Infection Control Risk Assessment - ICRA 101

THE MISSION Provide the health care facility with the best trained, knowledgeable and qualified construction workforce in order to get the job done right and protect the health and safety of patients, staff, workers and the public with minimal disruption of daily activities and operations.

THE CHALLENGE Hospital associated infections (HAIs) like MRSA and aspergillus continue to be a problem in health care facilities. It is estimated that each year in the US: 1.7 million patients acquire HAIs 99,000 patients die from these infections 5,000 HAI deaths are from construction related activities Studies indicate invasive aspergillosis can occur during construction and renovation

OBJECTIVES Describe the various risks and challenges involved in working in occupied health care facilities Explain how to develop a health and safety plan between the facility owner and contractor Identify different effective procedures to protect patients, staff, workers, and the public from any hazardous materials, contaminants or infectious agents Recognize and understand the remediation of hazardous materials, contaminants or infectious agents Differentiate the responsibilities of the contractor, architects, and facility owner

HEALTH CARE FACILITIES The primary goal is to maintain the patients’ health Patients are vulnerable to infections and diseases due to weakened immune systems Immunocompromised patients include burns, premature babies, organ & bone marrow transplant, ventilator, dialysis Daily operation of facility is critical Protect PATIENTS, staff, workers and the public

HAZARDOUS MATERIALS When working with or around hazardous materials it is essential to warn others of the possible dangers using: Placards Labels Containers MSDS

HAZARDOUS MATERIALS Materials that pose risk to: health, safety, and the environment Present at jobsites within health care facilities in many different forms Acute and chronic health effects can result from exposures over OSHA’s PEL

HAZARDOUS MATERIALS Materials that pose risk to: health, safety, and the environment Present at jobsites within health care facilities in many different forms Acute and chronic health effects can result from exposures over OSHA’s PEL Permissible Exposure Levels – What is your level? What are some Hazardous Materials you see at work?

HAZARDOUS SUBSTANCES Hazards found in occupied building: Asbestos Lead Fungi Silica Chemicals Asbestos is < 3 microns, human hair is 70. Can be friable (reduced to dust) and remain airborne for days. Lead can cause headaches, seizures and brain damage. Silica, 2nd most common material in the earth’s crust. Fungi, over 60,000 species, (mold, yeast and mushrooms). Mold, needs food, oxygen and moisture to grow (your lungs). Mold is 25% of the living matter on earth.

HAZARDOUS SUBSTANCES Hazards found in occupied buildings: Bacteria Mold Radiation Mercury Medical Waste Bacteria, exposure can result from breathing, touching or ingestion. Mercury can cause birth defects and damage the central nervous system. One thermometer can contaminate a 60 acre lake. Radiation, depending on intensity, amount and duration can cause acute and chronic conditions from headaches and sterility to death. Electromagnetic (MRI), Mechanical (sound waves), Particle (X-Rays). Fungi: over 100,000 species. Medical waste: needles, instruments, and dressings that can transfer bloodborne diseases such as hepatitis and HIV.

I.L.S.M. TEAM Interim Life Safety Measures (ILSM) team’s goal is to ensure safety of patients Implements emergency evacuation plans and identifies fire, safety, and security measures Must have and maintain an unimpeded exit plan. If construction work blocks the exit plan, the ILSM team must have an alternate plan PATIENT safety must come first

I.C.R.A. TEAM Infection Control Risk Assessment (ICRA) team’s goal is to minimize risk of hospital acquired infections (secondary infections) Studies scope of work to be done and evaluates risk factors and potential hazards Matrix: Matches project type and patient risk group to determine work area classification ICRA forms – required by The Joint Commission (TJC)

CONSTRUCTION PROCEDURES Classification determines the type of barriers Can change if mold, lead or asbestos are found Air tight seals are essential Portable cubes Soft walls Hard walls Anterooms Positive and/or negative air pressures

PORTABLE ISOLATION CUBE Small single person containment used for inspection or short term Collapsible barrier that can be easily maneuvered and deployed Great for working above ceilings Negative HEPA air seal and vacuum cleaner What is the estimated total cost of all the items in this picture?

SOFT WALL SYSTEM Quick and safe Suitable for short term Convenient for emergencies Zipper door for access Will this work with negative and/or positive air pressure?

