Control the Chaos and the Spread of Infection During Construction
By Kelly M. Pyrek
Controlled chaos. Thats the way many hospitals describe their construction and renovation projects.
Healthcare construction industry expert Wayne Hansen, PE, REA, CEM, says there are ways healthcare facilities can mitigate the chaos and emphasize the control, especially of the transmission of particulates, bacteria and fungi that can trigger nosocomial infections.
The first and most important step, Hansen says, is achieving consensus on expectations, goals and strategies for completing construction or renovation projects without endangering the safety of patients or hospital personnel.
Ive seen healthcare facility administrators brought to the table still kicking and screaming over costs related to infection control measures during construction activity, he says. Unfortunately, a few had to be brought to the table because of litigation. I hate to see that.
Hansen encourages infection control practitioners (ICPs) to take the lead in helping the construction project team cope with and manage the process.
He says ICPs know instinctively what must be done to protect patients and staff from situations such as an outbreak of nosocomial Aspergillosis.
Whats the cost for something like that? Hansen asks. Hospitalacquired infections can cost thousands or hundreds of thousands of dollars, as can remediation of the source of the problem, and the ICP has a good feel for what must be done to try to prevent these circumstances. The only way to make it happen is to bring in the administrator, the ICP, the engineer, the risk manager, the employee health designee and anyone else having to do with the burgeoning costs of workers comp claims. I know of one hospital alone that had to increase its workers compensation by $5 million to handle complaints. Thats where the ICP almost needs to be an insurance specialist.
Hansen continues, The ICP must take the lead in saying, We must plan this construction/renovation project in a smart fashion. I think if ICPs, with their defined interests, call a meeting and say, This is what we have to accomplish, they can offer a value-added service to their hospital.
In many hospitals, weve seen a huge turnaround in attitudes between ICPs and construction and engineering personnel, Hansen adds. Years ago they were at loggerheads. Now they are sitting down to discuss issues. If you get people with different perspectives to come to the table, you can make good things happen.
Construction and extended maintenance projects in a hospital provide the greatest potential for introducing contaminants that can lead to nosocomial infections, writes Hansen in the book he edited, Infection Control During Construction: A Guide to Prevention and JCAHO Compliance. All buildings, including hospitals, harbor biological pathogens in the cavities of walls, floors and ceilings. Whenever these cavities are penetrated and the air in them disturbed, the risk of aerosolizing these pathogens is high. An infectious containment and environmental monitoring program must be established to eliminate or minimize the incidence of nosocomial infections associated with construction or repair projects. Every organization must assess the level of protection needed for the various construction, repair, replacement and maintenance activities that will be undertaken in the hospital.
Hansen outlines a list of common contaminants generated during construction or renovation:
- Inorganic nuisance dust and respirable dust that can cause eye and throat irritation and general discomfort
- Fibers that can be a source of mechanical irritation to mucous membranes
- Chemical odors (often caused by microbiological contamination) that can be hard to trace
- Microbiological contaminants that include bacteria and fungi In healthcare facilities, opportunistic infection caused by exposure of highly susceptible patient populations to environmental organisms such as the fungus Aspergillus and the bacteria Legionella is of critical concern, according to Philip R. Morey, PhD, CIH, director of microbiology and IAQ and vice president for AQS Sciences and a contributor to Hansens book.
In healthcare facilities with highly efficient HVAC system filters, the total concentration of fungi in the indoor air is generally much lower than that found outdoors, Morey writes. Transportation of debris, soil and dust associated with construction often leads to indoor accumulation of Aspergillus and Penicillium species, especially in flooring systems. The growth of fungi in buildings is primarily dependent on the presence of moisture on the surfaces and in the capillary spaces of construction and finishing materials. Moisture problems and consequent fungal growth can occur in building components such as the building envelope, porous materials in damp locations and paper facers of gypsum board.
Morey explains that Legionella and other gram-negative bacteria can grow in the water systems of hospitals, including in cooling towers, evaporative condensers, hot-water storage and transport systems, whirlpools and steam rooms that are maintained at lukewarm temperatures. Additionally, species of Pseudomonas and Flavobacterium can grow in stagnant water such as humidifiers and water spray systems, or on wet HVAC system surfaces such as cooling coils and drain pans. The occurrence of a biofilm on a wet surface is a certain indication of poor maintenance as well as the occurrence of gram-negative bacteria and other microorganisms, Morey writes.
Mold has been a hot topic in healthcare facilities as well as in residential and commercial dwellings with the recent onslaught of highly publicized mold-related litigation.
