Upholding Infection Control Principles in HospitalConstruction and Renovation Projects

Upholding Infection Control Principles in HospitalConstruction and Renovation Projects

By Jennifer Schraag

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

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

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

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

Trying to find more ways of partnering with safetyprofessionals and the safety contractor when construction begins will be onehighlight, she says. I think this is a plus for IC because it means there canbe more shared labor and shared responsibility, but that means goodcommunication.

The challenge of course is communicating, points out Andrew J. Streifel, hospital environment specialistwith the department of environmental health and safety at the University ofMinnesota, Minneapolis. Streifel is also a member of the AIA guidelines revisioncommittee and has served as a technical expert for the Centers forDisease Control and Preventions (CDC) Guidelines for EnvironmentalInfection 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 areworking together better everyday.

Bartley says such teamwork is imperative in these projects, asis spelling out the specifics for everyone involved. If they dont assignwhos doing what, theyll be in big trouble, she warns. In other words, whos the safety officer? Whoson call 24/7 in case something goes wrong? You know there has never been aproject where something doesnt go wrong ever. Hopefully its notsomething terrible, but sooner or later there is a power outage, there will bewindows left open somewhere, there will be trash left behind or transportedinappropriately. What do they do? Call IC? That is not the right answer. IC should not be the trouble-shootereven if they are well-skilled as problem-solvers. This is a management issue andplanning results in everyone understanding that when things go wrong they areclear 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 backso that in the project meeting every week or every two weeks, it is very clearwhat the expectations were for resolving the issue and what was the agreed uponaccountability? What happens if its not done? Why go through all of this, ifthere are going to be major gaps in the process resulting in a patient exposureanyway? What it all boils down to is communication that includes very clearassigning of responsibilities.

Bartleys reference to follow-up is important because asStreifel mentions, the proposed AIA guidelines revisions include the addition ofIC 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 ina certain area, the response to how you remediate or respond to the damage needsto be written down now.

The new AIA guidelines are expected to be issued in March2006, according to Joseph G. Sprague, FAIA, FACHA, chairman of the AIA healthcareguidelines revision committee and senior vice president of Dallas, Texas-basedHKS Inc. Sprague says they received more than 2,000 comments and proposals forthe updated guidelines.

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

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

Sprague says the ICRA information has been updated and someimprovements to that section have been incorporated. I think it makes thedocument more user-friendly to the hospitals and the designers, and IC, hesays. One such change includes refocusing on the fact that any IC process orrisk assessment has to begin with the assessment of the patient population andprogram.

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

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

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

Planning for new construction or major renovation requiresearly 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 newbuilding, according to Bartley, Meaning you have to think long-range as wellas the immediate project controls.

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

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

Bacteria on hospital floors predominantly consist of skinorganisms such as coagulasenegative Staphylococci.4 Bacillusspp. and diphtheroids can be cultured, as well as Staphylococcusaureus and Clostridium spp. Infection risk from contaminated floors is small, however, thesurvival of microbes on carpeting is different. They are present in largernumbers on this surface, posing a greater risk for infection. Carpeting shouldbe avoided, especially in high-risk areas because the cleaning process mayaerosolize fungal spores.

Streifel says healthcare is moving toward more resistantmaterials, more stainless steel and nonporous surfaces, and more waterless handcleansing systems.

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

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

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

The education piece is also very critical for the currentstaff, Bartley continues. Sometimes we think about the subcontractors and forgetabout our own facilitys staff and the OR staff because we think Oh theyreclinical; theyll know what this is. Its amazing how many staff are notalways thinking about the implications of dust and fungi like Aspergillus.

The CDC recommends construction crews be provided:³

• Designated entrances, corridors, and elevators whereverpractical

• Essential services (e.g., toilet facilities) and convenienceservices (e.g., vending machines)

• Protective clothing (e.g., coveralls,footgear, and headgear) for travel to patient-care areas

• A space or anteroomfor changing clothing and storing equipment.

