IC in Care Series: Construction and Renovation Risk Management

By Kelly M. Pyrek

Construction or renovation projects in the healthcare environment can pose moderate to significant risks of particulate-borne disease trans-mission, so experts emphasize the need for control measures as part of a risk-mitigation plan.

Lewis Johnson, CIH, the industrial hygienist at Lee Memorial Health System in Fort Myers, Fla., confirms the need to be vigilant for potential breaches in infection prevention and control in hospital construction and/or renovation projects. "Each project is unique and this is why it is important to identify the potential infection control issues for each project through an infection control risk assessment (ICRA). In general, the most significant concerns are pathogenic mold spores becoming airborne or tracked through the facility by workers, and waterborne pathogens. There are numerous reports in literature of healthcare associated infections related to construction caused by Aspergillus and other pathogenic molds, or waterborne pathogens such as Legionella and Pseudomonas."

According to Johnson, there have been cases where outbreaks/infections have been traced directly to construction/renovation activities, "especially Aspergillus infections during demolition and Legionnaires’ disease and Pseudomonas infections from plumbing disruptions. There have also been cases of pseudo-infections where work in or near a microbiology laboratory contaminated cultures and gave the appearance of infections where they did not actually exist."

Johnson, who is the author of the 2015 APIC Text chapter on construction and renovation, continues, "Mold spores are a concern, especially during the demolition phase, mold spores survive for long periods in the environment. Construction work, even accessing walls and ceilings for inspection, has the potential to disturb mold spores that developed during previous water damage or just settled in the space overtime. Due to their size and shape, these mold spores are able to drift long distances with air movements once disturbed. Waterborne pathogens are a concern during periods of water stagnation in plumbing, and from disruption of established biofilms during construction. There is a loss of chlorine when water is stagnant, allowing growth of pathogens and other microbes. Physical impact to plumbing, adding new connections, and shutting off and restarting water service can disturb established biofilms increasing the level of microbial contamination in the water."

Bartley, et al. (2010) say that the backbone of any plan is the infection control risk mitigation recommendations (ICRMRs), which are "written plans that must describe the specific methods by which transmission of air- and waterborne biologic contaminants will be avoided during construction as well as during commissioning when HVAC and plumbing systems and equipment (e.g., ice machines, steam sterilization systems) are started and restarted."

The infection control risk assessment is a key component, and as Johnson explains, "The IP’s role in the ICRA process is very important. Clinical staff members for the space to being built or renovated understand their space very well, but may not be aware of the infection concerns in adjacent spaces. The facility design team has good knowledge of the facility and systems, but is less aware of the infection prevention concerns. The IP brings a facility wide view of infection prevention to the ICRA process. By reviewing and understanding how the construction will occur the IP can evaluate not just the localized infection risk, but also the risk for adjacent spaces and impacts to facility plumbing and ventilation systems."

Johnson adds, "Having a multi-disciplinary team complete an ICRA for the work during the design phase is an important step. This team should include representatives of the project design and construction team, facilities operations, occupants of the space, as well as an IP. De-pending on the complexity of the project, additional experts in ventilation, plumbing, and contamination control may be beneficial. This team should look at the potential risks the project presents to the spaces adjacent to the work, as well as building plumbing, ventilation, and other systems, and then specify infection control risk mitigation measures (ICRMM) to address these risks."

Johnson adds, "The ICRA team should also specify how to validate and monitor the ICRMMs. For example, check contained work zones un-der negative pressure to ensure there is adequate negative pressure relative to the adjacent spaces, and conducting routine measurement of airborne particles to ensure the ICRMMs are controlling dust, and thereby any mold spores."

Lemke, et al. emphasize that "A few specific measures can make a huge difference on construction projects in a healthcare environment." They add, "Infection control should always be the top priority when renovating or building a healthcare facility. Getting all of the details right … will ensure the highest level of protection for current and future patients of the facility."

