Construction Management and Infection Control

Andrew StreifelHospital Environment Specialist

strei001@umn.edu

Barriers in the old days..What did they contain?

Dust gathers around electrical workWater spills in dialysis are common.

Why was the infection control risk assessment developed?

Evidence based experiences helps assure patient safety during hospital construction.

Chart11269323Construction Work (probably)Construction Work (possibly)Air Supply SystemUnknown SourceOther SourceDistribution of Sources in 53 Nosocomial Aspergillosis OutbreaksR-P. Vonberg, P. Gastmeier - Journal of Hospital Infection (2006) 63, p.25023%11%17%6%43%Sheet1Unknown sourceOther sourceAir Supply SystemConstruction work (possibly)Construction work (probable)1269323Sheet1Construction Work (probably)Construction Work (possibly)Air Supply SystemUnknown SourceOther SourceDistribution of Sources in 53 Nosocomial Aspergillosis OutbreaksR-P. Vonberg, P. Gastmeier - Journal of Hospital Infection (2006) 63, p.25023%11%17%6%43%Sheet2Sheet3

Provide visual indicators-pressure -signage-flexible door

Cover debris during transport

How did the carpenters become involved with infection control?

Environmental Infection Control Construction Management Training

Training provides a forum forunderstanding what to do and when to do it.

What process was involved in thedevelopment of the Carpenters

ICRA program curriculum?

Protect floors and minimize track dirt

Moldy sink in pharmacy Negative pressure indicator

Infection ControlRisk AssessmentMitigation ResponseNotification Process

Areas affected Work description Start & finish date Work hours Notification/permits Information included Noise & vibration Contractor Sub and Sup phone Meeting time

Assure training reaches all who work in healthcare.

Objectives for Infection Control during Construction in Healthcare Facilities

Respectful of patients Control aerosols Maintain a clean environment Prevent water damage Respond to emergencies Provide documentation Be trained & communicate

Infection Control Risk Assessment

November 13, 2018

Larry F. Rubin - CEM, CPE, CHFM, CHSP, CHC Senior Director - Facilities Management, Cleveland Clinic

Healthcare Construction Projects

Run wiring Install a dishwasher Replace a door Replace FlooringRenovate an ORGut an entire unitBuild a new building

Hospital Construction: Who is affected?

The list goes on and on

DID WE FORGET ANYONE?

Doctors NursesEVS

VisitorsGift Shop Personnel

PATIENTS! Patients are first priority in all we do

All construction professionals become healthcare workers when working in a medical facility

The health and safety of every patient, employee, and

construction professional is our NUMBER ONE PRIORITY

What makes some people more vulnerable? Chronic obstructive pulmonary disease Elderly and Newborns HIV infection Organ transplant Kidney/heart disease Lung/liver disease Malignancy - leukemia/lymphoma Bone marrow transplant

CommunicationCommunication between Healthcare Workers (HCW) and Construction

Personnel is vital to protecting patientsEnsures safe, clean environment free of contaminants and debris

ICRA Training builds a bridge between HCW and Construction

Communication

Partnership formed April 2015 because CCF recognized the value in this program

First ICRA training class May 2015 In-house ICRA training completed January 2018 Training to all healthcare partners at NO COST Continuous ICRA training for contractors Confirmation through Feedback

Why We Need ICRA 8-hour Training

Crossing the bridge between construction professionals and infection prevention leads to:

Understanding of the others perspective Better compliance with infection control healthcare

construction standards Efficient use of time for completing projects Safe, clean and dust-free healthcare environment during

all phases of constructionAnd

To Prevent infections

Patients, visitors, employees deserve a clean and healthy atmosphere

Dust can contain contaminants such as Aspergillus

You never know what condition a person might have

In order to maintain a safe environment

Infection Control Risk Assessment (ICRA)

Healthcare Construction Tool for the IP team toidentify and effectively analyze the critical

information relating to the Infection Prevention Risk Assessment

during construction, maintenance, renovation activities

Facility Management

Maintenance workers Construction, Planning & Design

Life Safety Team (ILSM)

Risk Management

Regulatory Compliance

Patient Quality & Safety

Infection Preventionists (IP)

Nurse Management

Information Technology (IT)

Environmental Services Team

Security Team

Who Should Receive ICRA Training?Everyone on your team!