HARD WALL SYSTEM Long term temporary partition Protects patients and the public from contaminants Built with common construction materials like metal studs and drywall Sealing is essential Sustains impacts from gurneys

ANTEROOM Changing room for PPA Extra protection in sensitive areas May be hard or soft wall systems Excellent transition between differential air pressures

AIR PRESSURE Positive Negative Equal Monitoring: Flutter gauge Ball gauge Magnehelic Documentation - using data from an air particulate counter

PERSONAL PROTECTION Personal protection equipment (PPE) is worn inside contaminated and protects workers from hazards or contaminated material PPE is donned prior to entering contaminated area and removed prior to entering patient occupied area What is PPA?

PATIENT PROTECTION APPAREL Protective apparel designed to prevent transferring of contaminants from worker to patients Used when entering or exiting the containment area

WORKSITE PREPARATION Before construction work commences existing finishes must be protected Fixtures, furniture, floors, computers, walls, floors, doors, windows, window treatments, casework and contents, elevator cabs and all equipment Protective materials – polyethylene sheeting, hardboard, plywood, cardboard, tape and self sticking floor protector Decommission any equipment or computers in cooperation with hospital staff. Patient privacy must be protected at all times, ie.. charts

JOB COMPLETION Obtain inspection documents Jobsite cleaned and disinfected by contractor and the hospitals environmental services team Fire alarms and smoke detectors tested HVAC systems functioning properly Remove barriers and signs Final cleaning performed by the facility

WORKER TRAINING UBC members get a 24 hour class that includes classroom and “hands on” shop activities 8 hour Trades Awareness class available to everyone AIA continuing education class – 1 ½ hour lunch and learn Look at the shop picture, see anything wrong or concerning?

WORKING TOGETHER AWARENESS – COMMUNICATION - PROTOCOL To minimize risks of secondary infection and other issues, contractors and workers must understand procedures of working in an occupied health care facility (29 CFR 1926, OSHA, NYC Guidelines for mold remediation) Knowledgeable facility managers and employees will help reduce risk of secondary infections (CDC, TJC, CMS, ASHE) Architects recognize the risks and protocol involved and inform contractors and facility managers of specific precautions. Recognize the importance of a highly trained workforce. (FGI - 2010 edition)

Infection Control Risk Assessment - ICRA 101 The United Brotherhood of Carpenters and Joiners of America is a Registered Provider with The American Institute of Architects Continuing Education Systems (AIA/CES) for AIA members. Certificates of Completion for both AIA members and non-AIA members are available upon request. This program is registered with the AIA/CES for continuing professional education. As such, it does not include content that may be deemed or construed to be an approval or endorsement by the AIA of any material of construction or any method or manner of handling, using, distributing, or dealing in any material or product. Questions related to specific materials, methods, and services will be addressed at the conclusion of this presentation

Training and Qualification Program Construction ICRA: Best Practices in Healthcare Construction The Carpenters International Training Fund responded by creating: Construction ICRA: Best Practices in Health Care Construction in Occupied Facilities Training and Qualification Program Refer to course syllabus.

Best Practices in Healthcare Construction Curriculum Construction ICRA: Best Practices in Healthcare Construction November 2008 Training Program Goals Develop comprehensive skill-sets to address the concerns of health care administrators for containing pathogens, protecting patients, and working without disrupting operations Heighten the sense of accountability and responsibility by those working in occupied facilities Create a workforce for all levels of the project: From apprentices and journeymen, to foremen and superintendents Our mission is to provide trained – productive workers to our industry partners.   We have a large training infrastructure that works together to achieve our mission. We have the highest quality training material available. The UBC is the 6th largest producer of training manuals. UBC spends around 200 mill. On training top down and bottom up We have a curriculum development process in place to develop additional training materials to meet the current and future needs of our industry partners.

Best Practices in Healthcare Construction Curriculum Construction ICRA: Best Practices in Healthcare Construction November 2008 Developing Core Training Protocols Consulted with industry experts in pathogen containment during construction work in occupied facilities to collect relevant, up-to-date technical material Researched which best practices would deliver the trained professionals that a health care jobsite requires Established a system for the ongoing review of all training materials with industry experts to refine technical information and anticipate emerging job site requirements Take a look at the Professionals who helped write the course. Andy Streifel, Judene Bartley UBC takes pro-active approach to all training

Best Practices in Healthcare Construction Construction ICRA: Best Practices in Healthcare Construction Curriculum Training Delivery Tier 1: Train-the-Trainer Prerequisite: CITF Master Instructor Status Parameters: 40-hours of hands-on training in simulated conditions at the CITC Frequent refresher courses are required Qualification certificates issued by CITF Re-certification mandatory every 48 months Base comments on slide content November 2008 31

