January 2006 pp62-66
Don’t Let Construction Compromise Infection Control
Here’s how to minimize the potential negative effects of dust, dirt and extra people moving through your center.
Judene Bartley, MS, MPH, CIC
On the WebResources for maintaining infection control standards while under construction:
Ms. Bartley () is the vice president of ECSI and a clinical consultant for the Premier Safety Institute.
Have you built infection prevention into the design of your construction or renovation project? Construction activities — even such minor jobs as installing T1 lines, removing ceiling tiles and working on your HVAC ducts — can disperse dirt, dust, bacteria and sometimes even fungal spores into the environment. If inhaled, these may cause severe infection in patients with immune systems compromised by surgery. Here are four construction projects, and the precautions to take for each.
Surgical building and renovation have been associated with outbreaks of invasive fungal infection such as Aspergillosis, which can enter your facility through open doors and windows, can survive at almost any temperature and needs only a couple days to grow in water-damaged building materials such as drywall, plaster, carpeting and ceiling tiles.1. Freshening up the lobby
The admit area needs a new coat of paint to liven it up. It’s a simple, in-and-out job, and that’s why it’s considered a type A construction project — inspection or non-invasive activities.
Yes, outpatient surgery patients will be coming through there, as will whoever is accompanying them. But the lobby is considered an office area. It is not sterile, nor is it connected to any sterile area. Therefore, everyone is considered to be part of the low-risk patient group.
While you will need to keep the lobby well ventilated, there are few other precautions needed, as those doing the work shouldn’t need to enter your facility’s sterile and sub-sterile areas in order to complete the job. Signs and good communication will keep patients and families from worrying that this work will compromise the surgical area and affect them.
Precautions you should take during construction:
- Ensure the work is executed by methods that minimize dust and dirt related to the work.
Upon completion:
- Clean up the work area.
2. A fancy monitor in the endoscopy suite
Your physicians like toys, so they decide to get some ceiling-mounted LCD screens for the endoscopy suites. Any time you have to open the ceiling, you may be interfering with the HVAC system, which poses the risk of circulating construction dust throughout your facility. Ceiling-mounted monitors, booms, major cabling activities, and minor duct or electrical work are among the construction activities considered type C construction.
Because some endo suites are used for procedures and not invasive surgery (air exchange requirements are less stringent, and procedure rooms don’t have to be on a sterile corridor, for example), patients are medium-risk. Pain
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January 2006 pp62-66
practice patients would also fall into this category. The combination of medium-risk patients and type C construction calls for class III procedures.
Risk of Infection and Extent of ConstructionHere’s a quick and easy way to get the class of precautions you need to take.
Patient-risk Groups
Low / Medium / High / Highest
Office areas / Cardiology / CCU / Any area with immunocompromised patients
Echocardiography / ER / Burn unit
Endoscopy / Labor and delivery / Cardiac cath lab
Nuclear medicine / Newborn nursery / Central sterile supply
Labs (specimen) / Outpatient surgery / Negative-pressure isolation rooms
Physical therapy / Pediatrics / ICU
Radiology/MRI / Pharmacy / Medical unit
Respiratory therapy / PACU / Oncology
Surgical units / ORs including C-section rooms
Construction Project Activity
TYPE A
Examples of inspection and non-invasive activities
- removal of ceiling tiles for inspection (limit: one tile per 50 square feet)
- painting (but not sanding)
- wallcovering, electrical trim work, minor plumbing and other activities that don’t generate dust, or require cutting of walls or access to ceilings other than for visual inspection
TYPE B
Examples of small-scale, short-duration activities that create minimal dust
- installation of telephone and computer cabling
- access to chase spaces
- cutting of walls or ceiling where dust migration can be controlled
TYPE C
Examples of work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies
- sanding of walls for painting or wall covering
- removal of floorcoverings, ceiling tiles and casework
- new wall construction
- minor duct work or electrical work above ceilings
- major cabling activities
- any activity that cannot be completed in a single workshift
TYPE D
Examples of major demolition and construction projects
- activities that require consecutive work shifts
- requires heavy demolition or removal of a complete cabling system
- new construction
Infection Control Matrix
Construction Project Type
Patient-risk Group / Type A / Type B / Type C / Type D
Low / I / II / II / III/IV
Medium / I / II / III / IV
High / I / II / III/IV / IV
Highest / II / III/IV / III/IV / IV
Precautions you should take during construction:
- Isolate the HVAC system in the area where the work is being performed.
