2002 update1 construction risk assessment an overview of environmental infection control and...
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2002 Update 1
Construction Risk Assessment
An Overview of Environmental Infection Control and Construction
Related Activities
2002 Update 2
2002 Update 3
2002 Update 4
“Indoor-air-quality (IAQ) challenges out number all others in the health-care industry. Unfortunately, the cost-conscious powers that be have failed to make the management of critical infection-control systems a top priority.”
Andy Streifel, MPH, REHS
2002 Update 5
Commercial Airline Analogy
A typical commercial airliner transports approximately 100 passengers and if the same number of deaths occurred in the aviation industry as a result of airline crashes it would equate to 17 commercial airliner crashes a week. Of which approximately 4 per month would have to do with construction/maintenance related activities.
2002 Update 6
Here’s Our Problem!
Annual Passenger DeparturesAnnual Hospital Admissions
Deaths per year/Nosocomial Deaths per year
Deaths per Scheduled Activity
Airline Industry 1,009,971,000 525
1death/1,923,750passenger departures
Hospital Industry 34,890,76888,000 (all nosocomial)
1 death/396
admissions
Hospital Industry 34,890,7684,400 (airborne)
1 death/7,930
admissions
2002 Update 7
Current Regulations and Guidelines
Joint Commission on Accreditation of Healthcare Organizations
Guidelines for the Design and Construction of Hospital and Health Care Facilities (mandated by state law)
CDC – Guidelines on Environmental Infection Control
State Licensure (in many states)
2002 Update 8
JCAHO
Environment of Care Standards EC.3.2.1
Patient Safety Standard
2002 Update 9
EC.3.2.1 – effective 1/1/02
Demolition, Construction or Renovation
Proactive Risk Assessment Identify hazards that could
potentially compromise patient care Address impact on:
air quality requirements, infection control, utility requirements, noise, vibration, and emergency procedures.
2002 Update 10
Construction & Renovation
Disruption of settled dust Disruption of ceiling tiles Repair/renovation of elevator shafts Repair of under sink cabinets Pulling up carpeting Disturb “environmental reservoirs”
2002 Update 11
Construction, Demolition, and Repair
Multi-disciplinary team approach to review:
design and function of new area risk assessment in preventing airborne
nosocomial disease dust and moisture containment
barrier walls negative pressure differential
2002 Update 12
Air Water Environmental Services Laundry and Bedding Animals in Healthcare Facilities Regulated Medical Waste
CDC Guidelines for Environmental …What it Covers
2002 Update 13
HVAC System Design
Temperature Humidity ACH Mixing of air in the room
Filtration Filter Types and Efficiencies HEPA
Where they are required Portable units
Maintenance
CDC Guidelines for Environmental Infection Control - Air
2002 Update 14
Infection control impact of system maintenance and repair Duct cleaning System shutdowns Moisture in the system Backup emergency electrical power
CDC Guidelines for Environmental Infection Control - Air
2002 Update 15
Construction, Renovation, Remediation, Repair and Demolition ICRA (Infection Control Risk
Assessment) Multidisciplinary team Risk assessment of project P&P to protect patients Procedure to Correct Problems Rapidly
CDC Guidelines for Environmental Infection Control - Air
2002 Update 16
Construction, Renovation, Remediation, Repair and Demolition Preliminary considerations
Resources for education of internal staff and contractors
Penalties for non-compliance with contract documents
Contingency Plans for Utility Disruption
CDC Guidelines for Environmental Infection Control - Air
2002 Update 17
Construction, Renovation, Remediation, Repair and Demolition Air sampling External and internal demolition (Barriers
Required?) Working with plumbing in sensitive areas Exposure of ceiling spaces Crawling into ceiling spaces Work on elevator shafts Demo of wallboard, plaster, ceramic tile, ceiling
tile Removal of flooring Removal of windows and doors Removal of casework
CDC Guidelines for Environmental Infection Control - Air
2002 Update 18
2001 Guidelines for Design and Construction of Hospitals and Health Care Facilities – Chapter 5
AIA Guidelines
2002 Update 19
Chapter 5 – Planning and Design
All new and existing construction Due to the hazards of construction
consultation from: Infection control professionals Safety professionals
Development of an Infection Control Risk Assessment (ICRA)
2002 Update 20
Chapter 5 – Elements of an ICRA
Continuous process Component of the facility functional
program or master program Initiated in planning and design and