Best Practices in Healthcare Construction Construction ICRA: Best Practices in Healthcare Construction Curriculum Training Delivery Tier 1: Train-the-Trainer: Topics focus on awareness and best practices in: Blood-Borne Pathogens Hazmat Material Overview Recognizing Hazardous Material Lead, Asbestos, Silica and Mold Controlling Exposure Exposure Limits Routes of Entry Health Effects Site-Specific Considerations Work Practices Health Care Facility Awareness Individual Responsibilities Regulatory Agencies and Organizations Risk Evaluation Base comments on slide content 32 November 2008 32

Best Practices in Healthcare Construction Construction ICRA: Best Practices in Healthcare Construction Curriculum Training Delivery Tier 1: Train-the-Trainer: Instruction also covers… Documentation Contaminants and Infectious Agents Controlling Contaminants Air Pressure Containing the Work Area Pre-work Activities Work Activities Work Area Classifications Mold in a Health Care Facility Pre-Remediation Activities and Considerations Personal Protection Remediation Work Practices for Mold Base comments on slide content 33 November 2008 33

Best Practices in Healthcare Construction Construction ICRA: Best Practices in Healthcare Construction Curriculum Training Delivery Tier 2: UBC member training 24 HOURS of TOTAL TRAINING (16 hrs. of class time/8 hrs. hands on) Training spans all levels needed on a health care jobsite Apprentices - Journeymen Foremen - Superintendents Qualification cards earned: Best Practices in Health Care Construction Refresher & ongoing training courses required Re-certification mandatory every 4 years Blood Borne Pathogens Card Re-certification available every year We don’t want to push dozens of carpenters through the training. 8 members per instructor. We want them to get it the first time and use what they’ve learned all the time. 34 November 2008 34

Best Practices in Healthcare Construction Construction ICRA: Best Practices in Healthcare Construction Curriculum Training Delivery Tier 2: UBC member training Protocol and skill development addresses: Hazardous Materials Awareness Lead, Asbestos, Silica, and Mold Individual Responsibilities to Patients The Structure of the ICRA Form Regulatory Agencies and Organizations How to Deal with Hospital Personnel Containing the Work Area Base comments on slide content November 2008 35

Best Practices in Healthcare Construction Construction ICRA: Best Practices in Healthcare Construction Curriculum Training Delivery Tier 2: UBC member training Protocols and skill development addresses: Work Area Classifications Anteroom Construction Erecting and Sealing a Soft Wall Working Within a Portable Isolation Cube How to Establish a Negative Pressure Environment Personal Protective Equipment Familiarization How Secondary Infections are Acquired Base comments on slide content November 2008 36

The ICRA form is broken down into steps Step 1: Project Type

Step 2: Patient Risk Group The four types of Patient Risk Groups are: Low Risk Group Medium Risk Group High Risk Group Highest Risk Group

Step 3: ICRA Matrix The ICRA matrix is the graph used to match project type and patient risk to determine work area classification I, II, III, or IV.

Step 4: Surrounding Project Area Potential impact to rooms surrounding the project area is assessed. The patient risk group above, below, and around the project area is determined.

Step 5: Identify Specific Site The specific site is recorded: patient room, clean utility room, medication room, or other. Step 6: Related Issues All issues related to facility systems such as ventilation, plumbing, and electrical. The probability of system outages is indicated.

Step 7: Containment Measures Are containment measures needed? If so, is a soft or hard wall barrier needed? Is HEPA filtration required? Step 8: Potential Risk of Water Damage Information is determined and recorded, such as: potential risk of water damage information concerning structural members and sprinkler or plumbing pipes to be removed or altered Any potential risk of compromising structural integrity is determined.

Steps 10–13: Facility Design Step 9: Work Hours The actual time the work will be performed is recorded: Will it be done during nonpatient hours? Will it be done in segments? Steps 10–13: Facility Design building codes Americans with Disabilities Act (ADA) American Institute of Architects® guidelines (AIA) Step 14: Placement of Containment Barrier placement is determined by: traffic patterns, debris removal housekeeping needs, fire codes

Infection Control Construction Permit completed and issued by the ICRA team issued only for a Class III or Class IV project per the TJC Changes in Work Classification The classification level can change during the course of the project. Changes may occur due to processes that create dust or due to the discovery of mold or other hazardous material in the containment area. If there are any hazardous materials discovered on the jobsite, the supervisory staff must be notified immediately. Communication is essential for the success and safety of projects.

