ICRA Policy Template

ICRA

FACILITY NAME

Number: System Policy Manual

Page:

Subject:Infection Control Risk AssessmentEffective Date:1/30/200X

for Use During Programming, Planning,

Design, Construction, & Maintenance

Resource:Infection Control Consortium,

Approval: Medical Director,

Facilities Council and

Infection Control, Facilities

Construction Department

ManagementSupersedes: Policy dated 12/12/200X

Review Date:

I.POLICY

It is the policy of FACILITY NAME to provide the safest possible environment for patients, associates, physicians, and visitors during the performance of programming, planning, design, construction, and maintenance. FACILITY NAME will utilize the Infection Control Risk Assessment methodology.

II. DEFINITIONS

1. Infection Control Risk Assessment (ICRA) a tool to assess the level of infection control risk in an activity. The ICRA shall address, but not be limited to:

disruptions of essential services to patients, associates, and physicians

patient placement or relocation

placement of effective barriers to protect susceptible patients from airborne contaminants

air handling and ventilation needs in critical areas such as surgery and isolation room, laboratories, and special exhaust systems

determination of the required numbers of airborne infection isolation or protective environment rooms

protection of the domestic water system to limit waterborne pathogens like Legionella protection of patients from construction project hazards such as planned or unplanned power outages, demolition and movement of debris, managing changes in ventilation and water systems, cleanup, certification, etc.

The FACILITY NAME facility is responsible for providing the ICRA. The design professional is responsible for incorporating the specific construction-related requirements of the ICRA in the contract documents, which shall require the constructor to implement these specific requirements during construction. The constructor is responsible for implementing those specific requirements during construction.

2. Utility Disruption an interruption of water, electric, gas (medical and natural), and vertical transportation (elevators).

III. PROCEDURE

1.A multidisciplinary panel with expertise in infection control, risk management, facility design, construction, ventilation, safety and epidemiology will conduct and document an ICRA during the programming phase of every construction project and update it as the project proceeds through planning, design, and construction.

2.Key elements to be addressed during programming include, but are not limited to: handwashing facilities, ventilation, water systems, anterooms, traffic patterns, and storage facilities.

3. To determine the level of infection control activities required, perform the following 3 steps.

Step 1:

Using the following table, identify the Construction Activity Type (A-D)

Type AInspection and Non-Invasive Activities

Includes, but is not limited to:

removal of ceiling tiles for visual inspection limited to 1 tile per 50 square feet

painting (but not sanding)

wall covering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection

Type BSmall scale, short duration activities that create minimal dust


installation of telephone and computer cabling

access to chase spaces

cutting of walls or ceiling where dust migration can be controlled

Type CWork that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies

sanding of wall for painting or wall covering removal of floor coverings, ceiling tiles and casework new wall construction minor ductwork or electrical work above ceilings major cabling activities any activity which cannot be completed within a single work shift

Type DMajor demolition and construction projects


activities which require consecutive work shifts

activities which require heavy demolition or removal of a complete ceiling system

new construction

Step 2:

Using the following table, identify the Patient Risk Group that will be affected. If more than one risk group will be affected, select the higher risk group:

gROUP 1

lOWESTGROUP 2

MEDIUMGROUP 3

MEDIUM HIGHGROUP 4

HIGHEST

1.) Office areas

2.) Administration

3.) Public areas1.) All patient care areas not mentioned in groups 3 or 4 (example: Cardiac Rehabilitation, Neurophysiology)

2.) Admission

3.) Outpatient areas1) Emergency Department

2) Radiology/MRI

3) Post-anesthesia Care Unit

4) Labor and Delivery

5) Newborn Nurseries

6) Pediatrics

7) Nuclear Medicine

8) PT tank areas

9) Kitchen

10) Echocardiography

11) Laboratories

12) Diagnostic Imaging

13) Respiratory Therapy1) Transplant units

2) Operating Rooms; Sterile Processing

3) Labor and Delivery Operating Rooms

4) Intensive Care Units

5) Cardiovascular Recovery

6) Cardiac Catheterization & Angiography Areas

7) Outpatient chemotherapy areas

8) Dialysis

9) Oncology

10) All endoscopy areas

11) Pharmacy Admixture

12) Special Procedures

13) HIV Unit

Step 3:

Match the Patient Risk Group (1, 2, 3, 4) with the planned Construction Activity Type

(A, B, C, D) on the following Infection Control Matrix to determine the Class of Infection Control Procedures (I, II, III, IV).