- Before construction begins, complete all critical barriers (sheetrock, plywood or plastic) to seal the area from non-construction areas or implement an anteroom connected to the work site, using a HEPA vacuum for vacuuming workers’ clothing before exit.
- Maintain negative air pressure within the work site, utilizing HEPA-equipped air filtration units.
- Contain construction waste before transport, which should be done using tightly covered containers.
- Cover transport receptacles or carts using tape unless there is a solid lid.
Upon completion:
- Don’t remove barriers from the work area until the safety and infection control departments inspect the completed project.
- Remove barrier materials carefully to minimize spreading dirt and debris.
- Vacuum the work area with HEPA-filtered vacuums.
- Wet mop work area surfaces with disinfectant.
- Return ventilation to the areas where the work has been performed.
- Have environmental services thoroughly clean the area.
3. Digitizing your ORs
You’ve decided to enter the digital age and put computer stations in the ORs — enhancing and easing record-keeping and information transfer. Even small-scale, short-duration activities like installing computer cabling are cause for special precautions.
The OR is a step up from the endoscopy procedure room in our last example, and the patients hosted in your outpatient ORs are considered high-risk. Although it may appear that putting in the computer cables is likely only to cause minimal dust — and therefore considered type B construction — you need to carefully consider the amount of dust production and whether this activity may actually be type C.
Precautions you should take during construction:
- Minimal dust will be generated if no drilling is required. However, even if only minor drilling is needed and dustless drills are used to minimize dispersal, the area must be separated from clean and sterile corridors — even if the project’s length will be brief. Pre-framed plastic barriers sealed into place can separate the work area from the clean area.
- Block off and seal air vents.
- Place a dust mat at the entrance and exit of the work area.
Upon completion:
- Wipe work surfaces with disinfectant.
- Contain construction waste before transport using tightly covered containers.
- Wet mop and vacuum with HEPA-filtered vacuum before leaving work area.
- Remove the barriers and re-clean.
Tips for a Successful Infection Control Risk Assessment
Five steps for successfully planning and following through on your infection control risk assessment:
- Say multidisciplinary and mean it. Planning for new construction or major renovation requires early consultation and collaboration among infection control professionals, epidemiologists, architects, engineers, risk and safety professionals, and environmental care managers to ensure that you build infection prevention into the process. I’ve seen ICRA committees that didn’t include the OR manager, who should be a mandatory member. At the very least, members should include the facility manager, a manager from the construction company, the architect and someone from your infection control department.
- Take advantage of the resources. The American Institute of Architects’ guidelines and recommendations from the CDC and JCAHO are now aligned, since the ICRA is based on the same science. You won’t be going in circles because of conflicting information. The background literature is easily found in the CDC’s “Guidelines for Environmental Infection Control,” so there’s no excuse to not brief yourself.
- Put your heads together. When the ICRA committee meets, it’s critical that you come up with clear statements about the precautions that you’ll communicate to staff — and how you will go about it. To do that, you need to anticipate problems. Map out the traffic flow in your facility. Are you going to have one OR under construction that’s near an active OR? How will construction workers be directed to ensure they don’t bring dirt in and out (on their bodies and supplies)? When do healthcare and construction workers need to be protected? How will you inform them of what to do and were to go for eating, toilet areas and break time? Will you follow up memos with signage? How will you mark hazardous areas? When will you do especially noisy activities or those that cause vibrations? Is it possible to break those activities up? By answering these questions in advance, you’ll be able to come up with policies for facility staff to follow.