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

Map it out, she advises. Map out in the ICRA documentwhat the traffic patterns are going to be for the patients that are going tocome and go, for the visitors, for the staff so that everyone understandswhat the expectations are and they are assured that what they are doing is notgoing to produce a risk.

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

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

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

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

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

Proper preparedness also includes increased forethought of theprocesses required. One of the things that has to be considered is they haveto be thinking about what they need to do to protect the area during the actualprocess of putting in the barriers, Bartley points out. They may forgetthat when they put up barriers, they are already creating dust. So one of the things to consider when setting up the area fora major renovation, is to plan first of all for using some barrier possiblyplastic to very quickly isolate the area and ensure a tight seal so whenthey are building a more permanent barrier for the project, they are notcreating a hazard.

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

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

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

Weve had fires where weve had to shut air handlingsystems down which immediately impacts patient care in the facility. Weve had situations during construction where weve hadto evacuate buildings because of gas line ruptures how do you evacuatepeople 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 ICthought process and its that planning that helps all aspects of emergencyresponse.

Bartley points out some additional areas where common mishapsoccur:

• Exhausting air from a negative air machine through an openwindow however it is not sealed around the tubing so the effort is totallyineffective

• Open windows

• Areas with HEPA filtration hospital claimedhighly filtered air, but there was no tight seal. Weather stripping around thewindows was so loose that unfiltered air was infiltrating into the room withnearly a breeze a clear indication that there was no positive pressure, andHEPA filters merely provided a false sense of security

• Pre-filters for anair handler either not put in at all, or put in so carelessly that they were notseated properly, not clipped down, and nonfunctional.

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

Bartley says mold is the biggest problem. In terms of thetypical hospital, I think were still primarily focused on the risk from dustthat carries fungi and of course tubercle bacilli or TB germs. The 2006 AIAguideline still requires planning for the appropriate number of airborneisolation rooms. TB and fungal agents like Aspergillus speciesremain 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 otherwaterborne mycobacteria can contaminate the water and cause problems in waterquality that affect the laboratory as well as patients. Those things have notchanged much. They continue to be the major concerns.

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

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

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

Streifel agrees, Each construction project has a planningphase, an implementation phase, and an acceptance phase. What is commonlyoverlooked is the acceptance phase. Is your ventilation working the way it wasspecified? Is your space clean enough for an OR? Well, what is clean enough?

Allchanges mentioned for the 2006 AIA Guidelines for Design and Construction ofHospitals and Healthcare Facilities are subject to final ballot. Furtherrevisions or omissions may occur.

References:

1.) Premier Inc. Construction - Infection control riskassessment. Available onlinewww.premierinc.com/all/safety/resources/construction/.

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

3.) MMWR Recommendations and Reports, Guidelines forEnvironmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection ControlPractices 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 GuidelinesCommittees. The APIC State-Of-the-Art-Report on Construction and Renovation(SOAR) The role of infection control during construction in health carefacilities, 2000. American Journal of Infection Control 28:156-169, 2000.

In 2002, Johns Hopkins researchers conducteda study assessing the ability of hospital air handling systems to filter Aspergillus,as well as other fungi and particles, following the implosion of an adjacentbuilding.¹ The scientists found that Aspergillus countsrose more than tenfold at outdoor locations up to 200 meters from the implosionsite. In addition, total fungal counts rose more than six-fold at 100 and 200meters 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 offilamentous fungi in the air following the demolition of a maternity building ata Madrid hospital.² Samples were collected before and following the demolition,and were obtained from external air, non-protected internal air, and fromprotected internal air. A significant increase in the colony count offilamentous fungi occurred after the demolition, with counts returning tobaseline levels after day 11. A significant increase in the fungal colony countsalso was found in external and non-protected internal air.

References:

1.) Srinivasan A, et. al. The ability of hospital ventilationsystems to filter Aspergillus andother fungi following a building implosion. InfectControl Hosp Epidemiol 23(9):520-4, 2002.

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