ah icra policy updated 5-7-2014 mjd revisions

Entity(s): Network: Systemwide Corporate Policy Entity(s) Policy No. ICRA

Corporate Policy No. of 1Standard Policy Department: Accreditation

Model Policy: Category/Section: Policy Manual: Policy/Procedure

POLICY: INFECTION CONTROL RISK ASSESSMENT (ICRA) FOR CONSTRUCTION, RENOVATION AND MAINTENANCE ACTIVITIES

POLICY SUMMARY/INTENT: An Infection Control Risk Assessment will be performed to assess infection risk that may arise as a result of construction, renovation, and maintenance activities, so that hazards are identified, implications are considered and appropriate interventions are addressed for construction, renovation and/or maintenance activities. TThis will promotevide a safe environment and will reduce the risk ofprevent transmission of infectious agents to vulnerable patient populations, health care workers and visitors by environmental dispersion due to construction activities. In order to ensure Infection Prevention hazards are identified, implications are considered and appropriate interventions are addressed for construction, renovation and/or maintenance activities.

DEFINITIONS:

1. ICRA-Infection Control Risk Assessment-An ICRA is multidisciplinary documented process that focuses on reduction of risk from infection through phases of facility planning, design, construction, renovation, facility maintenance. It coordinates and weighs knowledge about infection, infectious agents, and care environment, permitting the organization to anticipate potential impact.

2. Shift-Shift work is an employment practice designed to make use of, or provide service across, all 24 hours of the clock each day of the week (abbreviated as 24/7). The practice typically sees the day divided into "shifts", set periods of time during which different groups of workers take up their posts. The term "shift work" includes both long-term night shifts and work schedules in which employees change or rotate shifts. (from Wikipedia)

AFFECTED DEPARTMENTS/SERVICES:

1. All

POLICY: COMPLIANCE – KEY ELEMENTS

Infection Prevention will be notified prior to construction, maintenance or renovation projects. Infection Prevention risks, interventions and control strategies must be considered in planning for new construction, renovation and some maintenance activities of healthcare facilities. Infection Prevention design, and expected practice, will be considered for projects by Planning and Design Services. This process should occur during the design phase and continue throughout the planning phases. Part of the process includes the completion of an Infection Control Risk Assessment (ICRA).

The current Facility Guidelines Institute (FGA) Guidelines for Design and Construction of Health Care Facilities and the Center for Disease Control (CDC) Guidelines for Environmental Infection Prevention in Healthcare Facilities are guidelines which are used for construction and renovation projects.

PROCEDURE:

http://en.wikipedia.org/wiki/24/7

http://en.wikipedia.org/wiki/Employment

Policy: INFECTION CONTROL RISK ASSESSMENT (ICRA) FOR CONSTRUCTION, RENOVATION AND MAINTENANCE ACTIVITIES

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A. An Infection Prevention Construction Matrix (see Attachment A) will be required to be completed for construction, renovation and maintenance activities (as deemed necessary). Infection Prevention, in conjunction with Facilities and/or Planning Design Services will determine the Infection Prevention implications of the design and document recommendations on the ICRA Matrix form. The form can be initiated by any of the three disciplines. Final review of the form is done by Infection Prevention. To complete the form, the team will:

1. Determine type of construction activity (refer to Step 1 of the Matrix in Appendix A):

a. A=Inspection and non-invasive activities

b. B=Small scale, short duration creating minimal dust

c. C=Moderate to high level of dust generation

d. D=Major demolition and construction

2. Determine infection control risk group (refer to step 2 in the Matrix in Appendix A):

a. 1=low risk

b. 2=medium risk

c. 3=medium high risk

d. 4=high risk

3. Determine construction activity and need for an ICRA permit (refer to Step 3 in the Matrix in Appendix A)):

a. Class 1=No permit needed-minor activity

b. Class 2=No permit needed-extra precautions needed

c. Class 3=Permit required, critical barriers and needed

d. Class 4=Permit required, anteroom needed

B. An Infection Prevention Construction Permit (refer to Attachment B) is required when construction activity and risk level indicate that Class III and IV control procedures are necessary. The type of project will determine measures to employ when construction and/or renovation are undertaken. A multidisciplinary team may be convened when the project is more complex. This team may be comprised of: hospital administration, infection prevention, risk management, facilities, construction, safety, patient care and other department representation as needed. The permit is completed based on information gathered from the completed Matrix.

