1. Infection control risk assessment with construction and renovation
Cara Cruz, BA, RN, CIC
Infection control risk assessment with construction and renovation

3. CAH – Barton Memorial Hospital and Renown
23 beds
Avg daily census:
1,000 avg ED visits per month
Carson City – closest larger hospital
About me:
Quality Manager, Infection Control Officer, Patient Safety Officer, Environmental Services Manager (2014)
RN since 2004, LVN 2003: House Supervisor, Inpatient Manager, ICU, Med/Surg, Ortho, SNF, OB, clinic settings
No other disclosures

4. Scenario:
You are the lone IP and your hospital is remodeling an existing radiology room into a new stereotactic mammography room. Your Facilities staff and Administrators just informed you that this project will be starting within the next month. What do you do?

6. Purpose OF ICRA
To maintain an environment that is safe and functional for patients, families, staff and others in the organization by the prevention of infections during construction, renovation, alterations, and maintenance work.
Proper infection prevention and control practices are important during dust generating work to minimize exposure of hospitalized patients, visitors, and staff to micro- organisms, most notably filamentous fungi.
Completed by Infection Preventionist – not facilities, contractor, etc.!
Living document – may change

7. IP role Part of the team Patient Safety Officer
Safety Officer (Interim life safety measures – ISLM)
Facilities
Involvement from initial planning phase to completion
ICRA complete before bid – precautions likely change bid
Oversee construction precautions and risk of project related to infection control
Resource and expert for infection control related issues (design, process, etc.)

8. Buy in Comply with regulatory agencies
State, Facility Guidelines Institute (FGI), Joint Commission
Demonstrate the value of the team/IP involvement
Demonstrate how input from IPs results in an enhanced outcome and lack of input leads to adverse outcome (HAIs, employee/contractor illness, etc.)
Nationally recognized resources (APIC, FGI, Joint Commission, CDC (isolation rooms), OSHA, etc.)
Policy & Procedures (examples in APIC Construction text)

9. Step 1: gather information
2 basic questions:
EXACTLY what type of work will be done?
Where is the project taking place?

10. TYPE OF WORK TO BE DONE
Looking specifically for DUST GENERATION or SPORE ARESOLIZATION
Minor cutting/drilling
New flooring/walls/doors/cabinetry
Removal or addition of building structures
Complete demolition/renovation
Duration
Hours? Days? Weeks? Months?

11. 4 “types” of construction activity
Type A: Inspection and noninvasive activities
Removal of ceiling tiles for visual inspection only, limited to one tile per 50 square feet (or 8 square feet of tile)
Painting (but not sanding)
Wall covering replacement
Electrical trim work
Minor plumbing
Activities which do not require cutting into walls/ceilings/floors other than for visual inspection

12. Type B: Small-scale, short duration activities that create minimal dust
Short duration = 1 day
Installation of telephone and computer cabling
Access to chase spaces
Cutting of walls or ceiling where dust migration can be controlled

13. Type C: Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies
Sanding of walls for painting or wall covering
Removal of floor/wall coverings, ceiling tiles, and casework
New wall construction
Minor duct work or electrical work above ceilings
Major cabling activities
Any activity that cannot be completed within a single work shift

14. Type D: Major demolition and construction projects
Activities that require consecutive work shifts
Activities that require heavy demolition or removal of a complete cabling system
New construction

15. WHERE? Nursing unit Hallway? Patient room? Ceiling? Flooring?
Nurses’ station?
Patient Care area?
Occupancy?
Business hours work?
Night/weekend work?
Patient care vs staff only?

16. 4 levels of risk related to location
Low Risk
Office areas not within or near patient care areas
Office space in Medium Risk areas not near to patient care areas
Unoccupied/Vacant areas
Outpatient areas after business hours unless noted in high risk
Non-patient care areas not otherwise specified

17. Medium Risk Echocardiography Nuclear Medicine Physical Therapy
Radiology
Respiratory Therapy
Outpatient Clinics unless noted in high risk
Public areas and public corridors
Corridors in Medium Risk areas
Office space – near medium risk patient care areas
Areas with staff working during construction who are diagnosed by a physician with severe dust allergies or immune-compromised

18. High Risk Emergency Room Medical/Surgical Units Labor and Delivery
Laboratories
Post Anesthesia Care Unit
Office space – near high risk patient care areas
Corridors in high risk areas
Areas with staff working during construction who are diagnosed by a physician with severe dust allergies or immune- compromised

19. Highest Risk • ICU • Operating/Procedure Rooms • Transplant units
• Pharmacy
• Negative pressure isolation rooms
• Any area currently caring for immune-compromised patients
• Central Sterile Supply
• Interventional Radiology
• Infusion Areas
• Oncology
• Food preparation/eating areas
• Outpatient Surgical Suites

20. Step 2: Determine construction class
Class = procedures to be followed during projects
IP judgement
Risk Area
Construction Project Type
Type A
Type B
Type C
Type D
Low Risk I II
III/IV
Medium Risk
III IV
High Risk
Highest Risk

21. Class I
During project
Upon completion
Execute work by methods to minimize raising dust from construction operations
• Immediately replace a ceiling tile displaced for visual inspection
Clean work area upon completion of task

