, signage, supplies & equipment,

waste, populations at risk; think 3-D Barriers - planning & monitoring

Type & integrity, approvals, checklists Education for construction workers,

management, HCWs, others Level & content as appropriate

(tomorrow) Involve experts; ask key questions

Resources, content experts, site visits

2002 Update 41

Controlling Construction and Maintenance ActivitiesControlling Construction and Maintenance Activities

Need for containment General containment barriers – and

hindrances to barriers Point of entry control units Negative pressure requirement HVAC system protection and

isolation

2002 Update 42

How Do We Do It?How Do We Do It?

Define contractor building entry and path to the construction zone

Define the construction zone maintenance procedures and use of tacky mats and “bunny suits”

Identify HVAC System and how to isolate it from the construction zone

Establish background bioaerosols level prior to construction

2002 Update 43

Type Of ConstructionType Of Construction

Minor repairs Major system upgrades Area renovation and tenant improvements

Major additions and remodels – both yours and your neighbors

New construction – both yours and your neighbors

Landscaping – both yours and your neighbors

2002 Update 44

Envelope PenetrationsEnvelope Penetrations

Ceiling cavities Wall panels and service access

ports Dumb waiters

2002 Update 45

Envelope PenetrationsEnvelope Penetrations

Building shafts and chutes Stairwells Elevators

2002 Update 46

Environmental Containment UnitEnvironmental Containment Unit

Photo courtesy of Mintie Corporation

2002 Update 47

Construction BarriersConstruction Barriers

Photo courtesy of Mintie Corporation

2002 Update 48

Who Applies It?Who Applies It?

It can be applied by hospital staff if they have the manpower available.

Most healthcare organizations use an outside third party contractor that specializes in containment programs.- Dedicated expertise- IMC contractor assumes the liability

2002 Update 49

NEW CONSTRUCTIONNEW CONSTRUCTION

Constructing problems OUT of the building.

General clean up: How clean is clean?

2002 Update 50


Condition at time of pre-inspection

Photo courtesy of Rob Case, RCCS

2002 Update 51


Protecting the equipment. Building in future savings.

2002 Update 52


Protection of HVAC ductwork

Photo courtesy of Rob Case, RCCS

2002 Update 53

Ventilation Control in Hospital

• Airborne Infection Isolation & Protective Environment

– outage control

– ventilation assurance

– air changes per hour

– HEPA filtration

– pressurization

• Construction barriers

– external project protection

– internal barriers

– negative pressure

2002 Update 54

Establishing Baseline Information

Air quality Non viable & viable particles

Ventilation Air exchanges, filtration & pressure

Operational Practice Preventative maintenance Housekeeping Visitation

2002 Update 55

Interpretation of Microbiology Data

Rank order analysis Lowest counts in the areas with best filtration Comparison necessary with outdoor control

Qualitative analysis Pathogen recovery

Temperature selectivity Pathogens grow best at >35C Filtration efficacy determined at 25C

2002 Update 56

Air Sample Considerations

When to sample?

• Commissioning-before occupancy=baseline data- All parameters for ventilation assurance and cleanliness- Provide comparison data

• Disease outbreak analysis- All parameters with emphasis on source detection- Surface and air content for fungi

• Surveillance - Pressure most meaningful- Air exchanges needed for purging- Non viable particles can be used to assess filtration efficacy- Medical staff understand the viable counts the best

2002 Update 57

2002 Update 58

2002 Update 59

Healthcare Air Flow Management

• Airflow ventilation control with offset:– supply versus exhaust/return– greater exhaust = negative – greater supply = positive

• Pressure differential– 0.01 inch water gauge (2.5 Pascal’s)– air flow velocity about 400 fpm– consistent airflow necessary for control

2002 Update 60

2002 Update 61

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2002 Update 63

Room Leakage Areas

• Airflow leakage occurs around:– plumbing connections

– medical gases

– electrical/video connection

– lighting

– ceilings

– windows/doors

– door cracks

– in wall mounted fixtures

2002 Update 64

2002 Update 65

2002 Update 66

gauge

2002 Update 67

EXERNAL CONSTRUCTION MANAGEMENT

Verification of existing protective ventilation

Control of building entrances Window infiltration Utility tunnel access to construction Building tie-ins Employee training Street cleaning Emergency response

2002 Update 68

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2002 Update 70

2002 Update 71