Central to the prevention of opportunistic-pathogen transmission during any construction activity, be it new build or renovation projects, is the infection control risk assessment (ICRA). The ICRA is the tool with which the construction team can determine the levels of infection prevention needed at the site. In 2001, the American Institute of Architects (AIA) formalized this assessment tool and in 2002, the Joint Commission adopted the AIA’s Guidelines for Design and Construction of Hospitals and Health Care Facilities as part if its standards for survey and accreditation.
According to the firm Environmental Health & Engineering, the ICRA must address the impact of disruption to patients and facility staff as well as potential patient relocation; must provide for the placement of barriers to protect immune-compromised patients from airborne pathogens such as Aspergillums sp.; must ensure that air handling and ventilation issues are addressed; must determine the number of isolation rooms required; and must address how waterborne pathogens such as Legionella sp. will be controlled. As Bartley, et al. (2000) explains, “An ICRA provides for strategic, proactive design to mitigate environmental sources of microbes and for prevention of infection through architectural design (e.g., handwashing facilities, separation of patients with communicable diseases), as well as specific needs of the population served by the facility.”
It is the responsibility of the ICRA committee to oversee the construction process, and members should include representatives from infection prevention and control, epidemiology, risk management, construction, safety and administration. Bartley et al. (2000) notes, “The planning group’s charge is to consider communicable disease prevalence in the community while recognizing the importance of disease variation and distribution across geographic regions and to weigh the availability of public support agencies, as well as to consider the needs of health systems that manage patients with communicable disease, patients who are severely immune-suppressed, or both.”
While the AIA guidelines provide adequate theory, in practice, some say there are significant challenges to implementation. Richard Bennett, MSPH, CIH, president and chief science officer at Charleston, S.C.-based Risk Tech, LLC, says he is concerned about two big issues facing hospitals that are attempting to balance cost-effective construction activities with patient-safety imperatives.
“Since 2001, when the AIA and APIC guidelines came together with the Joint Commission standards, there has been a tremendous amount of progress relative to the sophistication of the infection control risk assessment that is being conducted prior to construction and renovation,” Bennett says. “However, with hospital budgets tightening up, there seems to be a little less money being allocated to addressing the infection control risk assessment and monitoring the necessary controls than there was five years ago. Budgets are simply not allowing for the monitoring of construction activity to the degree that it should be monitored.”
What’s more, Bennett adds, there is an abject lack of infection prevention-related oversight in greenfield, or brand-new, healthcare construction. “In greenfield construction, I see a lack of monitoring by infection preventionists,” he says. “People think that with new construction, there is no need for environmental rounds, for example. However, we have identified many problems that are actually built into new construction, such as in a new bed tower being added to an existing facility. And these problems can be easily rectified had there been more rigor on the part of the construction planning team members when closely monitoring the construction process. It’s a significant blind spot, and there must be more education about this in the infection prevention community and in the design, architectural and engineering communities. People are not as tuned into infection control in a Greenfield project as they are in a renovation project.”