Lemke, et al. recommend the following considerations:
- Completely separate construction personnel from hospital staff and visitors by assigning a dedicated exterior access point and dedicated elevators, etc. If dedicated access is not possible, another option is for construction personnel to share the access points used by hospital maintenance staff. If access points cannot be segregated, coordinate and schedule the work so that the hospital’s operations are not disrupted.
- Enclose or cover all construction materials and debris brought in or out through the hospital. Whenever possible completely enclose the materials in a clean container, or at the very least, cover them with a clean sheet of plastic.
- Properly plan and monitor the negative pressure containment area. Infection control plans usually require the use of negative pressure to ensure that dust does not escape from the work site.
- Use the right containment barriers. If the infection control plan does not specify the type of material to be used for the dust containment barrier, your decision should be based on two considerations: first, the amount of dust that will be generated, and second, the length of time the barrier needs to be in place.
- Keep air quality records. Even if the infection control plan does not require permanent records, keep in mind that records are important risk management tools and are sometimes needed for documentation after the fact.
- Work closely with hospital staff. Double-check before disrupting systems. Emergencies frequently arise in a healthcare facility, so even if a shutdown is approved weeks in advance always get a last-minute go-ahead from the head nurse on duty.
- Choose subcontractors with experience. Hire subcontractors carefully and provide training. Using subcontractors with healthcare experience can make all the difference, but also make sure they know the specifics of the infection control plan on every project.

As we have seen, collaboration among staff during a construction or renovation project is imperative, and the IP can play a pivotal role in risk management during all stages of the process.

"There are important roles for the IP in all stages of a construction/renovation project," Johnson says. "The IP provides input in the planning phase on the number, locations, and design of handwashing and hand hygiene stations, isolation rooms, and other features. While there are codes that specify minimums for each of these, the IP brings the knowledge of local conditions that may affect the decisions. For example, additional airborne infection isolation rooms may be necessary in a facility with an above average experience with active TB patients."

Johnson continues, "During the design phase, the IP can help to ensure that layout of the space and the flow of patients, providers, and supplies minimizes cross-contamination and infection risk. The IP also provides important insight into the potential infection risk created through the construction process, and the design of ICRMMs to address those risks. During the construction phase, the IP audits the project records to ensure that ICRMMs are validated and operating effectively. The IP monitors cultures, and alerts medical staff to be aware of the potential for construction related infections during the construction phase. This is especially true after any breach in the ICRMMs. After construction, the IP is an important member of the acceptance team inspecting the built space, and reviewing the commissioning records for critical ventilation and plumbing systems to ensure that they are operating as expected."

As a healthcare industrial hygienist, Johnson wants IPs and other healthcare stakeholders to know that "Managing construction infection risks, especially on a large or complicated project, can call for knowledge and skills that are not a part of the typical IP or project manager’s experience." He adds, "In these situations, the ICRA team should consider including a consultant with broad healthcare construction experience as a part of the ICRA team. An experienced consultant can provide assistance with both the design and the on-going validation of ICRMMs dur-ing the project. During the design phase, a consultant may be able to provide alternatives for ICRMM that the local team has not considered and help to coordinate the ICRA process. During the construction phase, the consultant should have the tools and skills necessary to verify HEPA filters in vacuums and negative air machines are not leaking, monitor for dust leakage from contained workspaces, monitor the health of water systems during the project, and assess the impact of the project on the facility ventilation systems. The consultant can also assist with training construction workers in how to implement and work with the ICRMMs."

References:

Bartley JM, Olmsted RN, and Haas J. Current views of healthcare design and construction: Practical implications for safer, cleaner environments. Am J Infect Control 2010;38:S1-12.

Lemke B, Flint D and Stubits M. Healthcare Construction: Getting the Details Right in Infection Control. Accessed at:

Recommended reading:

Johnson L. Construction and Renovation. APIC Text. December 2015. http://text.apic.org/toc/infection-prevention-for-support-services-and-the-care-environment/construction-and-renovation