ICRA training breaks down the silos and builds a bridge of communication for patient safety

ICRA MATRIX

ICRA FORMS Various ICRA templates are available from Centers for Disease Control

(CDC), Association for Professionals in Infection Control (APIC), American Institute of Architects (AIA), American Society for Healthcare Engineering (ASHE), Joint Commission (JC)

Each institution can choose an ICRA form and customize it based on needs, likes, and wants

Customizable electronic and paper/manual forms are available that can allow access to all involved parties

ICRA Distribution Construction Project Manager completes initial required information Sent via email to teams mentioned previously-(i.e. infection

prevention, facilities management) Given a deadline for completion Reminder sent if not complete

Copy of approved ICRA at every job siteNo project can begin without completed form

Ongoing Assessment Construction activities need continual attention from ICRA team Rounds for monitoring and collaborating with construction team is

essential to safely carry out a construction project Rounds should take place on all projects Daily rounds can include

Site inspection Discussion with construction team of any deficiencies Helping each other understand barriers and work together on solutions Involve additional team members if necessary

Attention-seeking Construction SitesIf I hold onto this dust someone will pay attention to

me

Aspergillus gets through even

small openings

Open zip walls allow contaminants to

escape and affects pressurization

EC.02.06.05 EP 2 Preconstruction Risk Assessment (PRA) during construction,

renovation, or general maintenance in occupied healthcare facilities can result in environmental problems such as:

Air quality Infection control (creation or spread of contaminants) Disruption of essential services Noise Vibration Emergency Procedures

PRA Summary Convene those involved in the potential project

Only address anticipated areas affected by construction Joint Commission doesnt require any one particular form be

used to conduct PRA

Determine level of risk based on: Construction or maintenance activity type

PRA Summary Identify risk-reduction strategies

Class of IC Procedures Type of patients seen in the designated area determines:

Level of patient risk Needed precautions

PRA Summary Document the process

Infection control permit Establish policies and procedures to ensure

consistent process Document frequent site visits to ensure

compliance with risk reduction strategies

Why do we need to do this?

Environmental contamination from fungi (Aspergillus)

Water contamination from water-associated microorganisms (Legionella)

Immuno-compromised patients are reservoirs of these agents

Patients can die from an infection caused by this organism

Why do we need to do this? According to the CDC every year hospital

acquired infections 722,000 HAIs Kill approx. 75,000 Adds more than $30 billion to health care costs Est. 5000* deaths per year from construction,

renovation, and ITM related hazards* Health Facilities Management, February 2002

Why do we need to do this?

Implementation of the PRA EC.02.06.05 EP 3: The hospital takes action based on its assessment to minimize

risks during demolition, construction, renovation, or general maintenance. EC.02.05.05 EP 1: When performing repairs or maintenance activities, the

hospital has a process to manage risks that affect care, treatment, or services for patients, staff, and visitors

Air quality Infection control Utility requirements Noise

Odor Dust Vibration Other

Thank You

Construction and Renovation in Healthcare Facilities

Richard Vogel, MS, CIC, FAPICInfection Control Specialist

Learning Objectives

Know the value of training for infection prevention practice during construction and renovation of healthcare facilities

Learn the importance of infection prevention and control involvement in all phases of construction projects.

Become familiar with materials, finishes and equipment that may be incorporated in construction projects.

Learn the importance of the FGI guidelines in construction and renovation projects.

Learn how to develop an Infection Control Risk Assessment and a Dust Control Plan.

Infection Control Risk Assessment(ICRA)Determining Dust Control Measures

STEP 1: Type of Construction

STEP 2: Identify the Risk Group

STEP 3: Project Class

How big is the construction project?

How ill/frail are the patients?