[C.] An ILSM/ICRA Weekly Checklist (refer to Attachment C) will be required for projects lasting more than one shift. Contracted workers will receive information on Infection Prevention procedures prior to starting work. Project site will be monitored at least daily and more frequently as deemed necessary by the Infection PreventionistProject Manager. Infection Prevention will be notified immediately of barrier disturbances resulting in loss of negative pressure and appropriate ventilation. Documentation will be kept with the owner of the project (Project Management or Facilities).


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C.[D.] Infection Prevention, Facilities and/or Planning Design Services may seek outside resources or consultant services as appropriate to assist with the ICRA. This may include mechanical or other engineering, environmental consulting, insurance consulting, etc.

[E.] Education – All maintenance and construction workers (contract and employees) will receive iInfection pPrevention training shall provide training to the contract workers with regard to hospital-specific needs related to potential Infection Prevention risks and mitigation strategies prior to beginning workconstruction. Infection Prevention will approve educational materials. The Project Manager is responsible for ensuring that training occurs and maintaining dDocumentation of education.will be kept with the owner of the project (Project Management or Facilities).

D.[F.] Personal Protective Equipment/Clothing – Contractor personnel clothing should be free of loose soil and debris before leaving the construction area. If protective apparel is not worn, a HEPA-filtered vacuum should be used to remove dust from clothing before leaving the barricade. Personal protective equipment is worn as appropriate. Contractors entering invasive procedure areas should be provided with disposable suits and head and shoe coverings. Protective clothing should be removed before exiting the work area. Tools and equipment should be damp wiped before entry and exit from the work areas.

E.[G.] Infection Prevention Monitoring During Construction:

1. Need for targeted patient surveillance near construction areas will be a part of the Infection Prevention Risk Assessment.

2. Outbreak associated with construction (suspected or identified): Follow the hospital’s suspected outbreak protocol.

3. Infection Prevention will be notified regarding environmental emergencies (water contamination, disruption of water, electrical or sewage services, damage/design issues). Timely Infection Prevention consultation is critical with input regarding remediation.

RESPONSIBILITIES:

A. Environment of Care/Facilities Department:

1. Notify Infection Prevention at the time construction, renovation or certain types of maintenance are planned.

2. Include Infection Prevention in the planning, construction and post-construction/cleanup phases as required by the construction permit.

3. Work with Infection Prevention in remediation of environmental emergencies or Outbreaks associated with Construction.

4. Monitor air ducts, windows and air filters adjacent to the work site and change as needed.

5. Participate in remediation of environmental emergencies. Notify Infection Prevention when patient care may be potentially or actually affected.

6. Participate in monitoring site for preparation for return to service per permit.

B. Infection Prevention:

1. Complete forms with Facilities and/or Planning Design Services.


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2. Partner with architects and contractors during design and pre-construction.

3. Participate in planning and monitoring during area preparation and throughout the demolition, construction, cleanup, preparation for return to service, and final project review.

[4.] Infection Prevention shall approve training matierialsprovide training to the contract workers with regard to hospital-specific needs related to potential Infection Prevention risks prior to construction. Documentation will be kept with the Project Manager or owner of the project (Project Management or Facilities).

4.[5.] Surveillance of targeted areas.

5.[6.] Serve as a resource during all phases of construction and in remediation of environmental emergencies or outbreaks associated with construction.

C. Contractors and Contracted Employees:

1. Comply with planned monitoring of area preparation and throughout the demolition, construction, cleanup, preparation for return to service and final project review.

[2.] Infection Prevention shall provide training to the contract workers with regard to hospital-specific needs related to potential Infection Prevention risks prior to construction. Documentation will be kept with the owner of the project (Project Management or Facilities).Comply and follow IP recommendations for risk mitigation.

2.[3.] Notify Facilities, who will notify Infection Prevention in case of environmental emergencies during construction.

D. Environmental Services:

1. Participate in monitoring site for cleanliness during construction and prior to return to service.

2. Monitor and provide or additional cleaning in adjacent areas to construction as needed.

E. Resolution/Completion:

[1.] The project manager/coordinator manager will notify Infection Prevention when the project is completed.

1.[2.] Any post-project monitoring results affecting the ICRA permit closure will be made available.

2.[3.] Affected individuals/departments will be notified when work is completed.