- Put a stop to worrying before it starts. Bring in your most vocal and passionate surgeon to communicate to other surgeons that they need not worry about patients being compromised. Same goes for your director of nursing with nurses. This effort to put a surgeon and nurse on your ICRA committee may pay off enormously in terms of support for project plans, and can be reassuring for families as well.
- Know how you’ll handle problems. Broker an agreement between construction workers and clinical staff so that they understand the process of communication if something goes wrong. Whom do you call if you lose power or if a worker is tracking dirt through the facility? Most construction companies have a safety officer who’ll act as a neutral party to address problems, but it takes regular ICRA team meetings and communication to resolve problems throughout the project.
4. Inspecting ceiling tiles in central sterile
You should be monitoring areas including tiles for stains or signs of leaks. Visual checks for stains may be clues that mold or fungus is taking root, and serious problems may be prevented if caught in time. Even though this activity is considered type A, the location in this example is the key.
Central sterile supply needs to be maintained as clean as possible, or you could end up compromising all your patients with contaminated materials. Despite the minor nature of the activity, central sterile is considered a high-risk area, and you should err on the side of caution by engaging in stringent class IV precautions.
Because a visible stain may actually represent a very large area of mold above the ceiling, the very act of pushing the tile up could disturb the mold, disperse it into the area and cause major contamination — at which point it’s beyond control. This should be considered Class IV under such a circumstance.
Precautions you should take during construction:
If a special containment cube is sealed up tight against the ceiling with a HEPA machine connected to it, you have essentially created the proper barrier and negative pressure needed to contain the contamination. Workers entering the ceiling should be properly protected.
Any tiles removed should be carefully bagged and the area cleaned.
Upon completion:
- Carefully remove barrier material.
- Put waste in tightly covered containers before transport.
- Cover carts for transporting waste.
- Vacuum with HEPA-filtered vacuum before leaving work area.
- Wet mop with disinfectant.
Ensure Your Infection Control Measures Are Working
You can call for and implement all the infection control measures your ICRA requires, but if you don’t monitor compliance, you won’t know if the measures are working — or if clinical and construction staff are following them.
Here at St. JohnHospital & MedicalCenter, a 607-bed tertiary care teaching facility in Detroit, we noted that, despite our ICRA-related efforts, there were frequent breaches of dust-control measures. Renovation and new construction are routine events at SJH&MC, so infection control staff devised a three-step system to apply to any project:
- Infection control construction permit. The ICCP lists key personnel contact information and a description of dust control methods; one is displayed at the entrance of each Class III or IV project.
- Checklist for daily monitoring. We review each construction site daily to assess integrity of barriers and adherence to control measures discussed during planning. Using the checklist as a guide, we document whether each construction site passed or failed our inspection on the corrective action log. Compliance is an all-or-none assessment. Non-compliance is handled at the site, or depending on the degree of non-compliance, we may conduct more extensive follow-up with project managers, construction superintendents and hospital administration.
- Educational module. The infection control department trains contractors via a formal orientation program and on-site education. A construction risk assessment and planning module was created on the hospital intranet for easy access. The module included the ICRA, ICCP, daily monitoring checklist, educational materials, IC contact information and a link to the IC homepage.
— Janice E. Rey, MT (ASCP), CIC
Ms. Rey () is an infection control practitioner at St. JohnHospital and MedicalCenter in Detroit. She reported the results of her hospital’s monitoring and compliance program at the 2005 APIC annual meeting in Baltimore.
Apply the matrix
Ultimately, the goal is to keep dust and dirt inside the work area and keep the patient or support area clean. This isn’t simply a matter of paper or plastic barriers — the precautions you take must be strong enough to hold up for the work and length of time needed to complete the project.
As you can see from examples three and four, the matrix is just a starting point of how to assess the risk for patients — not everything fits the matrix perfectly. The key is empirically determining the extent of your actions. Gauge the risk of infectious agents’ being released, and take steps from there to contain dust and debris so as not to expose patients and clean areas to them.
Ms. Bartley () is the vice president of ECSI and a clinical consultant for the Premier Safety Institute.
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