Non-patient area? Ambulatory Patient / Patient access

area? In-patient area/ High risk ambulatory?

Minor repair?

Major renovation?

Infection Control Risk Assessment(ICRA)STEP 1: INFECTION CONTROL RISK ASSESSMENT (MATRIX) OF PRECAUTIONS FOR CONSTRUCTION & RENOVATION

TYPE A:

Inspection and Non-Invasive Activities such as:

No cutting of any dry wall;

Removal of ceiling tiles for visual inspection.

TYPE B:

Generally less than 72 hours, Small scale, short duration, activities which create minimal dust such as:

Cutting of walls or ceiling if dust migration can be controlled

TYPE C:

Generally greater than 72 hours, Long term activity or activities that generates a moderate to high level of dust such as:

Sanding of walls for painting

Prolonged activities such as demolition in which dust migration cannot be easily controlled.

TYPE D:

Major demolition and construction projects such as:

Extensive demolition or removal of a complete cabling system

New construction or extensive renovation

STEP 2: IDENTIFY THE AREA RISK GROUP

If more than one risk group will be affected, select the higher risk group.

Low Risk Site Non-patient care area Non-patient occupancy area (Administrative Office)

Medium Risk Site

Outpatient care area (excluding high risk areas)

Patient occupancy (e.g. elevator lobby)

Support areas (e.g. Kitchen)

High Risk Site

High Risk Outpatient Areas includes:

Oncology Services

Transplant Services

Lung Clinic

Cystic Fibrosis

Interventional Radiology

Cath Lab

All Inpatient areas

ICRA

ICRASTEP 3: INFECTION CONTROL CONSTRUCTION MATRIX

Match the Area Risk Group, Construction Project Type and Class of Precautions

Area Risk Group

Type A Type B Type C Type D

Low Risk I I II IV

Medium Risk

I II III IV

High Risk II III/IV III/IV IV

Construction Project Type

ICRA STEP 4: RISK MITIGATION MEASURES

Class Example

I HEPA Vacuum and damp mopping used to minimize raising dust from construction operations

II Control dust migration through the use of portable dust control cart

Sticky mats to be placed at the exit from the work area Maintain negative pressure within the worksite utilizing

HEPA filters or fans

III Isolate HVAC to prevent contamination of duct system. Solid Partitions to seal of the work area Construct an anteroom and require all personnel to pass

through this room.

IV During demolition, overalls and shoe covers are to be worn and removed in the anteroom when leaving the work

Precautions, to be followed, are defined by the Class

Determining Dust Control Measures

Minor

Construction

Heavy

Construction

Non-Patient Areas Critically Ill Patient Areas

FGI Guidelines

For new construction Minimum guidelines Source of information in planning , design, and

implementation of Infection Prevention and Control requirements in construction projects

In 2014 edition. Infection Control (ICRA) is now included in the Safety Risk Assessment (SRA)

FGI Guidelines

Two Volumes in 2014Hospital & Outpatient Facilities (HOP)Residential Health, Care, and Support Facilities

Three Volumes in 2018HospitalOutpatient FacilitiesResidential Health, Care, and Support Facilities

Same process for SRA in all volumes

FGI Guidelines

Safety Risk Assessment (SRA) Similar to ICRA Looks at many conditions including:

Lights Surfaces Sources of Infection Standardized location of equipment Visibility of patients Noise and Vibration

Multidisciplinary Team Requires documentation of recommended design features

and written records must be part of project documents

FGI Guidelines

1.2-3.2.1 ICRA Requirement. For a health care facility project to support safe designs, HVAC/plumbing systems, and surfaces and finishing material selections, an infection control risk assessment shall be a part of integrated facility planning, design, construction, and commissioning activities and shall be incorporated into the safety risk assessment.

