Construction and Environmental Concerns for IP

1. Construction and Environmental Concerns for IP Linda R. Greene, RN, MPS,CIC, FAPIC Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester.edu

2. FGI- Types of Evidence • Rational understanding/experience: The requirements supported by this kind of evidence are practical, common sense items everyone can agree on, such as a paved road leading to an emergency department entrance. • Clinical practice, policy, or guidelines: This category includes physical environment features needed to support clinical practice and a safe environment for the provision of care. An example is the CDC guidelines for hand hygiene. • Direct evidence: This type of evidence demonstrates a direct association between a requirement and a patient or staff outcome. For example, the requirement for an airborne infection isolation room to be a single-patient room is supported by documentation showing that airborne transmission of pathogens to other patients and to staff is reduced when patients with airborne infections are isolated. • Indirect evidence: Indirect evidence shows an association between a design requirement and an outcome that does not directly affected a patient or staff outcome but can be inferred to affect that outcome. An example is air change rates for exam rooms. The current requirement is for six air changes per hour, which reduces the number of airborne particulates in the room and has been shown to provide a safe environment. However, a direct correlation has not been shown between this number of air changes and reduced infection rates for staff or patients.

3. FGI Guidelines Examples • Vertical ED issue • Ultrasound processing, • Sterile processing (since we took out the two-room sterile processing facility in 2014 and put it back in for the 2018) • New imaging classification system • Exam/treatment, procedure, and operating room requirements (knowing when you need which room type) • Functional program purpose and how-to • Telemedicine spaces

4. Trends • More health care provided at home • More access to medical care in the community • More specialized diagnosis and treatment facilities • Hospitals provide only for the sickest or those with most complicated needs • Navigators and health coaches provide assistance to patients, providers, and/or payers • Increased use of technology for health care monitoring and communication • Continued government involvement in regulating health care

5. The Future • Health care will increasingly be provided in outpatient facilities and residential care settings of numerous types. • Acute care facilities will see slower growth and be focused on providing care to higher acuity patients with more complex treatment and care needs. • As a society the United States needs to encourage development of “high value, high engagement” models of care; how the design of health care facilities can relate to this goal should be considered.

6. Increase in Diverse Settings

7. Examples Source L Dickey 2015 APIC

8. ICRA Definitions and elements • Definition: An ICRA is multidisciplinary, organizational, documented process that after considering the facility’s patient population and program: • Focuses on reduction of risk from infection, • Acts through phases of facility planning, design, construction, renovation, facility maintenance, and • Coordinates and weighs knowledge about infection, infectious agents, and care environment, permitting the organization to anticipate potential impact.

9. ICRA Design • The design area requires “long-range planning” for new or renovated buildings and adds a new element “finishes and surfaces” a critical feature over the lifetime of the facility. Considerations include: • Number, location, and type of airborne infection isolation and protective environment rooms. • Location of special ventilation and filtration such as emergency department waiting and intake areas. • Air handling and ventilation needs in surgical services, airborne infection isolation and protective environment rooms, laboratories, local exhaust systems for hazardous agents, and other special areas. • Water systems to limit Legionella sp. and other waterborne opportunistic pathogens. • Finishes and surfaces.

10. ICRA Construction • The building and site areas anticipated to be affected by construction shall include consideration of the following: • Impact of disrupting essential services to patients and employees. • Determination of the specific hazards and protection levels for each. • Location of patients by susceptibility to infection and definition of risks to each. • Impact of potential outages or emergencies and protection of patients during planned or unplanned outages, movement of debris, traffic flow, cleanup, and testing and certification. • Assessment of external as well as internal construction activities.

11. ICRA Infection Control Risk Mitigation • The mitigation recommendations from the ICRA panel shall address the following: • Patient placement and relocation. • Standards for barriers and other protective measures required to protect adjacent areas and susceptible patients from airborne contaminants. • Temporary provisions or phasing for construction or modification of heating, ventilating , air conditioning and water supply systems. • Protection from demolition. • Measures taken to train hospital staff, visitors and construction personnel.

15. Air Flow Examples: Negative Airflow - TB rooms Janitors Closets Triage Construction Dirty utility

16. Air Flow Positive Pressure: ORs Bone Marrow, Oncology Clean Utility Clean Storage

17. Accident Causation Model

18. Key Issues Infection literature reflects the fact that the design of the physical environment impacts nosocomial infection rates by affecting all three major transmission routes—air, contact, and water.