Construction Activity TYPE(TYPE

ATYPE

BTYPE

CTYPE

D

PATIENT RISK GROUP (

Group 1 LowestIIIIIIII/IV

Group 2 MediumIIIIIIIV

Group 3 Medium HighIIIIIII/IVIV

Group 4 HighestIIIIII/IVIII/IVIV

Note: Infection Control approval will be required when the Construction Project Activity Type and the Patient Risk Group indicate that Class III or Class IV infection control procedures are necessary.

Infection Control Procedures

Class I

Execute work by method to limit raising dust from construction Ceiling tiles: Immediately replace tiles displaced for visual inspection Traffic: Visitor traffic routes should limit contact with patients Maintain manpower and equipment including dust mops, brooms, buckets and clean wiping rags for cleaning fine dust from floors and other surfaces on adjacent occupied areas. Transportation route or storage for clean supplies not near contaminated materials Traffic: Patient movement: Limit exposure of patients to construction Utility Disruption: Schedule interruptions during low activity

Class IIin addition to points for Class I above: Water: mist work surfaces when cutting

HVAC: Air vents blocked and sealed before starting

Monitor need to change or clean filters during construction

Area contained to 1 room with walls from floor to ceiling. Close door and duct tape frames and door

Debris: covered, sealed and taped shut during transport

No elevators used for debris removal

Contractor will clean up dust tracked outside construction area immediately, using HEPA vacuum or damp mop. Dust: wet-mop and place adhesive door mats at entrance. Mats shall be changed daily or more frequently, if necessary.

Holes in walls not exposed > 4 hours. Cover if longer time period.

Ceiling: access panels without barriers must be closed when unattended

Ceiling Tiles, porous: remove and replace if wet

Ceiling Tiles, non-porous: remove, clean with dilute hypochlorite or other approved cleaning solution and dry before replacement

Class III

in addition to points for Classes above: Consult Infection Control

Educate staff regarding risks

Examine design of operational laundry/trash chutes for potential transmission

Dust Minimization: partitions must be installed prior to starting (including construction in ceilings). These barriers, including those above ceilings, shall be dust tight.

Debris: Chute for debris removal: HEPA-filtered

Transport debris during low activity period

Site thoroughly cleaned before patient admittance; remove blockage of air vents and wet mop with disinfectant

Barriers: Dampers closed temporarily to limit circulation of contaminated air

Assure adjacent air filtering systems are functioning

Thoroughly clean new area before patient admittance

Airtight plastic barrier from floor to ceiling or drywall

Plastic seams must be sealed with duct tape

Remove barriers carefully to limit spread of dust/dirt

Barriers considered debris at disposal

Ceiling: Openings from removed tiles covered in plastic and sealed until replaced

HVAC: Bottom of outdoor air intakes serving central system 6 feet above ground or 3 feet above roof

Exhaust system above roof and 75 feet from air intake

Maintain negative pressure in construction area

Block off all existing ventilation ducts within the construction area. Method of capping ducts shall be dust tight and withstand airflow. Increase air filter change frequency

Fresh air intakes 25 feet from exhaust outlets of vent system, combustion equipment stacks, medical/surgical vacuum system, plumbing vents, or area near vehicular exhaust or other fumes

Vent system cleaned and balanced after completion of construction

Carpet: Avoid in clinical areas (including hallways)

Never in areas of frequent spillage or heavy soilage (OR, ICU, Lab)

Water: Mains, branch mains, risers, and branches to a group of fixtures have stop valves

No built-in soap dispensers

Adequate room for single-use paper towel dispensers and waste disposal

Water lines flushed at site And adjacent areas before patient occupation

Temperatures checked before patient admittance

Floor drains should be avoided

Obtain potable water when needed

Sinks: Easily accessible; nearby surfaces are non-porous to resist fungal growth

Cooling Tower, New: Direct tower drift away from air intake system. Operational: Drift eliminators present and biocides used regularly

Control Cube: When access panels are opened or new openings are made in existing ceilings in occupied areas use a Control Cube or provide a plastic enclosure around the ladder sealing off opening, fitted tight to the ceiling and floor.