1.2-3.2.2 ICRA Considerations. At a minimum, the ICRA shall address the following:Design Elements

Isolation RoomsHVAC needsWater/plumbing systemsSurfaces and furnishings

Construction ElementsInfection Control Risk Mitigation Requirements

FGI GuidelinesDesign Considerations

ICPs Role

Project organization and stages

Feasibility Schematic design Design development Construction documents (bid documents) Construction process Commissioning

ICPs Role

Feasibility - Look at the big picture

Impact on the department Enough staff? Redistribution of work

Basic Infection Control principles Utility rooms Isolation rooms

ICPs RoleFeasibility - Look at the big picture

ICPs Role

Schematic design- Ensure design addresses Infection Prevention issues

Room sizes Work flow Ventilation and air pressurizations

Redundancy Plumbing

Number and placement of sinks

IPCs RoleSchematic design Isolation rooms

ICPs Role

Design Development Insure that materials, equipment, and finishes specified are appropriate from an infection Prevention and Control perspective

Sink size and location Floors and ceilings Fixtures and wall finishes Cleanability Develop the ICRA Equipment

IPCs RoleDesign development Document review

IPCs Role

Design development - Sinks

Hand washing Sinks

IPCs RoleDesign development Document review

Elevations

IPCs RoleConstruction Documents (Bid Documents)

Final drawings which should include Infection Prevention requirements and the dust control barriers

Must be reviewed by Infection Prevention Value engineering = cost savings Insure that Infection Prevention requirements have not been

removed

IPCs RoleConstruction DocumentsDust Control/ILSM Drawing

ICPs RoleConstruction DocumentsDust Control/ILSM Drawing

Creating Negative PressureICPs Role

Creating Negative Pressure

Exhausting HEPA filtered air

ICPs Role

ICPs RoleCreating Negative Pressure

ICPs Role

Construction Process

Insure dust control measures are maintained. Findings/changes during construction may require

modification of the Infection Prevention measures. Inspect the sites and report findings.

IPCs Role

Construction inspection reportsICRA Compliance 1st Quarter 2018

No Yes Compliance No Yes Compliance No Yes Compliance No Yes Compliance

Site Clean East 0 42 100% 0 34 100% 0 40 100% 0 116 100%West 0 17 100% 0 27 100% 1 28 97% 1 72 99%

Barriers Intact East 1 41 98% 0 34 100% 1 39 98% 2 114 98%West 0 17 100% 0 27 100% 3 25 89% 3 69 96%

Mats Clean East 1 41 98% 1 33 97% 3 37 93% 5 111 96%West 0 17 100% 2 25 93% 1 27 96% 3 69 96%

HEPA Working East 1 17 94% 1 13 93% 0 12 100% 2 42 95%West 0 12 100% 2 18 90% 1 24 96% 3 54 95%

Neg. Pressure East 0 42 100% 0 34 100% 3 37 93% 3 113 97%West 1 16 94% 0 27 100% 1 27 96% 2 70 97%

95%

2018 TOTALSJan-18 Feb-18 Mar-18

IPCs Role

Commissioning

Make sure systems are operating as designed. Insure hand sanitizers, sharps containers, gloves and

other PPEs are in their proper location.

Design Standards

Healthcare facilities should develop design standards for all areas of the facility.

Specification for materials used in projects including flooring, types of sinks and other fixtures, ceiling tiles, wall coverings, fabrics, furniture and even paint colors. Cleanability, durability, and sustainability must be considered.

Should be developed by a multidisciplinary team.

Design Standards

Patient Environment Infection Prevention input is critical Work with Environmental Services and Facilities

to insure that all elements of the environment are acceptable.

Consider Linen storage Cleaning of surfaces Disinfection of patient care items Storage of isolation supplies Sink size

Panel Systems

Design Standards

Design Standards

Fixtures

Design Standards

Building MaterialsGypsum - Mold and moisture resistant

Design StandardsBuilding Technology

RedundancyFan wall

Reveals Good and Bad

Architectural Features

Design Standards

Education

FGI 1.2-3.2.31.2-3.2.3.3 ICRMR Content ICRMRs shall at a minimum, address how the following issues will be addressed during construction

(5) Training of staff, visitors, and construction personnel5 groups to train

Construction company supervisorsConstruction WorkersProject managersFacilities personnelStaff affected by construction/renovation projects