continued through construction/renovation
Performed by a multidisciplinary panel Documented
2002 Update 21
Chapter 5 – Elements of an ICRA
Key Elements
Impact of disrupting essential services Patient placement or relocation Placement of barriers Evaluation of ventilation needs in
existing sensitive areas Number of AII and PE rooms
2002 Update 22
Chapter 5 – Elements of an ICRA
Key ElementsPatient protection from:
DemolitionUnplanned power outages effect
on ventilation and waterMovement of debrisPatient flow through the building
2002 Update 23
Chapter 5 – Bid Documents
Project bid documents shall include:
Control of airflow (clean to dirty)
Interruption of utility and/or building service equipment
Communications of the construction process manager and the facility staff
2002 Update 24
Role of the ICP. . . Overview
Help identify those effected by project Know your facility Facilitate teams & communication
Populations at risk Decreased immunity Allergies, asthma, COPD Noise and vibration
Assist w/ education, P&P, documentation
2002 Update 25
Know Your Facility
Types of patients based upon services Layout of services
3-D considerations Location of inpatient units Venues for outpatient specialties Ancillary support functions
TB risk in community - OSHA/CDC Long & short term planning Applicable regulations & guidelines
2002 Update 26
2002 Update 27
Facilitate Teamwork
Existing committees Reporting structure Responsibilities & authority Ownership - P&P (CRP)
Ad hoc team projects Key & ancillary members
Communication Internal & external Documentation
Epidemiology
2002 Update 28
Noise and Vibration
Patients and/or employeesRecent myocardial
infarctionPremature neonatesRecent ICH or strokeNeurological/psychiatric
disorders
2002 Update 29
Noise and Vibration
Procedures or testingEEG or EKGHearing assessmentsNeurological studiesFine motor skill procedures,
such as microsurgeryCertain laboratory proceduresSleep studies
2002 Update 30
Developing ICRA (1 of 3)
Determine potential spread of infectious agents in the healthcare environment
Provided by facility “owner” Continuous; essential part of
facility’s master program to provide a safe environment of care
Initiate at design & planning phase
2002 Update 31
Continue during renovation/construction through commissioning
ICRA limited to only affected areas Multidisciplinary team / expertise in:
IC, risk, facility design, construction, ventilation, safety and epidemiology
Team provides documentation of the risk assessment during PDC
Developing ICRA (2 of 3)
2002 Update 32
Design professional incorporates specific construction-related requirements of ICRA into contract documents
Contract documents require contractor to implement these specifics into renovation/construction activities
Consistent with JCAHO-EC and OSHA
Developing ICRA (3 of 3)
2002 Update 33
Regulations & guidelines Infectious agents & hazards change Microbiological ecology influenced by
patients & HCWs Physical surroundings Documents & reports Use as QI/PI activity?
ICRA Considerations
2002 Update 34
2002 Update 35
2002 Update 36
2002 Update 37
Physical Surroundings
Structure: HVAC, air flow, plumbing Fixtures: Handwashing sinks, “hoppers”,
showers, toilets Maintenance: Reservoirs and wet, porous
surfaces may support microbial growth Equipment: Location, fixed vs. moveable,
storage, prevent contamination Design: Flow; form follows function
2002 Update 38
ICRA Matrix
PATIENT Risk Group TYPE ATYPE A TYPE BTYPE B TYPE CTYPE C TYPE DTYPE D
LOWLOW Risk Group II II II III / IV
MEDIUMMEDIUM Risk Group
I II III IV
HIGHHIGH Risk Group
I II III / IV IV
HIGHESTHIGHEST Risk Group
II III / IV III / IV IV
2002 Update 39
IC Construction Permit
Suggest use based upon IC precautions
Some require for Classes III & IV Outlines steps required Assists in documentation
Project parameters Sign-off
Customize to your organization by ICRA team consensus
2002 Update 40
Effective Program Elements
Traffic patterns & patient relocation People, signage, supplies & equipment,
waste, populations at risk; think 3-D Barriers - planning & monitoring
Type & integrity, approvals, checklists Education for construction workers,
management, HCWs, others Level & content as appropriate
(tomorrow) Involve experts; ask key questions
Resources, content experts, site visits
2002 Update 41
Controlling Construction and Maintenance ActivitiesControlling Construction and Maintenance Activities
Need for containment General containment barriers – and
hindrances to barriers Point of entry control units Negative pressure requirement HVAC system protection and
isolation
2002 Update 42
How Do We Do It?How Do We Do It?
