Environmental and Engineering Solutions, Inc.

Prevent hospital acquired infections during construction projects

The issue of hospital acquired infections is a serious problem. According to several sources, three to four million hospital-acquired infections occur annually, with up to 80,000 fatalities. The costs of these infections are estimated to be between $4 billion and $5 billion per year (Air-Treatment Systems for Controlling Hospital acquired Infections, HPAC Engineering, April 2, 2008).

Healthcare facilities are under competitive pressure to continually incorporate new and modern equipment, new diagnostic procedures and new treatments, creating a constant need for renovation. However, construction projects increase the risk of infection by spreading microbes that cause disease.

This article offers some proactive steps for facilities managers and infection control personnel, to help minimize the risk of contamination during construction and renovation projects.

Airborne Disease
At least 16 percent of hospital acquired infections are airborne in origin. In addition, a third of all acute care hospital infections may involve airborne transmission at some point (Air-Treatment Systems for Controlling Hospital Acquired Infections).

Common diseases in health facilities caused by airborne bacteria and molds include pneumonias, surgical site infections, and contagious respiratory infections including tuberculosis and influenza. In addition, some urinary tract infections and even blood infections may result from airborne particles settling on equipment. A list of disease causing microorganisms is provided in Figure 1 (figure 1).

In addition, 30 percent of cases of hospital pneumonias are attributable to Legionella, a contaminant in hospital water systems (Legionella in Hospitals: A Review. The Journal of Hospital Infection, 18, Suppl A, 481-489). Legionella infection is caused by the inhalation of water aerosols containing the bacteria, which can be spread during construction projects.

Immuno-compromised patients are especially at risk for these infections. According to the Centers for Disease Control (CDC), these are patients whose immune mechanisms are deficient because of immunologic disorders such as HIV infection, congenital immune deficiency syndrome, chronic diseases or immuno-suppressive therapy.

The highest-risk patients are those who are severely neutropenic, allogeneic patients undergoing bone marrow transplantation, and those who have received intensive chemotherapy. (Guidelines for Environmental Infection Control in Health-Care Facilities, U.S. Department of Health and Human Services, Centers for Disease Control, 2003, Pg. 20).

Healthcare workers are also subject to disease from aerobiological hazards. They are routinely exposed to tuberculosis and influenza, which are occasionally fatal. Inadequate ventilation is often cited as the cause. The risk increases if contaminants enter the HVAC system during construction projects and are spread to work areas.

The following section outlines a six-step process for reducing the risk to these groups.

Step 1: Establish a Project Team
Building projects require substantial planning and coordination to minimize the risk of infection. Establishing a management team can help. The team should include representatives of infection control, laboratory, engineering, environmental services, administration and risk management. It should also include representatives of the project team including the architect, design engineer and construction administrators.

Topics to be addressed include: 1) the scope, design and function of the construction, 2) the environmental risks for airborne disease and opportunities for prevention 3) measures to contain dust and moisture including site specific work protocols and 4) how to educate staff and outside vendors in infection control procedures.

Step 2: Conduct a Risk Assessment
After the team has addressed issues, they should commission an Infection Control Risk Assessment (ICRA) (See Figure 2). The ICRA helps to determine the level of controls needed by comparing the complexity of the project to the proximity to high risk patient groups. The more extensive the project and the higher the patient risk level (i.e., susceptibility to infection), the greater the precautions required.

So for example, a construction project to renovate office areas (low risk group) with new coats of paint and minor modifications to the electrical outlets (Type A construction), would result in the need for Class I infection control precautions. Class I precautions are minimal and include mimizing dust from construction operations and immediately replacing any ceiling tiles displaced for visual inspection.

However, a construction project involving a new suite of operating rooms (Type D construction) adjacent to an existing cardiac cath lab (highest risk group), would result in the need for Class IV infection control precautions. Class IV precautions are extensive and include steps such as isolating the HVAC system to prevent contamination of duct system; constructing an anteroom for all personnel to pass through and be HEPA vacuumed before leaving work site; and maintaining negative air pressure within the work site to prevent microbes from migrating from the work area.

Step 3: Provide Training
Once the ICRA is completed and infection protocols established, the team needs to educate the staff and construction team regarding airborne and waterborne infection risks associated with construction projects and methods to control them. Some specific areas to cover include:

• Modes of dispersal of dust and microorganisms during construction projects
• Methods of contamination control
• Roles and responsibilities before, during and after the construction project, including emergency contacts should there be suspected contamination

Better still is to work with preferred contractors who already have competence in these areas. It is important to make sure that their subcontractors are trained in infection control procedures as well, either by offering training or requiring it as a precondition of employment. Training and resources can be obtained through several sources including the American Society for Healthcare Engineers (ASHE), The American Professionals in Infection Control and Epidemiology, Inc. (APIC) and The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE).

Step 4: Implement Control Measures
The construction team should then set up appropriate control measures, based on the ICRA. Following are some examples:
• Isolating the work area with construction barriers such as plastic sheeting
• Sealing doors and windows
• Maintaining negative pressure within the work site with HEPA filter units
• Requiring that workers wear personal protective equipment (PPE), such as protective gloves, respiratory protection and coverings for shoes
• Constructing an anteroom for changing into and out of PPE
• Placing dust mats at work site entrance and exit
• Providing tightly covered containers for waste materials
• Relocating staff and patients as needed

A list of recommended precautions based on ICRA classification is also available at (http://www.premierinc.com/quality-safety/tools-services/safety/topics/construction/downloads/02-icra-matrix-c-2006.pdf).

Step 5: Conduct Monitoring
An environmental engineering professional should regularly check the air quality of the site and adjacent areas. This involves taking a set of baseline readings prior to setting up the enclosures and beginning construction. Then, weekly samples should be taken and compared to the baseline to make sure that infection control measures are still effective.

For example, as part of a comprehensive infection control program at Frankford Hospital (Healthcare Building Ideas, Thinking Outside the Box, April 5, 2008), Environmental and Engineering Solutions, Inc. conducts baseline measurement s of airborne dust, mold and bacteria levels at the start of construction projects. Follow-up readings are conducted on a weekly basis inside the construction zone, in the anteroom, immediately outside the anteroom and in adjacent high risk areas, as well as any connected HVAC units.

If water systems are affected by the construction, conduct water testing, particularly in plumbing that has been shut-off or re-routed during construction.

Step 6: Perform Post Construction Inspection and Clearance Testing
When the construction project is complete, final inspections and clearance testing need to be conducted before turning the new space over for occupancy. The protective enclosures and anterooms should be kept intact during this period.

Once the first major cleaning is complete, a set of clearance samples should be taken and a clearance inspection conducted. After “all clear” is given, a final cleaning can be conducted and the ICRA enclosures removed. Only then should the space be turned over to the hospital for occupancy.

Limiting Risk is the Name of the Game
The increasing age of hospitals and other health-care facilities generates an ongoing need for repair and remediation work. These projects, large or small, can increase the potential for hospital acquired infections.

In light of public outcry demands over patient safety, as well as the growing number of insurers refusing to pay for hospital acquired infections, hospitals and health facilities should plan these projects with infection control in mind. This can help them limit the risk and protect their patients and workers, as well as the institutions they serve.

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