Class IV

In addition to points for Classes above: Consult Infection Control

Relocate patients to area remote from construction areas

OR and Delivery Room: air supply from ceiling outlets near center of work area. Returns (at least 2 and far apart as feasible) near floor Water: No floor drains

Sinks: Foot, knee, or sensor control units when risk of touch contamination (e.g., OR)

Air in OR: Must have at least 90% filters

Bone Marrow Transplant (BMT) or Protected Environment Room: HEPA filtered

Isolation Rooms Negative pressure for airborne isolation

Minimum of 12 air changes/hour

Exhaust to outside or recirculated after HEPA filtration

Separate toilet, bathtub (or shower) and sink

Adequate room for handwashing, gowning, and storage of clean and soiled materials Positive pressure for BMT

Anteroom(s) recommended (at least 1 room that can be made negative pressure for patient with an airborne infection)

Best air flow:

Hallwayanteroompatient room

HEPA-filtered

Rooms well-sealed

2. PERFORMANCE REQUIREMENTS

A. Infection control is critical in all areas of all facilities. Construction activities causing disturbance of existing dust, or creating new dust, must be conducted within ventilation-controlled areas that minimize the flow of airborne particles into patient areas.

B. FACILITY NAME requires any subcontractor, sub-subcontractors, material suppliers, vendors, employees, or agents to be bound by these same requirements. Before any construction on site begins, the Contractors on-site management team shall attend a mandatory education program approved by Infection Control, for instruction on precautions to be taken.

C. It should be determined whether the construction area uses fresh/outside or recirculated air; filters should be added or return vents covered as needed with filter material or plastic. Air must flow from clean to dirty areas.

D. The air within the construction area must be negative with respect to surrounding areas and with no disruption of air systems of adjacent areas. Constant negative pressure within the zone should be monitored with an alarmed device, which must be maintained and monitored by construction personnel. Exhaust from construction air should be directed outside with no recirculation if possible. If the exhaust must tie into a recirculated air system, a pre-filter and high efficiency filter (95%) should be used before exhaust to prevent contamination of the ducts. Fans should be turned off before opening ductwork and necessary interruptions (e.g., fire drills) should be planned for to minimize risk. High efficiency filter air machines shall provide airflow out of construction areas to create negative pressure at barricade entrances with doors fully open. HEPA equipped air filtration machines shall be connected to normal power hooked to a single switch for emergency shutoff and shall run continuously.

E. The Project Manager or Infection Control Department may modify performance requirements for certain activities. Any modification made by FACILITY NAMEs personnel does not relieve the contractor of compliance with proper infection control procedures.

3. SUBMITTALS

A. The contractor shall submit a report outlining the infection control procedures, including location and details of barrier.

B. Product Data: The contractor shall submit product data for products used in the project.

4. QUALITY CONTROL

FACILITY NAMEs Infection Control Department will monitor biological counts in vicinity of construction work as appropriate. Whenever safe levels are exceeded, contractor will be notified to correct conditions immediately.

1. All work shall be stopped on the project whenever a hazardous infection control deficiency exists.

2. Contractor shall take immediate action to correct all deficiencies.

3. Failure of Contractor to correct such deficiencies will result in corrective action taken and deduction of all costs from the contract. No work will proceed until corrective action is completed.

5. INFECTION CONTROL PERMIT

A. An Infection Control Permit is required for Class III or higher procedures and any activity in a Group 4 Infection Control Group. Refer to shaded area on Construction Activity/Infection Control Matrix.

B. When required, obtain Infection Control Permit from the Infection Control Department before beginning any demolition or construction work.

C. Permit to be displayed at entrance to work area during entire construction period.

D. Return permit at completion of work.

6. PRODUCTS and MATERIALS

A. Sheet Plastic: Fire retardant polystyrene, 6-mil thickness.

B. Barrier Doors: Solid core wood in metal frame, painted.

C. High Efficiency Particulate Air-Equipped filtration machine

D. Exhaust Hoses: Heavy duty, flexible steel reinforced; Ventilation Blower Hose

E. Adhesive Walk-Off Mats: Provide minimum size mats of 24 inches x 36 inches

F. Disinfectant: Hospital-approved disinfectant or equivalent product.

G. Portable Ceiling Access Module

7. BARRIERS

A. Closed door with masking tape applied over the frame and door is acceptable for projects that can be contained in a single room.