3.[4.] Completed ICRA is kept with Infection Prevention.


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APPENDIX A

ICRA MATRIX

MATRIX OF PRECAUTIONS FOR CONSTRUCTION & RENOVATION

Step 1.0:

Using the following table, identify the Type of Construction Project Activity (Check one)


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Type A

Inspection and Non-Invasive Activities.Includes, but is not limited to:* removal of ceiling tiles for visual inspection limited to 1 tile per 50

square feet* painting (but not sanding)* wall covering, electrical trim work, minor plumbing, and activities

which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.

Type B

Small scale, short duration activities which create minimal dustIncludes, but is not limed to:* installation of telephone and computer cabling* access to chase spaces* cutting of walls or ceilings where dust migration can be controlled.

Type C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assembliesIncludes, but is not limed to:* sanding of walls for painting or wall covering* removal of floor coverings, ceiling tiles and casework* new wall construction* minor duct work or electrical work above ceilings* major cabling activities* any activity which cannot be completed within a single work shift.

Type D

Major demolition and construction projectsIncludes, but is not limed to:* activities which require consecutive work shifts* requires heavy demolition or removal of a complete cabling system* new construction.

Step 2.0:

Using the following table, identify the Patient Risk Groups that will be affected. If more than one risk group will be affected, select the higher risk group:

Group1Low Risk

Group 2Medium Risk

Group 3High Risk

Group 4Highest Risk

Office areasCommon Areas

Cardiology UnitEchocardiographyRespiratory TherapyRehabilitation

Nuclear MedicineEmergency RoomLaboratories (Specimen)Pediatrics

Any area caring for immunocompromised patients

Burn Unit


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Outpatient Services PharmacyPost Anesthesia Care UnitMedical Unit Endoscopy EchocardiographyRadiology MRISurgical UnitCardiopulmonaryNutritional Services/BistroCentral Supply (Clean)

Cardiac Cath. LabLabor & DeliveryNegative Pressure -

Isolation RoomsIntensive Care UnitsNewborn NurseryOutpatient SurgeryOncology & Outpatient

ChemotherapyOperating RoomsC-section roomsDialysisAnesthesiaSterile Processing Dept (SPD)

Step 2 Group Determination (Check one)

1 2 3 4

Step 3.0:

Cross Reference…

The Patient Risk Group (Low, Medium, High, Highest) with the Construction Project Type (A, B, C, D) on the following matrix, to find the…Class of Precautions (I, II, III, or IV) or level of infection control activities required.

IC Matrix – Class of Precautions: Construction Project by Patient Risk

Construction Project Type


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Patient Risk Group TYPE A TYPE B TYPE C TYPE D

LOW Risk Group (1)

I II II III/IV*

MEDIUM Risk Group (2) I II III IVHIGH Risk Group (3)

I II III/IV* IV

HIGHEST Risk Group (4)

II III/IV* III/IV* IV

* Signifies it is the discretion of the Infection Control Officer to decide whether the project is to be classified a Class III or Class IV.

Note: Infection Control approval will be required when the Construction Activity and Risk Level indicate that Class III or Class IV control procedures are necessary.

Step 3 Determination;

Class I-IV or Color-Coded Precautions are delineated on the following page.

APPENDIX B--ICRA PERMIT

Infection Control Construction PermitProject Name: Permit No:Location of Construction: Project Start Date:Project Coordinator: Estimated Duration:Contact Number: Permit Issued By:YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP

TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk

TYPE B: Small scale, short duration, moderate to high levels

GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction activities Requiring consecutive work shifts

GROUP 4: Highest Risk


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CLASS I Execute work by methods to minimize raising dust from construction operations.

Immediately replace any ceiling tile displaced for visual inspection.

Minor Demolition for Remodeling

CLASS II Provides active means to prevent air-borne dust from dispersing into atmosphere

Water mist work surfaces to control dust while cutting.

Seal unused doors with duct tape.

Block off and seal air vents.

Wipe surfaces with cleaner/disinfectant.

Contain construction waste before transport in tightly covered containers.

Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

Place dust mat at entrance and exit of work area.

Isolate HVAC system in areas where work is being performed; restore when work completed.

CLASS III Obtain infection control permit before

construction begins.

Isolate HVAC system in area where work is being done to prevent contamination of the duct system.

Complete all critical barriers or implement control cube method before construction begins.

Vacuum work with HEPA filtered vacuums.