Mold is the next asbestos, Hansen says emphatically. Its the perception of mold and what it can and cant do that seizes the imagination. The fact that the occurrence of allergies and asthma is increasing exacerbates the issue. People who have never had allergies or asthma are suddenly getting these conditions and people are blaming it on the buildings they occupy, whether its right or wrong. You hear about big mold cases like Erin Brockovich or Ed McMahons and it stirs up a lot of awareness of mold on the part of the general public. I do expert witness work for the legal industry and almost all of it is about mold. Its a huge issue.
The Horror Stories
Hansen has seen his share of horrors in crawl spaces, between walls and above ceilings, and says the presence of contaminants is a given.
Whatever is outside and we know things like fungi are rampant outside comes inside, he says. Most of it is no-see-um, so no see-um, no-clean-um. Everyone has seen pictures of the horrors contained in ceiling cavities, and construction and engineering professionals know you have to clean the wall and ceiling cavities before they are buttoned up. The reason is, no matter how careful you are with construction you are going to have leaks. So you have to open up a wall and fix the pipes. Whatever is in the wall is now colonized and growing. And think about the number of times routine maintenance involves the ceiling, whether its changing light fixtures, changing out damper controllers, and every time, that reservoir is disturbed.
The air gets stirred up because duct leakage creates air currents and lights create heat and a rise in the air. All of these activities are keeping that mold and whatever else is up there moving around and airborne.
Hansen says many healthcare facilities are plagued by birds and rats that find their way into ventilation-system spaces.
Its difficult to go into any hospital and not find some evidence of pests and rodents someplace in the building, Hansen says. We have found some strange things in ceiling overheads.
He recalls the time when an electrician entered a ceiling overhead, grabbed a conduit to pull himself up and it moved. He discovered it was a 25-foot python.
At least there were no rats, Hansen says, laughing. Wildlife in the overhead is a fact of life. We find rodents, crickets, cockroaches and all kinds of insects, and birds, to a lesser degree. Weve had some nasty things happen when walls and undisturbed spaces are opened up.
The Clean-up Process
The most important components of fungi clean-up are physical removal of colonized materials; removal of settled dusts containing spores; prevention of spores and dusts generated during clean-up from entering clean areas and patient rooms; and the use of appropriate personal protective equipment (PPE) by knowledgeable clean-up personnel.
Healthcare facilities should have policies and procedures for fungi remediation and should include, at minimum, the following components:
- A description of the general mycological condition in the building General practices to be used for removing contaminated materials and control of construction or renovation dust
- Specific practices to be used in mold clean-up or during dust control
- Specific practices to be used for preventing cross contamination between contaminated or dusty areas, and clean areas and patient rooms PPE and practices to be used by clean-up personnel
- Location of patient areas, notably those with patients who are most susceptible to infection
- Qualifications of clean-up personnel
- Guidelines to be followed by the occupational health professional who is monitoring clean-up activities
Specific actions to prevent cross contamination during construction or renovation activity include:
- Techniques required to prevent fugitive dust emissions from the activity area
- Monitoring procedures needed to verify that work areas are depressurized relative to areas immediately outside of containment
- Administrative controls designed to prevent tracking dust and other contaminants into patient areas Hansen says it is vital to keep construction personnel and healthcare workers from inadvertently tracking on the floor or dispersing through the air construction- or cleanup-related contaminants.
Nurses are generally more aware of cross contamination than the doctors, Hansen says. When I talk to ICPs, of course, I am preaching to the choir. Nothing can be 100 percent foolproof. Weve had some hospital administrators who have said, I want my hospital to be totally contaminant free. Well, you cant do that with construction. Given the best cooperation between the contractors and hospital personnel theres always going to be breaches; sometimes they are caused by healthcare staff members.
Theyll say, Oh, whats going on in there, Ill just move this yellow tape and walk in and see. I hate to throw stones, but the doctors are a bigger offender than nurses. You can tell a charge nurse, Dont go in here because its contaminated and it might put your patients at risk, and theyre not going to go in. But the doctor always wants to see whats going on. Youre going to get someone who wants to take a shortcut and youre going to have honest accidents. Those things do happen and theres no way to make it 100 percent foolproof but we can get close.
Lack of Standards
If it seems challenging to establish consensus among construction team stakeholders, consider that there is no consensus in the industry regarding indoor air quality (IAQ). The proposed IAQ rule from the Occupational Safety and Health Administration (OSHA), first introduced in 1994, is no closer to adoption almost a decade later.
The IAQ was sandbagged by the tobacco industry and it didnt finish its tour in the Clinton administration, Hansen says. And then the Bush administration just shut it down. The next thing that could happen is the introduction of an IAQ standard being worked on by the International Organization for Standardization for the last nine years. They are getting closer to releasing a document, but since the ISO is very slow and methodical, the standard wont be bulletproof but awfully close. My guess is we might see a standard in late 2004 or 2005.