B. Construction, demolition or reconstruction not capable of containment within a single room must have the following barriers erected.

1. Airtight plastic barrier that extends from floor to ceiling. Seams must be sealed with duct tape to prevent dust and debris from escaping.

2. Drywall barriers erected with joints covered or sealed to prevent dust and debris from escaping.

3. Seal all penetrations in existing barrier airtight.

4. Barriers at penetration of ceiling envelopes, chases and ceiling spaces to stop movement of air and debris.

5. Anteroom or double entrance openings that allow workers to remove protective clothing or vacuum off existing clothing.

6. At elevator shafts or stairways within the field of construction.

7. Overlapping flap minimum 2 feet wide at polyethylene enclosures for personnel access.

8.INFECTION CONTROL PROCEDURESGENERAL

A. Maintain manpower and equipment including dust mops, wet mops, brooms, buckets and clean wiping rags for cleaning fine dust from floors in adjacent occupied areas.

B. Contain work areas outside of construction barriers, including spaces above ceilings, with full height polyethylene sheet barrier, tightly taped.

C. The contractor will clean up dust tracked outside of construction area immediately.

RESPONSIBLITIES: GENERAL and by ACTIVITY CLASSA. The Contractor is responsible for obtaining the Infection Control Permit from the FACILITY NAME sites Infection Control Department prior to commencing construction.

B. FACILITY NAMEs Construction Department and sites Infection Control Department will evaluate every work order. They reserve the right to add requirements to a project on an individual basis.

C. The sites Infection Control Department will make periodic visits to work site to ensure compliance of policy.

ENVIRONMENTAL MONITORING

A. Contractor is responsible for maintaining equipment and replacement of High Efficiency Particulate Air filters and other filters in accordance with manufacturers recommendations.

B. FACILITY NAMEs Project Manager and Infection Control Department will perform field inspection and testing.

C. FACILITY NAMEs Project Manager will confirm specified air velocity whenever barricades are erected or modified.

D. FACILITY NAME personnel will monitor air quality throughout project as needed.

ENFORCEMENT

A. For breach of this infection control policy FACILITY NAME will stop the work of the project and the contractor shall pay for all associated costs incurred by FACILITY NAME as well as for correction for the work.

B. FACILITY NAMEs Project Manager will record the following:

1. Document each violation with photographs

2. Extract Contractor or Department information from the work log.

3. Maintain a record of all infection control violations.

C. Violations of infection control policies may affect status as a contractor for bidding future work.

IV.CROSS REFERENCESIV. EXHIBITS/ATTACHMENTS

Infection Control Risk Assessment

SITE INSPECTION

Project :________________________Building/Location__________________Floor________

Date: ______________ Time: _____________ Inspector ___________________ Title _____________

Items to Check

YESNON/ACOMMENTSFOLLOW-UP

PROCEDUREICRA completed and filed

on site.

ICRA permit for Class III or higher construction activity displayed at entrance to work.

ICRA permit returned to safety following completion of work.

SUBMIT-TALSContractors infection control measures report on file with safety department.

Contractor has submitted product data for job site materials.

CONSTRUCTION PERFORMANCE REQUIREMENTS

Construction creating dust is conducted within ventilation controlled areas to minimize flow of airborne particles.

Contractors on site management team have attended infection control training.

Air flows from clean to dirty areas.

All air vents (return, and exhaust) are covered

The air within the construction area is negative with respect to surrounding areas.

Contractor is maintaining equipment and replacing high efficiency air filters.

Construction work complies with all requirements of Class III & IV infection control procedures.

QUALITY CONTROL

Work has been stopped on the project for a hazardous infection control deficiency.

The contractor has taken immediate action to correct all deficiencies.

Corrective action has been taken on the contractor. No work has proceeded until the corrective action is in place.

Project :________________________Building/Location__________________Floor________

Date: ______________ Time: _____________ Inspector ___________________ Title _____________

TOPIC

YES NON/ACOMMENTSFOLLOW-UP

BARRIERSAirtight plastic extends from floor to ceiling.

Drywall barriers erected with joints covered or sealed to prevent dust from escaping.

All penetrations in existing barriers are sealed air tight at ceiling envelopes etc.