19. Key Points • Use effective air quality control measures during construction and renovation to prevent the outbreak of airborne infections. Measures include, for example, using portable high-efficiency particulate air (HEPA) filters, installing barriers between patient-care areas and construction/renovation areas, generating negative air pressure for construction/renovation areas relative to patient-care areas, and sealing patient windows. • Install alcohol-based hand-rub dispensers at the bedside and in other accessible locations to increase hand-washing compliance and reduce contact transmission of infection. • Select easy-to-clean floor, wall, and furniture coverings, and employ proper cleaning and disinfection procedures. • Design and maintain the water system at the proper temperature and adequate pressure; minimize stagnation and back flow; eliminate dead- end pipes; regularly clean point-of-use fixtures; and consider the location of decorative fountains and carefully maintain them to minimize the risk of waterborne infection. • Provide single-bed rooms with private toilets to enable separation or isolation of patients on admission, so that those with unrecognized infections can be tested and identified without being mixed in with uninflected individuals

20. Problems

21. Fungal Infections

22. Outcomes

23. Risk Factors Persons at Risk for Aspergillus/Fungal Infection: • Any patient who is immunocompromised • Bone marrow and solid organ transplant • Chemotherapy • Prolonged steroid / antibiotic therapy • Dialysis

24. Documented Source of Spores in Construction Settings • False ceilings • Insulating material • •Fire-proofing material • •Open windows/doors • Contaminated carpeting • Dust from construction site • •Dust from excavation site

25. Vibration Five patients with severe postoperative Aspergillus endophthalmitis • All five patients came from one hospital in January and February during a period of active hospital construction • All five patients were subjected to aqueous or vitreous tap • Three patients had removal of the vitreous gel from the middle of the eye • Final outcome in each patient was evisceration (removal of the eye’s contents) or enucleation (removal of eye), despite an intensive course of antifungal therapy

26. Failure to Protect

27. Water Risks

29. Continued

30. CDC Report Timed delivery of biocide only when system is in use

31. CMS Regulations

32. Atypical Mycobacterium Contaminated rinsing water of instruments

36. Other Water Related Issues • Floods • Sewage leaks • Water back ups • Requires a multidisciplinary team

37. Water Damage A day in th A day in the life……………… Flood in the OR Monday, July 8, at approximately 6:05 PM Maintenance was called in for backed-up drains in the Operating Room caused by a rain storm. Copious amounts of water were overflowing the scrub sinks and floor drains in the Perioperative areas

38. Scenario • At approximately 6:15, after assessment of the situation, the maintenance worker called the Facilities Manager who directed the Telecommunications officer to call in all available Maintenance staff. • The Nursing Supervisor was at the scene and contacted the Nursing Administrator on call. Calls were also made to the Chief Operations Officer, Safety Officer, and Manager of Infection Prevention. • At 6:30 PM, the Infection Prevention Manager arrived and found water about three inches deep throughout the area. The nursing supervisor and Infection Prevention were assessing the situation when the Safety Officer arrived at 6:50 PM. Environmental Services staff and maintenance staff were actively removing water from the floors via wet vacs, mops, and towels. At that time, there was approximately ½” of water in the area. The decision to activate the Incident Command System was made in order to gain additional resources for decision-making, direction of resources

39. Priorities • Patients • Sterile Supplies • OR rooms - walls • Packaged supplies (e.g., prepackaged bandages packaged in paper and sterile supplies packaged in paper-peel packs) should be inspected for tears, dampness, visible moisture, mold growth, or signs of having been wet • (such as water stains or discoloration) and discarded if present • Sterile supplies whose packaging is compromised will need re-sterilization; items in undamaged, intact waterproof packaging may be kept • Manufacturers of affected supplies should be contacted to determine if in-house reprocessing of these items is appropriate and feasible; alternatively the manufacturer should provide the facility with instructions to return the items for reprocessing;

40. Other Issues

41. The Moisture Meter • Utilize a moisture meter to identify the extent of water damage and to determine sufficient dryness Typically, there is a 24-48 hour window after having been exposed to moisture. Once mold has begun to form, the contaminated areas must be removed and replaced

42. New Construction- we need to do an ICRA Infection Control Risk Assessment Do you know what you are looking at? Consider walking the walk

43. Barriers I am too busy Nothing to do with me

44. Tips for Assessment • Infection Prevention know BEFORE • Construction renovation activity is planned • Take a walk with Architects and Construction before hand • Visualizing the activity/location will help determine risk

45. Think • The project may be small in scale but big in dust • Painting a wall? • Dust free BUT- do you have to patch and sand the wall first? • Pulling off wall covering? • Is there mold behind that? • Pulling electrical cables?

46. The Infection Control Risk Assessment (ICRA)

50. Protection Coveralls Trash