The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE) has its standards related to construction, renovation and infection control, as does the Centers for Disease Control and Prevention (CDC). The American Institute of Architects (AIA), whose Guidelines for Design and Construction of Hospitals and Healthcare Facilities, compiled with assistance from the Department of Health and Human Services, places new emphasis on designing out potential issues associated with above-ceiling contaminants and paying attention to ventilation rates in patient rooms. Its an emphasis reflected in the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)s revised Environment of Care standard, but real-world pursuit of this standard is another thing altogether.
While a visit from JCAHO can strike fear in the hearts of hospital administrators in general, Hansen says the message of mandating construction- related infection control measures is not getting filtered down to the individual surveyors.
He continues, I see a huge dichotomy among surveyors; some are very well aware and others are not. One surveyor I know of walked into a Southern California hospital who knew surveyors in the past had looked at firewall penetration above the ceiling. The surveyor said, Id like to inspect that. They brought in a ladder, opened the tile and the surveyor wrote them up for not having containment. Its a big issue.
Also at issue is environmental sampling. I dont (advocate) that, Hansen says. If there is an issue of potential contamination, I investigate first. If I see some evidence of water intrusion or something that could lead to mold, then I say lets mitigate it. Clean it up and then test as a clearance document. If you are remodeling, go into the areas that abut the construction zone and do your baseline testing. Then during the term of construction, walk around with your particle counter and see how that compares. At determination, when everything is cleaned up, then do clearance testing. The problem I have with testing is that people say, Im sure its here; I can see mold, lets test. You have just created a negative document. Thats something I learned from my attorney friends that you dont want to do. So its better to address it if you have strong suspicions, if someone has been above the ceiling and you now have issues below the ceiling, or if you had a water or roof leak then lets get all those things cleaned up, tested and made right. Do some environmental fogging above the ceiling with a hospital-grade antifungal and then test. The clearance test is going to be your key to saying everything here is good. In the event the testing shows something, go back and find out why and repeat the test.
Following correct procedure is a learned behavior, according to Hansen, and encourages hospitals to educate their workers on infection control issues related to construction and renovation.
Technology can only help those who know how to apply it, Hansen says. They need to know how to use it to reduce the intrusion of environmental pathogens. Its important to get educated about policies, procedures and ways to remediate construction-related contaminants. Send healthcare professionals to educational seminars so they can learn from the experts and have the materials they can bring back with them to teach their colleagues. Education is a slow process, however. Some large hospitals are very aggressive about training while many smaller facilities arent. We need a dissemination of information on a more widespread basis to bring everyone up to speed.
Hansen says that from an infection control and convenience factor, he glad that hard surfaces are making a comeback in new construction and renovation projects. Carpets are awful. I go head to head with manufacturers because I dont like carpet in the healthcare environment. If they want to put it in the CEOs office and in administration areas, thats fine, but not in any corridor where a 110-pound nurse has to push someone my size on a gurney or there is concern about the flooring not being easily cleaned.
"The current movement toward antimicrobial products has implications for the physical plant that arent obvious, according to Hansen. I think a few of the antimicrobial products are good but overall they simply provide a nice psychological benefit, Hansen says. I get a lot of questions about antimicrobial components in filter pads. What we are dealing with in ventilation systems is mold, not bacteria. If you want to use antibacterial soaps and cleaners, thats fine. Where we have found a lot of people touting the antimicrobial component is carpet manufacturers and I would prefer not to have it at all. In general I think its overplayed.
The rush to embrace all manner of antimicrobial hand sanitizers and disinfectants also can lead to physical plant-related problems. Hansen recalls a hospital in Southern California where healthcare workers rinsed their hands and quickly turned off the water. They didnt let the water run long enough to thoroughly wash it down the drain and (these products) form a gel in the sewer. The only way to break through it is with compressed air because if you run a snake down the drain it punches through the gel like a tubeless tire and the gel is still there. We had a case where the hospital wasnt sure how to use the compressed air and used too much, popping the sewer connection and flooding five operating rooms. I think many products in hospitals today need to be looked at carefully.
"Im not a fan of the heavy lanolin-based soaps even though that seems to be the most common. I am a fan of waterless hand-hygiene stations, despite what the fire marshals say. I like having fewer sinks in the hospitals for the simple reason you end up having to oversize the hot water system that leads to the potential for Legionella outbreaks. In come cases, however, sinks are not used enough and the traps dry out and then you get the sewer smells. There are a lot of things weve done in hospitals that make sense and theres a lot of things that dont make sense.
What does make sense, Hansen adds, is conducting effective risk identification and management, a program whose cost easily creates the following returns on investment:
- Reduction in the incidence of airborne cases of nosocomial infections
- Improvements in healthcare worker productivity
- Reduction in workers compensation claims
- Reduction in healthcare worker turnover
- Reduction in patient and employee complaints
- Reduction in HVAC system energy consumption