Education

Construction Company SupervisorsAttendance at a mandatory in-service education

session required May be combined with fire safety, ILSM and other required

educational programs. Prior to the start of the project

Consider requiring that construction company supervisory personnel have completed the ASHE Health Care Construction Certificate course as a requirement for a construction company to be selected for work in your facility

Education

Construction WorkersEducational program should include:

Adverse effect of dust on patients The ICRA process Specific facility rules such as entry and exit from buildings Dust control measures Containment and transport of construction materials and

debris

Education

Construction WorkersChallenge: How to educate all the workers

Workers may often be on the jobsite for a short period of time

Different trades needed at different stages of the project Demolition workers at the beginning, with plumbers,

electricians, and HVAC workers next, followed by carpenters, sheetrock workers, and painters

Education

Education

Hospital staff who may be affected by a construction projectProgram should include

Review of ICRA plan Appropriate signage at the worksite What proper barriers should look like Proper above-ceiling dust control measures Importance of negative pressure Proper debris removal procedures Whom to notify about possible deficiencies

Education

Education

Healthcare project managersEducational program should include:

The ICRA process and their role Satisfactory dust control barriers and their maintenance The importance of maintaining negative pressure at all times Proper debris removal Monitoring HEPA filters to insure they are functioning properly The use of devices for continuous monitoring of negative pressure Education of construction company supervisors and construction workers The use of coveralls for construction workers

Education

Healthcare facility maintenance and engineering personnelEducational sessions with theses groups should emphasize the

following: The risk their work presents to patients Necessary measures for work in the ceilings and walls Assembling and maintaining acceptable dust control barriers The importance of maintaining negative pressure The use of mobile dust control carts or other barriers for work in the ceilings

Why we do what we do!

Takeaway Thoughts

Communication

Cooperation

Education

QUESTIONS?

Richard Vogel

richavogel@gmail.com

CCA Metro _Streifel, Rubin, Vogel(compressed).pdfCCA Metro - Andrew Streifel.pdfSlide Number 1 Construction Management and Infection ControlSlide Number 3Slide Number 4Slide Number 5Slide Number 6Slide Number 7Slide Number 8Slide Number 9Objectives for Infection Control during Construction in Healthcare Facilities4. CCA Metro - Richard Vogel.pdfSlide Number 1Construction and Renovation in Healthcare FacilitiesSlide Number 3Slide Number 4Slide Number 5Slide Number 6Slide Number 7Slide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Slide Number 17Slide Number 18Slide Number 19Slide Number 20Slide Number 21Slide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 26Slide Number 27Slide Number 28Slide Number 29Slide Number 30IPCs RoleSlide Number 32Slide Number 33Slide Number 34Slide Number 35Design StandardsSlide Number 37Slide Number 38Slide Number 39Slide Number 40Slide Number 41Slide Number 42Slide Number 43Slide Number 44Slide Number 45Slide Number 46Slide Number 47Slide Number 48Slide Number 49Slide Number 50Slide Number 51CCA Metro - Larry Rubin.pdfSlide Number 1Infection Control Risk AssessmentNovember 13, 2018 Larry F. Rubin - CEM, CPE, CHFM, CHSP, CHC Senior Director - Facilities Management, Cleveland Clinic Slide Number 3Slide Number 4Slide Number 5Slide Number 6Slide Number 7Slide Number 8Healthcare Construction ProjectsHospital Construction: Who is affected?PATIENTS! What makes some people more vulnerable?CommunicationCommunicationWhy We Need ICRA 8-hour TrainingTo Prevent infectionsIn order to maintain a safe environmentWho Should Receive ICRA Training?Everyone on your team!Slide Number 19ICRA MATRIXICRA FORMSICRA DistributionOngoing AssessmentAttention-seeking Construction SitesEC.02.06.05 EP 2PRA SummaryPRA SummaryPRA SummaryWhy do we need to do this?Why do we need to do this?Why do we need to do this?Implementation of the PRAThank You