Best Practices in Healthcare Construction Curriculum Construction ICRA: Best Practices in Healthcare Construction November 2008 How Can We Help You? We aren’t looking to re-write your hospital’s protocol; we simply want to work collectively ensuring the patients safety remains the #1 Priority! Use the resources that are available to you right now What do you see a need for? Specialized training? More training in a specific area? Training for your hospital staff or yourselves? We can tailor this training to fit the needs of your facility.

8 hour awareness for other trades or maintenance Curriculum Construction ICRA: Best Practices in Healthcare Construction November 2008 8 hour awareness for other trades or maintenance Can your maintenance personnel use some brushing up? Educate hospital staff, RN’s, and FM’s on the basics of Construction ICRA What do insurance carriers think about Continuing Education? Remember, this training can be tailored to fit your Hospital’s needs *Worker training is a critical component of a multifaceted approach to Infection Control* Explain the 8 hour Training. Does your maintenance personnel or FM's have any continuing education or monthly safety meetings? Everyone who comes in contact with a hospital renovation project should have some understanding of what they may see and what to expect while the project is going on. **Mention the hand out on worker continuing education.**

Best Practices in Healthcare Construction Curriculum Construction ICRA: Best Practices in Healthcare Construction November 2008 8 HOUR OVERVIEW Gain a better understanding of infection control in an occupied facility Adhere to all work class precautions Have the ability to recognize hazards Basic understanding of barriers, HEPA machines, air changes, regulatory agencies, finding mold, etc. Understand their responsibilities during emergency situations Go off slide

How Can You Help Yourselves? Curriculum Construction ICRA: Best Practices in Healthcare Construction November 2008 How Can You Help Yourselves? *You have the resources available NOW to implement the Construction ICRA Qualification in your Facilities* *Put language in your Pre-bid Docs, Hospital Spec Docs, and Construction Docs.* We welcome the opportunity for the IP’s or FM’s to sit in on Training. Take the time to evaluate the training.

How Can You Help Yourselves? Curriculum Construction ICRA: Best Practices in Healthcare Construction November 2008 How Can You Help Yourselves? **REQUIRE OR MANDATE ALL CARPENTERS WHO WORK IN YOUR FACILITY SHOW PROOF THEY HAVE TAKEN THE UBC 24 HOUR CONSTRUCTION ICRA TRAINING** Both stickers and qualification cards We can help with that or the contractor can have a letter head from the training centers showing proof the members have this training and the date of expiration. **SHOW RECOMMENDATION LETTER**

Best Practices in Healthcare Construction AGC 2009 Construction ICRA: Best Practices in Healthcare Construction 31 March 2017 Coalition Building Our ICRA Leads are members of various Healthcare organizations and are AIA Providers. We’re members because we share the same concerns as you do and we want to make sure when we attend the various chapter meetings we gain a better knowledge of the roles you play on Infection Control and we can pass on the valuable information to our members and contractors. They are the ones on the front lines in the prevention of secondary infections on Hospital renovations. 50

Best Practices in Healthcare Construction Construction ICRA: Best Practices in Healthcare Construction EST PPt January 22, 2009 A Collaborative Approach Meeting the Needs of Health Care Organizations… This Best Practices program is designed to enhance the existing craft skills of UBC members Its training is consistent with the CITF’s standard protocol of industry-based, expert-reviewed, certified-instructor curriculum delivery The needs of the end-user remain a focal point during training, so that UBC members meet and exceed project expectations UBC members work a huge number of hours in the Interior Systems industry. We cover the core and advanced skills required in the Interior Systems industry. Ceilings, walls, and soffits – lath, metal studs, and drywall – Interior walls and exterior curtain walls – it’s all here – it’s up to date – it’s ready to go.

Best Practices in Healthcare Construction AGC 2009 Construction ICRA: Best Practices in Healthcare Construction 31 March 2017 Working Together Healthcare facility managers who understand the procedures involved in construction-related infection control help to reduce the risks Architects who understand the specific risks involved help to communicate the facility’s needs to the contractor Contractors and workers who understand the issues involved when working in a healthcare facility help to add value, safety and professionalism to healthcare construction projects Communication is key!

Best Practices in Healthcare Construction AGC 2009 Construction ICRA: Best Practices in Healthcare Construction 31 March 2017 Q & A *Thank you for your time and we enjoyed speaking to you about our Construction ICRA Training*