Anterooms are in place that allows workers to remove protective clothing.

ENFORCEMENTAir quality is monitored and recorded.

Infection control violations are being recorded.

Site inspection is monitored, evaluated, and logged twice a month by the Project Manager or Infection Control together with Public Safety, and the General Contractor. FACILITY NAMEs Project Manager and Infection Control Department will perform any testing requirements.ADDITIONAL COMMENTS: __________________________________________________

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____________________________________________________________________________________FACILITY NAME HospitalInfection Control Risk Assessment

Construction and Facility Maintenance

Initial Risk Assessment Checklist

Projected Start Date: _________________________ Projected End Date: _________________________

Project Number/Name: __________________________________________________________________

Project Location: _______________________________________________________________________

Brief Scope of Work: ___________________________________________________________________

Assessed By: __________________________________________________________________________

_____________________________________________________________________________________

Rating Summary: (Refer to IC Matrix below)

Class of Precautions: ____ Construction Activity: A, B, C, D; Risk Level: Low, Medium, High, Highest

IC Matrix-Class of Precautions

Type A

Type B

Type C

Type D

Low Risk Group

I

II

II

III/IV

Medium Risk Group

I

II

III

IV

High Risk Group

I

II

III/IV

IV

Highest Risk Group

II

III/IV

III/IV

IV

Project Duration:

[ ] Short-term Project: Project Duration of a single work shift or less than 24 hours

[ ] Long-term Project: Project duration greater than 24 hours

[ ] Large Scale Project: Project which may result in significant interruption

V. Infection Control Precautions by Class

Coordination of activities in these areas is to occur before the project is started. The project manager is responsible to coordinate area activities with the area/unit manager and infection control. Items not checked are determined to be not applicable.

VI. Class I

[ ] Immediate area is to be unoccupied.

[ ] Close doors to adjacent areas and patient care rooms prior to activity

[ ] Immediately replace any ceiling tile removed for visual inspection

[ ] Local plastic non-rigid containment barrier tightly sealed at ceiling, walls, and floor. A single slit entrance

w/closed flap or zippered opening may be used for access.

[ ] Seal unused doors with duct tape and/or plastic sheeting.

[ ] Debris and dust are promptly cleaned up and disposed of.

[ ] Mist or vacuum work surfaces while cutting to minimize dust.

VII. Class II

[ ] Class I requirements plus[ ] If hard barrier is required, complete barrier before construction/facility maintenance activity.

[ ] Block off or seal air vents.

[ ] Negative airflow with HEPA filter, filter exhaust directly to outside or tied into return air system.

[ ] Contain construction debris in tightly covered containers. Establish routes and times for disposal.

[ ] Adhesive walk-off mats to be placed immediately inside & outside of containment areas.

[ ] Wet mop and/or vacuum (HEPA-filtered) surfaces at the end of the shift.

VIII. Class III

[ ] Class I and II requirements plus[ ] Rigid floor to ceiling barriers required w/sealed joints.

[ ] Isolate HVAC system.

[ ] Negative airflow with HEPA filter, filter exhaust directly to outside or tied into return air system.

[ ] All personnel entering work site must wear jump suit and shoe covers.

[ ] Seal holes, pipes, conduits and punctures.

[ ] At the end of project, hang temporary plastic non-rigid barrier to remove construction materials and rigid

barriers, to minimize dispersion of dust.

Class IV [ ] Class I, II, and III plus

[ ] Construct ante-room.

[ ] All personnel must wear jump suit, shoe covers, mask, and hair cover to enter or travel through the clean/sterile

area. (Items are removed, left in the anteroom and put on again when the worker leaves the work area)

[ ] If sterile/invasive procedure area is entered, tools must be damp-wiped or bagged prior to entering and exiting

work area. Debris cart must be damp-wiped prior to entering and exiting work area.

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[ ] Additional Infection Control related training required.

[ ] Risk Assessment posted outside activity area.

[ ] Additional Infection Control measures required for specific circumstances. Refer to System Policy;

Infection Control Measures for Use During Facilities Maintenance & Construction.

Special Notes: ____________________________________________________________________________________________

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Infection Control Professional Project Manager

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Date

Date

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[ ] Infection Control [ ] Facilities [ ] Project Site [ ] Unit/Department Manager

Documents

ICRA Policy Template