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.
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.
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.