Infection Control in Healthcare Construction
INFECTION CONTROL IN HEALTHCARE CONSTRUCTION
What construction managers like CG Schmidt are doing to ensure patient health and safety during construction
Working in a hospital setting requires a clean, safe environment for positive patient outcomes. According to the United Brotherhood of Carpenters (UBC), approximately 99,000 people die in hospitals every year due to secondary infections contracted during their stay. One of the major causes of secondary infections is cross contamination, which can occur when air quality is threatened, or pathogens introduced by outside visitors and workers, including during poorly-managed remodels or renovations. In order to eliminate the risk of jeopardizing cross contamination, Construction Managers like CG Schmidt put into place an Infection Control Risk Assessment (ICRA) and Interim Life Safety Measures (ILSM) plan well before a project starts.
WHAT IS “ICRA”?
Infection Control Risk Assessment, or ICRA, is a plan for assessing the risk activities associated with the project and how to mitigate them. Developing a project-specific ICRA plan provides qualified tradespeople information to contain pathogens, control airflow, protect patients, and work without disrupting adjacent operations. Creating an effective Infection Control plan is a five-step process, starting with:
STEP 1: IDENTIFY TYPE OF CONSTRUCTION ACTIVITY
TYPE A
Inspection and non-invasive activities that create no dust
TYPE B
Small-scale, short-duration activities that create minimal dust
TYPE C
Activities that create a moderate to high level of dust
TYPE D
Large-scale remodels, renovations, and additions
There are four “types” of construction activity, categorized in order of impact, duration and potential risk for air-borne contaminants.
- Type A: Simple inspections, such as removing an access panel, looking above-ceiling, small plumbing tasks, and painting.
- Type B: Construction work that is small in nature, can be completed in a short amount of time, and doesn’t have much potential for creating dust or air-borne contaminants. Common Type B activities could include activities such as installing new IT equipment or cables. A Type B activity may create a small amount of dust, but it should be easy to mitigate.
- Type C: Any construction activity, or series of tasks, that create a substantial amount of dust. Building (or removing) walls, installing new casework, sanding surfaces for painting, major electrical, plumbing, or mechanical work, or replacing flooring are all examples of a Type-C construction project.
- Type D: Includes any substantial construction work, such as major demolition, new construction, remodeling, or replacement of above-ceiling systems.
Identifying which category your construction project falls under is the first and most important step to creating an infection control plan. Once the type of activity has been identified, next we have to identify where the work will take place.
STEP 2: INDICATE THE RISK GROUP
LOW RISK
Areas not directly adjacent to patient care
MEDIUM RISK
Patient cares not included under “high” or “highest” risks
HIGH RISK
Cancer centers, ER, maternity, labs, food prep, pediatrics, etc.
HIGHEST RISK
ICUs, NICUs, operating rooms, imaging, radiation therapy, etc.
Just as with Step 1, with Step 2 we also have four designations or categories to assess, this time based not on the inherent risk of the construction activity, but instead based on the nature of the area in which the work is being done.
- Low Risk: These are areas that, while in a healthcare facility, aren’t directly adjacent to patient care areas. This would include lobby areas, storage, exterior / site work, or office spaces.
- Medium Risk: This is sort of a “catch-all” for any space that doesn’t fall into the high-risk or highest-risk categories. While the areas are related to patient care, they aren’t patient areas where sensitive activities are occurring, or where patients would be immunocompromised. This would include areas like rehab spaces, outpatient services, and cafeterias where food is not prepared.
- High Risk: These are patient care areas where patients are considered substantially at risk of infection, where specimens are handled, or where food is prepared. This includes cancer centers, emergency departments, labor and delivery, maternity wards, pediatrics, outpatient care, laboratories, and more.
- Highest Risk: As the name implies, these spaces are the most sensitive and where the most care must be taken in ICRA planning. These include Intensive and Neonatal Intensive Care Units (ICU/NICU), operating rooms, oncology, radiation therapy, and any area where patients are immunocompromised or immunosuppressed.
STEP 3: ASSESS RISK POTENTIAL FOR ANY AREAS SURROUNDING THE PROJECT AREA
No construction work in an occupied facility happens in a vacuum, so chances are high that any work planned will in some way affect neighboring rooms, departments, or thoroughfares. Planning for construction means identifying these potentially impacted areas and assessing their inherent risk factor.
STEP 4: USE THE TYPE AND RISK ASSESSMENTS TO DETERMINE “CLASS”
Once we’ve completed Step One, Two, and Three and we have identified both the type and risk level of the construction activity, we use the chart below to determine the class of activity. The Class type is what determines the actual methods of infection control needed.
| TYPE A | TYPE B | TYPE C | TYPE D | |
|---|---|---|---|---|
| LOW RISK | Class 1 | Class 2 | Class 2 | Class 3/4 |
| MEDIUM RISK | Class 1 | Class 2 | Class 3 | Class 4 |
| HIGH RISK | Class 1 | Class 2 | Class 3/4 | Class 4 |
| HIGHEST RISK | Class 2 | Class 3/4 | Class 3/4 | Class 4 |
INFECTION CONTROL METHODS
Once the sequence, layout and temporary accommodations are planned, infection control techniques can be implemented. Most ICRA are focused on preventing contamination, especially with air contamination. Many different tools and methods of control are used, such as:
- Ante Rooms for negative pressure to keep dust out of adjacent areas
- Negative air pressure in work areas to keep odors and dirt from getting to immune compromised residents
- Sticky walk-off mats to prevent particulate and debris from being tracked onto clean floors
- Ductwork protection to prevent airborne transmission of dust and pathogens into other areas of the facility
- Use of a wet mop or HEPA-filtered vacuum on affected areas
- Lightly misting or covering and material before removal
- Lightly misting workplace surfaces and materials before performing any cutting
- Regular inspections, more than once a day, to make sure temporary enclosures are air-tight and clean
- Air sampling and testing to ensure no contaminates are escaping into occupied areas
- Shoe covers
- HEPA air filtration units
- Utilization of self-contained ceiling access apparatus for small connection work above the ceiling
Covered utility dumpster
Shoe covers and protective gear
Transition chamber
Sealed ductwork
Sticky walk-off mats
Each class of work identified in the previous step identifies what procedures must be done, at a minimum, to control the risk for infection. It should also be noted that with each successive class, workers must adhere to all steps outlined in the previous class as well. For example, a contractor operating in a Class 3 environment must also adhere to all steps for a Class 2 and a Class 1.
INTERIM LIFE SAFETY
In addition to creating project-specific Infection Control plans, additional Interim Life Safety Measures are put into place to protect patients, staff, visitors and construction personnel. Some of these plans include:
- Ensuring free and unobstructed exits, including areas affected as well as other exits nearby.
- Ensuring the fire alarm, detection and suppression systems are in good, working order or providing temporary systems when any fire system is impaired.
- Ensuring temporary partitions are smoke-tight and built of noncombustible or limited combustible materials that will not contribute to the development or spread of fire.
- Providing additional firefighting equipment and training personnel in its use.
- Developing and enforcing storage, housekeeping and debris removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.
- Increasing hazard surveillance of buildings, grounds and equipment with special attention to excavations, construction areas, construction storage and field offices.
- Training personnel to compensate for impaired structural or compartmentalization features of fire safety.
- Conducting hospital-wide safety education programs to promote awareness of Life Safety, code deficiencies, construction activities and ILSM planning to verify JCAHO compliance.
ADDITIONAL CONSIDERATIONS FOR POSITIVE PATIENT OUTCOMES
