Upholding Infection Control Principles in HospitalConstruction and Renovation Projects

November 1, 2005

Upholding Infection Control Principles in Hospital
Construction and Renovation Projects


By Jennifer Schraag

They say bigger is better and todays healthcare facilities
are no exception. As new facilities are birthed and expansions are never-ending,
the role of any facilitys infection control practitioner (ICP) is as
indispensable as ever.

Infection control (IC) is as vital
as the bricks and mortar needed for the construction and renovation of
healthcare facilities. ICPs must implement a strong plan and carry it through from
the initial planning stages to the first few uses of the new facilities.

The use of multi-disciplinary personnel is imperative for the
success of any large-scale project, and planning and implementation teams should
include a vast array of both hospital and contractor personnel. In fact, one
proposed revision for the 2006 American Institute of Architects (AIA) Guidelines
for Design and Construction of Hospitals and Healthcare Facilities,* reflects
the inclusion of someone who does direct patient care, according to Judene Bartley, MS, MPH, CIC, vice president of
Beverly Hills, Mich.-based Epidemiology Consulting Services Inc. and a member of
the steering committee of the AIA/Facility Guidelines Institute (FGI) healthcare
guidelines revisions. We want to make sure that the persons with the most
interest in a given project are involved, like the director of the operating
room (OR) or intensive care unit (ICU). I guess I took for granted all along
that that would occur, but that is not a given at all, she says.

Bartley says the expected AIA guidelines changes will have an
impact on IC, and ICPs may find themselves needing to adapt slightly. There will be a number of changes and I think they are good
ones, but there will be challenges to IC to perhaps position our concerns with
the Infection Control Risk Assessment (ICRA) to refocus infectious risks as part
of the overall safety and life safety, and I now like to add environmentally
friendly issues.

Trying to find more ways of partnering with safety
professionals and the safety contractor when construction begins will be one
highlight, she says. I think this is a plus for IC because it means there can
be more shared labor and shared responsibility, but that means good
communication.

The challenge of course is communicating, points out Andrew J. Streifel, hospital environment specialist
with the department of environmental health and safety at the University of
Minnesota, Minneapolis. Streifel is also a member of the AIA guidelines revision
committee and has served as a technical expert for the Centers for
Disease Control and Preventions (CDC) Guidelines for Environmental
Infection Control in Health-Care Facilities.

I see that (communication) to be a challenge, he continues, but I also see that to be the latest trend.
Thats happening more and more. Theres more cooperation, and people are
working together better everyday.

Bartley says such teamwork is imperative in these projects, as
is spelling out the specifics for everyone involved. If they dont assign
whos doing what, theyll be in big trouble, she warns. In other words, whos the safety officer? Whos
on call 24/7 in case something goes wrong? You know there has never been a
project where something doesnt go wrong ever. Hopefully its not
something terrible, but sooner or later there is a power outage, there will be
windows left open somewhere, there will be trash left behind or transported
inappropriately. What do they do? Call IC? That is not the right answer. IC should not be the trouble-shooter
even if they are well-skilled as problem-solvers. This is a management issue and
planning results in everyone understanding that when things go wrong they are
clear about what the chain of command is and whos carrying the beeper.

Then, there is the follow-up of the problem. What are the expectations for fixing it, who communicates back
so that in the project meeting every week or every two weeks, it is very clear
what the expectations were for resolving the issue and what was the agreed upon
accountability? What happens if its not done? Why go through all of this, if
there are going to be major gaps in the process resulting in a patient exposure
anyway? What it all boils down to is communication that includes very clear
assigning of responsibilities.

Bartleys reference to follow-up is important because as
Streifel mentions, the proposed AIA guidelines revisions include the addition of
IC mitigation response documentation. Documentation of response will now be required, he says.
For example if theres been a heavy rain storm and water damage occurred in
a certain area, the response to how you remediate or respond to the damage needs
to be written down now.

The new AIA guidelines are expected to be issued in March
2006, according to Joseph G. Sprague, FAIA, FACHA, chairman of the AIA healthcare
guidelines revision committee and senior vice president of Dallas, Texas-based
HKS Inc. Sprague says they received more than 2,000 comments and proposals for
the updated guidelines.

We do have, I believe, this time a lot more evidence basis
for changes in this 2006 edition. Which is the direction the FGI has as one of its goals to
increase the evidence-based guideline development as opposed to practice and
experience, he adds.

In chapter five of the AIA guidelines, for example, ICPs can
expect some changes related to the ICRA. ICRA has taken on a little different
look, affirms Bartley.

Sprague says the ICRA information has been updated and some
improvements to that section have been incorporated. I think it makes the
document more user-friendly to the hospitals and the designers, and IC, he
says. One such change includes refocusing on the fact that any IC process or
risk assessment has to begin with the assessment of the patient population and
program.

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

An ICRA is a determination of the potential risk of
transmission of various biological agents in the facility. In addition to the
ICRA, the Infection Control Risk Mitigation Recommendations (ICRMR) describes
the specific methods by which transmission will be avoided during the course of the construction project. This
also should be introduced along with proper monitoring of the effectiveness of
the applied ICRMR during the course of the project.2 Provisions for monitoring
shall include written procedures for emergency suspension of work and protective
measures indicating the responsibilities and limitations of each party.

To further support the established ICRA, mandatory adherence
agreements also should be incorporated for IC into construction contracts, with
penalties for noncompliance and mechanisms to ensure a timely correction of the problem(s).3

Planning for new construction or major renovation requires
early consultation and collaboration to ensure that infection prevention is not only adhered to, but built into the design.1

The ICRA more clearly separates out the processes of a new
building, according to Bartley, Meaning you have to think long-range as well
as the immediate project controls.

Sprague points out there has been a lot of argument to go with
single-bed patient rooms with new construction, one of those arguments being the
improvements it provides for IC practices. The AIA guidelines will advise, Unless
the functional program demonstrates the value of a multiple-bed arrangement, the
maximum number of beds per room shall be one.2

The long-range thinking Bartley mentioned includes the
addition in the document of selecting finishes and surfaces that consider IC as
well as materials that are environmentally friendly. Carpet is a big issue, Bartley says, not only for IC issues, but ergonomics as
well.

Bacteria on hospital floors predominantly consist of skin
organisms such as coagulasenegative Staphylococci.4 Bacillus
spp.
and diphtheroids can be cultured, as well as Staphylococcus
aureus
and Clostridium spp. Infection risk from contaminated floors is small, however, the
survival of microbes on carpeting is different. They are present in larger
numbers on this surface, posing a greater risk for infection. Carpeting should
be avoided, especially in high-risk areas because the cleaning process may
aerosolize fungal spores.

Streifel says healthcare is moving toward more resistant
materials, more stainless steel and nonporous surfaces, and more waterless hand
cleansing systems.

Airborne isolation rooms are fast becoming a requirement, but
as Streifel points out, they must be functional. In addition, all airborne
isolation rooms should have self-closing doors. Thats what the guidelines have said since 1996 and
honestly about half of them dont. You cant have ventilation control if the door doesnt
close its that basic, he states. Another key point is that of education being incorporated into
the plan.

To protect the workers, really, we need to make sure they
have training, recommends Streifel. We do not train our workers; thats
truly an oversight. A lot of these guys come from a warehouse into a hospital
and dont realize theres a difference. Warehouse construction or outdoor
construction in a home or residence unoccupied is not the same thing as
a building that is occupied 24/7. I think that is a real disconnect. A lot of
those workers dont realize there are microorganisms in the dust that can
attack and can start to digest these patients. The workers really need training
in order to best protect the patients and employees.

This is going to be a continuing challenge for IC to
find more efficient, better ways to educate hospital staff, visitors, and
construction personnel, adds Bartley. I think thats always been the
area where ICPs feel they have an important role, but I think that is because it
wasnt mentioned in the earlier AIA guidelines specifically; it tended to get overlooked in the
planning. By having education included as an AIA requirement it may also lead to
planning education costs as part of the bid document.

The education piece is also very critical for the current
staff, Bartley continues. Sometimes we think about the subcontractors and forget
about our own facilitys staff and the OR staff because we think Oh theyre
clinical; theyll know what this is. Its amazing how many staff are not
always thinking about the implications of dust and fungi like Aspergillus.

The CDC recommends construction crews be provided:3

  • Designated entrances, corridors, and elevators wherever
    practical
  • Essential services (e.g., toilet facilities) and convenience
    services (e.g., vending machines)
  • Protective clothing (e.g., coveralls,
    footgear, and headgear) for travel to patient-care areas
  • A space or anteroom
    for changing clothing and storing equipment.

Bartley says agreeing what the dress code will be also is
important, as is agreement for how the construction staff will come and go at
the work site.

Map it out, she advises. Map out in the ICRA document
what the traffic patterns are going to be for the patients that are going to
come and go, for the visitors, for the staff so that everyone understands
what the expectations are and they are assured that what they are doing is not
going to produce a risk.

She adds these details also should be communicated through
good signage and posters.

Signage is important, Streifel says. The signage
should both warn and remind the workers of areas where the potential of
transmission may exist. They heed that, he affirms.

ORs are faced with their own unique sets of challenges when it
comes to construction. The best thing you can do is have the construction
crew work after hours, advises Streifel. But he also points out the
challenges that go along with that, such as just how realistic a request that
may be and how any OR can adjust for emergency surgeries that may come in. That
will often present a problem, he says.

He also notes that any construction near an OR can create both
noise and vibration hazards. He used the scenario of a brain surgery being conducted while
a jack hammer or other large machinery is in use nearby. Not only is the
vibration detrimental to the procedure, the noise disallows for proper
communication among the surgical team.

Another point Bartley brings to light is that of access to the
OR and ensuring proper thought to the impact of the ORs ventilation. One of the most important steps is to determine what the
ventilation flow will be and then communicate that to the OR manager and staff
so they know why theyre doing what theyre doing and so they can alert
people if they think something is not functioning properly, she says.

Proper preparedness also includes increased forethought of the
processes required. One of the things that has to be considered is they have
to be thinking about what they need to do to protect the area during the actual
process of putting in the barriers, Bartley points out. They may forget
that when they put up barriers, they are already creating dust. So one of the things to consider when setting up the area for
a major renovation, is to plan first of all for using some barrier possibly
plastic to very quickly isolate the area and ensure a tight seal so when
they are building a more permanent barrier for the project, they are not
creating a hazard.

Streifel says barriers also should have monitoring devices on
them such as a flutter strip, so you can always tell which way the air is
flowing.

Its very hard to prevent exposure; exposure is going to
occur, he says. I think the thing that happens most often is water damage
during construction projects. In one Florida hospital last year, a plumbers
plug in a roof let loose and flooded nine stories of bathrooms, he recalls. He
advises a proactive approach to water damage. For example, elevator shaft
walls should be made with water-resistant chips and board materials.

There are unusual circumstances that have occurred during
construction as well, he adds.

Weve had fires where weve had to shut air handling
systems down which immediately impacts patient care in the facility. Weve had situations during construction where weve had
to evacuate buildings because of gas line ruptures how do you evacuate
people who are under anesthesia? These are extremely complex and not necessarily IC problems,
yet they are very unusual and require emergency planning which comprise an IC
thought process and its that planning that helps all aspects of emergency
response.

Bartley points out some additional areas where common mishaps
occur:

  • Exhausting air from a negative air machine through an open
    window however it is not sealed around the tubing so the effort is totally
    ineffective
  • Open windows
  • Areas with HEPA filtration hospital claimed
    highly filtered air, but there was no tight seal. Weather stripping around the
    windows was so loose that unfiltered air was infiltrating into the room with
    nearly a breeze a clear indication that there was no positive pressure, and
    HEPA filters merely provided a false sense of security
  • Pre-filters for an
    air handler either not put in at all, or put in so carelessly that they were not
    seated properly, not clipped down, and nonfunctional.

Streifel says Aspergillus and
water quality problems are the big concerns to watch for as a result of
construction and renovation projects. Utility services may be interrupted during any type of
construction.5 Outages disrupting the water supply can disrupt bio-film in the
pipes which can release not only gram-negative organisms, but could also release
Legionella and other potentially infectious waterborne pathogens. Outages
associated with electricity can affect critical ventilation systems, he advises, and unscheduled outages do occur, he
says.

Bartley says mold is the biggest problem. In terms of the
typical hospital, I think were still primarily focused on the risk from dust
that carries fungi and of course tubercle bacilli or TB germs. The 2006 AIA
guideline still requires planning for the appropriate number of airborne
isolation rooms. TB and fungal agents like Aspergillus species
remain the infectious agents of greatest concern for high-risk patients.

The other biggest issue still remains the water systems,
she says, agreeing with Streifel. Contamination with Legionella and other
waterborne mycobacteria can contaminate the water and cause problems in water
quality that affect the laboratory as well as patients. Those things have not
changed much. They continue to be the major concerns.

No recommendation is offered regarding routine microbiologic
air sampling before, during, or after construction.3 However, the physical
parameters do need to be sampled, according to Streifel. In other words, what
are your pressure relationships? What is your filtration capability? What are
your air change rates? These are more important than sampling for fungi or
particles in the air because those three are the controlling ventilation
parameters. So, its their functions that prevent infection, he says.

Whatever challenges your facility may encounter during its
next project, your greatest tool will be total awareness.

I think people do tend to look at the basics like trash
removal, but its often the things that go along with that, Bartley points
out. They forget to point out that the trash needs to be covered or agree
which elevators are going to be used during which hours. I think if they use the
current, more extensive ICRA tool, I think that will help remind them of things
that typically in the past might have been overlooked. One of the hardest things is to get people to think out of the
box to really see whats there, not what they expect to see.

Streifel agrees, Each construction project has a planning
phase, an implementation phase, and an acceptance phase. What is commonly
overlooked is the acceptance phase. Is your ventilation working the way it was
specified? Is your space clean enough for an OR? Well, what is clean enough?

All
changes mentioned for the 2006 AIA Guidelines for Design and Construction of
Hospitals and Healthcare Facilities are subject to final ballot. Further
revisions or omissions may occur.



References:

1.) Premier Inc. Construction - Infection control risk
assessment. Available online
www.premierinc.com/all/safety/resources/construction/.

2.) American Institute of Architects/Facility Guidelines
Institute Guidelines for Design and Construction of Hospitals and Healthcare
Facilities. Proposed revisions for 2006 edition. Available online at
www.aia.org/aah_gd_hospcons.

3.) MMWR Recommendations and Reports, Guidelines for
Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control
Practices Advisory Committee (HICPAC), 52(RR10);1-42, June 6, 2003.

4.) Noskin, Gary A. and Peterson, Lance R. Engineering Infection Control through Facility Design.
Emerging Infectious Diseases 7(2) Mar-April, 2001.

5.) Bartley JM and the 1997, 1998, and 1999 APIC Guidelines
Committees. The APIC State-Of-the-Art-Report on Construction and Renovation
(SOAR) The role of infection control during construction in health care
facilities, 2000. American Journal of Infection Control 28:156-169, 2000.




In 2002, Johns Hopkins researchers conducted
a study assessing the ability of hospital air handling systems to filter Aspergillus,
as well as other fungi and particles, following the implosion of an adjacent
building.1 The scientists found that Aspergillus counts
rose more than tenfold at outdoor locations up to 200 meters from the implosion
site. In addition, total fungal counts rose more than six-fold at 100 and 200
meters and two-fold at 400 meters. Similar to Aspergillus,
particle counts rose several-fold following the implosion at 100 and 200 meters.

A similar study was conducted measuring the load of
filamentous fungi in the air following the demolition of a maternity building at
a Madrid hospital.2 Samples were collected before and following the demolition,
and were obtained from external air, non-protected internal air, and from
protected internal air. A significant increase in the colony count of
filamentous fungi occurred after the demolition, with counts returning to
baseline levels after day 11. A significant increase in the fungal colony counts
also was found in external and non-protected internal air.

References:

1.) Srinivasan A, et. al. The ability of hospital ventilation
systems to filter Aspergillus and
other fungi following a building implosion. Infect
Control Hosp Epidemiol
23(9):520-4, 2002.

2.) Bouza E, et. al. Demolition of a hospital building by
controlled explosion: the impact on filamentous fungal load in internal and
external air. J Hosp Infect 52(4):234-42,
2002.