Wet mop with cleaner/disinfectant

Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

Contain construction waste before transport in

Date Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

Do not remove barriers from work area until complete project is checked by Infection Prevention & Control and thoroughly cleaned by Environmental Services.

tightly covered containers.

Cover transport receptacles or carts. Tape covering.

Upon completion, restore HVAC system where work was performed.

Initial

CLASS IV Obtain infection control permit before

construction begins.

Isolate HVAC system in area where work is being done to prevent contamination of duct system.

Complete all critical barriers or implement control cube method before construction begins.

Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

Seal holes, pipes, conduits, and punctures appropriately.

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 they can wear cloth or paper coveralls that are removed each time they leave the work site.

All personnel entering work site are required to wear appropriate PPE, including shoe covers.

Do not remove barriers from work area until completed project is checked by Infection Prevention & Control and thoroughly cleaned by Environmental. Services.

Vacuum work area with HEPA filtered vacuums.

Wet mop with disinfectant.

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.

Upon completion, restore HVAC system where work was performed.

Date

Initial

Description of Construction/Additional Requirements:

Permit Request By: Permit Authorized By:

Date: Date:


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APPENDIX C


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Week Date: Project:

Area assessed/surveyed:

Completed by:

M T W TH F SA SU Comments

1. Exits provide free and unobstructed egress through construction.

2. Alternative exits are clearly identified.

3. Means of egress in construction area inspected daily.

4. Free & unobstructed access to ED/Services and for emergency forces.

5. Fire alarms, detection, and suppression systems are operational.

6. Fire alarms, detection, and suppression systems are not impaired.

7. Temporary fire alarm, detection, and suppression systems been inspected and tested monthly.

8. Training and additional fire equipment been provided for personnel.

9. Power has been properly secured at the end of each workday.

10. ‘No smoking’ policy been implemented in and adjacent to the construction areas.

11. Construction areas are free of storage and housekeeping materials, food waste, and debris for daily operations to reduce flammable and combustible fire load of the building; floor area leading to/from construction site cleaned daily.

12. There has been a minimum of two fire drills conducted per shift per quarter.

13. Number of hazard surveillance inspections in construction area has increased.

14. Safety education programs have been conducted to ensure awareness of any ILS Safety Code deficiencies and construction hazards.

15. Power is properly secured at the end of each workday.

16. Hand and safety rails are in place and in good condition.

17. Extension cords are grounded and in good condition.

18. Power tools are in good condition.

19. Workers wearing required identification and hard hats/PPE are used as required.

20. Cutting and welding operations are properly and safely conducted and have appropriate hot work permits.


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21. Documentation of worker instruction in Right-To-Know, Infection Control and Fall hazards is available if requested.

22. All scaffolding complies with OSHA requirements (1926.451).

23. Construction site secure and properly isolated from fresh air intakes.

24. Lock out / tag out procedures are used as appropriate

25. Materials used (i.e., fire retardants) comply with necessary safety regulations.

26. Construction barriers maintain negative pressure relationships.

27. Workers demonstrate compliance with traffic patterns.

28. Workers comply with use of PPE (Hard hats, eye protection etc) as needed.

29. HEPA filtration units, HEPA vacuum equipment, &/or continuous use of exhaust fans demonstrate they are functioning appropriately.

30. Exhaust ducts sealed/capped as agreed by ICRA.

31. Construction area doors are closed and gaskets & hardware are intact.

32. Construction carts transporting debris are covered and consistent with agreement designed to minimize airborne particulate matter from debris.

33. All windows and doors remain closed to prevent circulation of dust/debris.

34. Walk-off mats, adhesive strips are clean and changed sufficiently, or construction exit cleaned sufficiently to maintain clean entry/exits.

35. No signs of water leakage or pests.

36. Ceiling tiles replaced when space not being accessed.

Additional comments

Project Manager/Facilities Date

Contractor Date


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Sent to Safety &/or IP Date

REFERENCES:

CALIFORNIA: HAWAII:OREGON:WASHINGTON:

AUTHOR: SITE SPECIFIC POLICY OWNER:HOSPITAL SPECIFIC COLLABORATION:

APPROVED BY:CORPORATE [name of approval committee, date approved]:HOSPITAL [name of approval committee, date approved]:

REVIEW DATE: REVISION DATE:ATTACHMENTS: DISTRIBUTION TO: