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Presented by : Bobbie Welch, MT, RN, MPH, CIC VA Connecticut Healthcare System

Infection prevention Issues During Construction and Renovation Activities and the Infection Control Risk Assessment. Presented by : Bobbie Welch, MT, RN, MPH, CIC VA Connecticut Healthcare System Infection Control Program Manager. OVERVIEW. Why the Construction Concerns?

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Presented by : Bobbie Welch, MT, RN, MPH, CIC VA Connecticut Healthcare System

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  1. Infection prevention Issues During Construction and Renovation Activities and the Infection Control Risk Assessment Presented by : Bobbie Welch, MT, RN, MPH, CIC VA Connecticut Healthcare System Infection Control Program Manager

  2. OVERVIEW • Why the Construction Concerns? • Healthcare Environment Issues • Pathogen Issues • Methods to minimize risk (Engineering vs Behavioral) • Infection Control Risk Assessment

  3. Why the Construction Concerns? • Increased public perception of HC associated infections (newreporting requirements) • Healthcare associated infections • Attributed Costs • Mortality • Government and Accrediting Agencies

  4. Healthcare Environment • Acute care • Outpatient • Home settings

  5. What must be considered? • Patient populations and programs • Impact of disruption on patients and healthcare workers • Patient displacement, relocation • Placement of effective barriers to protect environment • Air Handling • Control of waterborne pathogens

  6. Patient Populations • Age • Medical conditions • Medications • Medical care DEPENDENT ON: Degree of Risk Degree of Exposure

  7. THE USUAL SUSPECTS • AIR • Aspergillus • Other fungi • Tuberculosis • WATER • Legionella • Mycobacteria • SURFACES • Gram negative bacilli • Gram positive cocci • C. difficile

  8. Examples of airborne fungi • Aspergillus • Cladosporium • Stachybotrys • Fusarium • Penicillium

  9. Sources of fungi • Outdoor air • Soil and organic matter • Building materials • Dust

  10. Sources of water • Broken, leaking pipes • Condensation within building envelope • Vapor migration • Penetration of building envelope

  11. Fungi Growth & Prevention • Requires water • Significant growth after 24 to 48 hours wet1 • Wet biodegradable materials must be dried within 24-48 hours to prevent growth2 1. Pasanen AL Atmospheric Environment 1992;26B:117-120 2. Horner Proceedings ASHRAE IAQ 2001, 1-4

  12. ASPERGILLUS INFECTIONS

  13. Invasive Aspergillosis & Mortality

  14. STACHYBOTRUS AND SICK BUILDING SYNDROME • Persons with chronic exposure to the toxin produced by stachybotrus report cold or flu like symptoms with sore throat, diarrhea, headaches, fatigue, dermatitis and general malaise. • Toxin may cause sick-building syndrome. • The toxins may also suppress the immune system.

  15. Legionella • One of the top 3 most common causes of severe community associated pneumonia1 • CDC estimates 8,000-18,000 cases/yr2 • Approximately 35% cases healthcare associated2 • Legionella is common in hospital water 3,4 • Legionellae growth range = 68 -122 ° F (20 to 50 °C) • Torres Am Rev RespirDis 1991;144:312 3. Yu ICHE 1998;19:893 • Benin Clin Infect Dis 2002;35:1039 4. SabriaICHE 2002;22:673

  16. LEGIONELLA DISINFECTION • Disinfection range =70-80°C (158 to 176 °F) • 66 °C (151 °F): Legionellae die within 2 minutes • 60 °C (140 °F): Legionellae die within 32 minutes • 55 °C (131 °F): Legionellae die within 5 - 6 hours

  17. Legionella: Historical • July 21 – 24th 1976 • American Legion Convention, Philadelphia • 10,000 attendees Peak Jul 25-28 Cases July August

  18. Legionella Prevention • Renovation • Eliminate water systemdead legs • Instantaneous hot water heaters • Avoid faucet aerators • New water systems • Systemic disinfection • Copper/silver ionization

  19. Care for transplant pts • If no=Check if HCA LD • If yes=ICC for ongoing mitigation, monitoring • If no= is there monochloramine treated water • Yes= monitor for cases • No=conduct annual RA

  20. Minimizing risk Engineering and Administrative Controls

  21. Reducing Airborne Contamination • Filtration of hospital air • Initiated in 1970s • Removes fungal spores, decreases contamination • Dramatic decrease in frequency of aspergillosis 1. Rose Am Rev Resp Dis 1979;119:511-513. 2. Walsh Eur J Epidemiol 1989;5:131-142 3. Krasinski Infect Control 1985;6:278

  22. Contaminant Monitoring MEASURING INCLUDES: • Respirable dust, total particles in the 0.3to 0.5 µlrange • Simple non-speciated airborne fungi = total colony counts • Known construction related volatile organic compounds

  23. MoldPrevention • Avoid use of wall coverings which trap moisture in walls • Avoid installation of biodegradable materials in areas subject to wetting or dampness • Control humidity to limit moisture content in materials • Dirt and dust attract and retain moisture • Maintain clean HVAC systems

  24. Clean-up Guidance • Movement of moldy materials in an area will release spores • Ensure proper containment • Porous, biodegradable materials not dry within 24- 48 hours should be discarded!! • Minimize use of additional water, disinfectant in clean-up

  25. Excavation & Implosions • Great potential to overwhelm filters and cause significant HVAC contamination • Ensure doors/windows sealed • Monitor dust plume • Water mist to control dust • Consider closing air intakes while dust plume from implosion is passing

  26. New Construction • INSPECT FOR: • Water incursion • Intact ductwork, pipes • Insulation existing ductwork and water pipes • PROTECT FROM CONTAMINATION • HVAC systems, • Ductwork • Water pipes

  27. Controlling Activities InExisting Construction • Need for containment • General containment barriers • Point of entry control cubes • Negative pressure requirement • Contaminant monitoring • HVAC system protection and isolation

  28. Containment Barriers • Prevent spread of contamination • Extent of containment depends on extent of contamination and sensitivity of area small area versus large area…. • Consulting partners • Infection Control • Safety/Industrial Hygiene RautialaAmerican Industrial Hygiene Association Journal 1998;59:455-460

  29. More Controls • Consider dust migration • PPE • Tacky mats • Wet mopping • Cover trucks • Plan route(s) for debris, materials and personnel • Document all controls via ICRA (and PUT INTO contract) • Frequent inspection by IC, Safety, FMS, etc.

  30. Design Phase Considerations INFECTION CONTROL ISSUES

  31. FINISHES • Tile • Wood • Sides properly sealed • Replace/repair costs • Carpet • Difficult to adequately clean

  32. DECORATIVE WATER • Appealing to the senses • Creates a more serene atmosphere • Potential source of pathogens • Fungus • Legionella • Gram negative bacteria (Pseudomonas, Klebsiella, Serratia , etc) • IMPORTANTS POINTS TO CONSIDER: • Do not place in patient care areas • Avoid jets, spraying; favoring flowing water • Ensure proper maintenance • Consider sustainability during planning HICPAC/CDC Guidelines for Infection Control in Healthcare Facilities MMWR 2003

  33. Infection Control Risk Assessment

  34. INFECTION CONTROL RISK ASSESSMENT (ICRA) • Utilize a multi-disciplinary TEAM • IC, Risk Management, Facility Design, Facilities Management , Construction, Safety, Ventilation • Focus on reduction of risk from infection • Initiated in the design and planningphase and continues through construction and renovation • Education of contractors and FMS staff about infections and infectious agents and care of environment, • Anticipation of impact to surrounding areas 2006 AIA Guidelines 2009 ASHE/AHA Conference

  35. ISSUES TO ADDRESS OR CONSIDER • Patient Population • Disruption of essential services • Patient Placement/ Relocation • Air handling/Ventilation • Placement of Effective Barriers

  36. MORE ISSUES TO ADDRESS OR CONSIDER • Determine need for airborne isolation or PPV rooms • Water systems , decorativefountains, waterborne pathogens • Patient protection from demolition, ventilation, power outages & debris removal.

  37. Identify the TYPE of Construction

  38. Identify the TYPEof Construction (continued)

  39. Identify the Patient Risk Groups

  40. Infection Control Risk Assessment (ICRA) Matrix Match the patient risk group with the planned construction project type This will give you the class of precautions ConstructionProject Type Patient risk group

  41. IMPACT ON OTHER AREAS • It is also important to identify the areas surrounding the project area, assessing potential impact

  42. IMPACT ON OTHER AREAS Example:

  43. Description of Required IC Precautions • Obtain IC permit BEFORE construction begins. • Isolate HVAC system in area • Complete all critical barriers • Maintain NPV within work site • Seal holes, pipes, conduits & punctures • Construct anteroom • Use of Shoe Covers

  44. Description of Required IC Precautions(continued) • Vacuum work area w/ HEPA filtered vacuums • Wet mop area with disinfectant • If area is outside, wetting of dust may still be required • Remove isolation HVAC system in areas where work is being performed.

  45. Description of Required IC Precautions(continued) • Cover transport receptacles or carts. Tape covers unless solid lid. • Remove isolation HVAC system in areas where work is being performed. • Do not removed barriers from work area until completed project is inspected by Safety and IC.

  46. IMPORTANT IC CONSIDERATIONS • Identify specific sites of activity • Development of phase plan to address issues • Identify issues re: ventilation, plumbing, electrical in terms of the possible outages • Water shutdown issues • Identify containment measures, using prior assessment. • Solid deck to deck barriers.

  47. More.. • Consider potential risk of water damage. • Work hours Can or will the work be done during non-patient care hours? • Do plans allow for adequate number of isolation/negative airflow rooms? • Do the plans allow for the required number & type of handwashing sinks? • Does it include a place for soap and towels

  48. More… • Does Infection Control staff agree with the minimum number of sinks for the project? • Does IC staff agree with the plans relative to clean and soiled utility rooms? • Plan to discuss the following containment issues with the project team: • Traffic flow (people) • Housekeeping • Debris removal

  49. PRE PROJECT SIGN OFF FORM PROJECT NAME: ________________________ DATE:__________________ COTR: ___________________ PHONE: ________________ PROJECT LOCATION: _____________________________________________ SCOPE OF WORK OVERVIEW: PROJECT DONE : INHOUSE_________ CONTRACTED ________ STATEMENT OF WORK (SOW) PROVIDED WITH THIS SUBMITTAL: YES NO WILL PROJECT IMPACT PATIENT CARE AREA OR OCCUPIED SPACE:YES NO BLUE PRINTS PROVIDED WITH THIS SUBMITTAL : YES NOPRINTS ARE ___ _% COMPLETE ******************************** The following representative signature(s) must be on this document prior to the start of any project. SAFETY SVC: : _________________________Date:_________ • Special safety considerations: ___________________________________________________________________ FIRE/LIFE SAFETY: : _____________ Date___________ • ILSM required: YESNO Special Fire/Life Safety implications: YES NO If Yes, indicate what special considerations exist: ________________________________ GEMS: _______________________Date:__________ • NEPA review required? YES NO • Special Environmental Requirements: YES NO If yes, indicate what special considerations exist: POLICE: _______________________ Date:____________ Police reviewed project YES NO ID Badges/Background Investigations completed: YES NO Parking location. One Contractor vehicle on site. INF CONTROL: _____________________ Date:__________ • ICRA review required? YES NO _______________________________________ ENERGY MGMT : _____________________ Date:__________ • Utility Incentive Candidate YES NO • Metering Requirements YES NO • Commissioning/ Re-commissioning Requirements YES Comments:________________________ Office of Information & Technology (OI&T)____________ Date:__________ • Data Management issues YES NO IF ANY OF THE FOLLOWING ITEMS ARE CHECKED, IN THE REQUESTED COLUMN, THOSE ITEMS MUST BE RECEIVED PRIOR TO THE START OF ANY PROJECT:

  50. PRE-PROJECT SIGN OFF FORM PROJECT NAME: __________________________DATE:__________________ COTR: __________________________ PHONE: ________________ PROJECT LOCATION: _______________________________________ SCOPE OF WORK OVERVIEW: _________________________________________ PROJECT DONE INHOUSE_________ CONTRACTED ________ STATEMENT OF WORK (SOW) PROVIDED WITH THIS SUBMITTAL: YES NO WILL PROJECT IMPACT PATIENT CARE AREA OR OCCUPIED SPACE:YES NO BLUE PRINTS PROVIDED WITH THIS SUBMITTAL : YESNO PRINTS ARE ______% COMPLETE

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