22. Class II Upon completion During project
Provide active means to prevent airborne dust from dispersing into the atmosphere
Water mist work surfaces to control dust while cutting
Seal unused doors with duct tape
Block off and seal air vents
Place dust mat at entrance and exit of work area
Remove or isolate HVAC system in areas where work is being performed
Wipe work surfaces with cleaner/disinfectant
Contain construction waste before transport in tightly covered containers
Wet mop and/or vacuum with high-efficiency particulate air (HEPA) filtered vacuum before leaving work area
Upon completion, restore HVAC system where work was performed

23. Class III During project Upon completion
Remove or isolate HVAC system in area where work is being done to prevent contamination of duct system
Complete all critical barriers, e.g., sheetrock, plywood, plastic to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.
Maintain negative air pressure within work site utilizing HEPA-equipped air filtration units
Contain construction waste before transport in tightly covered containers
Cover transport receptacles or carts. Tape covering unless lid is solid.
Do not remove barriers from work area until completed project is inspected by the Infection Control or Safety Officer or representative and they are thoroughly cleaned by EVS staff.
Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.
Vacuum work area with HEPA-filtered vacuums.
Wet mop area with cleaner/disinfectant.
Upon completion, restore HVAC system where work was performed.

24. Class IV During project Upon completion
Isolate HVAC system in area where work is being done to prevent contamination of duct system.
Complete all critical barriers, e.g. sheetrock, plywood, plastic to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.
Maintain negative air pressure within work site utilizing HEPA-equipped air filtration units
Seal holes, pipes, conduits, and punctures.
Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or have them wear cloth or paper coveralls that are removed each time they leave work site.
All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area.
Do not remove barriers from work area until completed project is inspected by the Infection Control or Safety Officer or representative and they are thoroughly cleaned by CVMC EVS staff.
Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.
Contain construction waste before transport in tightly covered containers.
Cover transport receptacles or carts. Tape covering unless solid.
Vacuum work area with HEPA-filtered vacuums.
Wet mop area with cleaner/disinfectant.
Upon completion, restore HVAC system where work was performed.

25. Step 3: Permit Indicate construction class
IP, Facilities, Project Manager signatures
All precautions in place before project start
Project Name:
Date Prepared:
Location of project:
Permit No:
Project Manager:
Project Start Date:
Contractor Performing Work:
Estimated Duration:
Supervisor:
Permit Expiration Date:
Risk Group: Low Medium High Highest
Telephone:
Construction Class:
Construction project type: A B C D

27. Step 4: Daily checklist Class III or IV projects only
Completed by Project Manager upon completion of every shift
Returned to IP at least weekly
IP also tours project area regularly to ensure all precautions are being followed
IP should have the right to stop a project if out of compliance/safety issues discovered
Has # for IP and EVS on form
Monetary penalties if plan/precautions not followed?

29. Other considerations
ICRA will differ from facility to facility with circumstances
Prepare to encounter mold from the start
Licensed mold abatement contractor in plan
STOP all construction in the area until it is treated
Not treated by contractor or EVS staff
Dust, noise, smells, vibrations to other areas
Upstairs/downstairs, air circulation
Containment issues
Hole/tear in tape or plastic
Gap from floor/ceiling
Negative pressure

30. Path of travel
Construction workers/equipment
Waste removal
Air circulation
Break areas/eating – construction workers
Allowed in cafeteria?
Infection Control training for contractors and sub-contractors
Internal vs external projects
Photos

31. Scenario:
You are the lone IP and your hospital is remodeling an existing radiology room into a new stereotactic mammography room. Your Facilities staff and Administrators just informed you that this project will be starting within the next month. What do you do?

32. Type: sealing old door, adding new door, adding new sink, removal of cabinets, new flooring, cabling, new desk/cabinets Where: Radiology Duration: 2-3 weeks, during daytime

36. Fill out permit
Forward for signatures
Checklist will need to be completed every shift (class III)
Since process already started (bid, plan, etc.):
Speak with contractor/facilities/review contract
Ensure all precautions are in place before project starts
Ensure all needed equipment available (HEPA filter, fans, ventilation, etc.)
Review plans for room meet IC standards, review FGI with Safety Officer (handwashing sink for procedure room, instrument cleaning sink, etc.)
Make a map for path of travel; walk it
Ensure plan for mold abatement just in case
Consider other potentially effected areas (upstairs, downstairs, connected air vents, smells, etc.)
Ensure compliance with start of project
Checklist compliance

37. Scenario:
Your facility is replacing the autoclave, old flooring and adding stainless steel wall coverings to your ORs, reprocessing, and sterile supply areas. What do you do?

38. Type: removing current flooring, replacing with new flooring, adding stainless steel wall coverings (drilling, cutting, gluing, etc.) Where: ORs Duration: 5 days (day and night work)

42. Fill out permit
Forward for signatures
Checklist will need to be completed every shift (class III)
Surgery will need to be shut down for this time period
Notify EMS, Surgeons, Hospitalists, ED physicians, other departments for which instruments are processed, Leadership, PR
Work in phases – team to arrange phases
Arrange plan for where sterile supplies will be moved
New “red line” for each phase
Make map for path of travel
Have mold abatement plan
Ensure meticulous disinfection after project

43. References/resources
Vogel, Richard, MS, CIC, et. al. (2015). Infection Prevention Manual for Construction and Renovation. Tools | ASHE. (n.d.). Retrieved March 10, 2016, from APIC list serve APIC text

44. Thank you!!
Cara Cruz, BA, RN, CIC Carson Valley Medical Center (775)