Define contractor building entry and path to the construction zone
Define the construction zone maintenance procedures and use of tacky mats and “bunny suits”
Identify HVAC System and how to isolate it from the construction zone
Establish background bioaerosols level prior to construction
2002 Update 43
Type Of ConstructionType Of Construction
Minor repairs Major system upgrades Area renovation and tenant improvements
Major additions and remodels – both yours and your neighbors
New construction – both yours and your neighbors
Landscaping – both yours and your neighbors
2002 Update 44
Envelope PenetrationsEnvelope Penetrations
Ceiling cavities Wall panels and service access
ports Dumb waiters
2002 Update 45
Envelope PenetrationsEnvelope Penetrations
Building shafts and chutes Stairwells Elevators
2002 Update 46
Environmental Containment UnitEnvironmental Containment Unit
Photo courtesy of Mintie Corporation
2002 Update 47
Construction BarriersConstruction Barriers
Photo courtesy of Mintie Corporation
2002 Update 48
Who Applies It?Who Applies It?
It can be applied by hospital staff if they have the manpower available.
Most healthcare organizations use an outside third party contractor that specializes in containment programs.- Dedicated expertise- IMC contractor assumes the liability
2002 Update 49
NEW CONSTRUCTIONNEW CONSTRUCTION
Constructing problems OUT of the building.
General clean up: How clean is clean?
2002 Update 50
NEW CONSTRUCTIONNEW CONSTRUCTION
Condition at time of pre-inspection
Photo courtesy of Rob Case, RCCS
2002 Update 51
NEW CONSTRUCTIONNEW CONSTRUCTION
Protecting the equipment. Building in future savings.
2002 Update 52
NEW CONSTRUCTIONNEW CONSTRUCTION
Protection of HVAC ductwork
Photo courtesy of Rob Case, RCCS
2002 Update 53
Ventilation Control in Hospital
• Airborne Infection Isolation & Protective Environment
– outage control
– ventilation assurance
– air changes per hour
– HEPA filtration
– pressurization
• Construction barriers
– external project protection
– internal barriers
– negative pressure
2002 Update 54
Establishing Baseline Information
Air quality Non viable & viable particles
Ventilation Air exchanges, filtration & pressure
Operational Practice Preventative maintenance Housekeeping Visitation
2002 Update 55
Interpretation of Microbiology Data
Rank order analysis Lowest counts in the areas with best filtration Comparison necessary with outdoor control
Qualitative analysis Pathogen recovery
Temperature selectivity Pathogens grow best at >35C Filtration efficacy determined at 25C
2002 Update 56
Air Sample Considerations
When to sample?
• Commissioning-before occupancy=baseline data- All parameters for ventilation assurance and cleanliness- Provide comparison data
• Disease outbreak analysis- All parameters with emphasis on source detection- Surface and air content for fungi
• Surveillance - Pressure most meaningful- Air exchanges needed for purging- Non viable particles can be used to assess filtration efficacy- Medical staff understand the viable counts the best
2002 Update 57
2002 Update 58
2002 Update 59
Healthcare Air Flow Management
• Airflow ventilation control with offset:– supply versus exhaust/return– greater exhaust = negative – greater supply = positive
• Pressure differential– 0.01 inch water gauge (2.5 Pascal’s)– air flow velocity about 400 fpm– consistent airflow necessary for control
2002 Update 60
2002 Update 61
2002 Update 62
2002 Update 63
Room Leakage Areas
• Airflow leakage occurs around:– plumbing connections
– medical gases
– electrical/video connection
– lighting
– ceilings
– windows/doors
– door cracks
– in wall mounted fixtures
2002 Update 64
2002 Update 65
2002 Update 66
gauge
2002 Update 67
EXERNAL CONSTRUCTION MANAGEMENT
Verification of existing protective ventilation
Control of building entrances Window infiltration Utility tunnel access to construction Building tie-ins Employee training Street cleaning Emergency response
2002 Update 68
2002 Update 69
2002 Update 70
2002 Update 71