Copyright © Forensic Analytical Consulting Services, Inc. Current Trends in Managing Patient & Staff Health Risks during Healthcare Construction Projects Presented by: John Martinelli Director, Healthcare Services March 5, CSHRM 2015 Annual Conference

Copyright © Forensic Analytical Consulting Services, Inc. Session Objectives Upon completion of this session you will be able to: List regulations and guidance documents that call for proactive Infection Control/Pre-Construction Risk Assessments (ICRA/PCRA) List the elements to be considered when conducting a PCRA and the key participants that should be included in the multi- disciplinary risk assessment team List at least two common risk mitigation measures used to manage risks to the environment of care during construction, methods commonly used to monitor the effectiveness of those measures and the benefits and potential limitations of each 2

Copyright © Forensic Analytical Consulting Services, Inc. 3 The Joint Commission Environment of Care Standard Requirements EC EP 1. When planning for new, altered or renovated spaces the hospital uses design criteria, state rules and regulations, AIA Guidelines (2001), other reputable standards or guidelines air quality, infection control, utility requirements, noise, vibration and other hazards that affect care, treatment and services EP 2. The hospital conducts preconstruction risk assessments for air quality, infection control, utility requirements, noise, vibration and other hazards that affect care, treatment and services EP3. The hospital takes action based on its assessment to minimize risks during demolition, construction or renovation

Copyright © Forensic Analytical Consulting Services, Inc. 4 Updated PCRA Forms

Copyright © Forensic Analytical Consulting Services, Inc. 5 Joint Commission 2011

Copyright © Forensic Analytical Consulting Services, Inc. 6 Joint Commission 2010 FGI 2010 Guidelines PCRA (ICRA) Team Required Infection Prevention Direct Patient Care - clinical, from impacted department(s) Facility Knowledge – HVAC, MEP Scope of Project Other (s) as dictated by scope PCRA done (started) during planning, continued through commissioning Owner or 3 rd party conducts monitoring of risk mitigation measures for the duration

Copyright © Forensic Analytical Consulting Services, Inc. Multi-Disciplinary Team Approach Multiple experts to: –Help identify risks –Assign risk mitigation measures –Determine methods to evaluate effectiveness Which of the experts knows about: –Infection Control? –The buildings MEP systems? –The scope of the project? –Mold? –Noise? –What does Air Quality mean? –How to test, when to test? –How to interpret test data? –Generally no single person knows all of the issues 7

Copyright © Forensic Analytical Consulting Services, Inc. Multi-Disciplinary Team Approach Expert Infection Prevention Department Reps (Clinical) Facility Engineer Project Manager GC/CM Architect Specialty Trades EH&S Industrial Hygienist Issue Air Quality Infection Control Noise Vibration Utilities Other hazards Emergency Preparedness Documentation Testing Communications 8

Copyright © Forensic Analytical Consulting Services, Inc. Roles and Responsibilities Owner –Responsible to conduct the PCRA Infection Control Professional (aka Infection Prevention) –EC Infection Control –Identifies (or confirms) the risk group(s) impacted by the project –Typically a clinical professional, on hospital staff, may be a manager –May be the required signatory for the permit –Varying degrees of construction project expertise 9

Copyright © Forensic Analytical Consulting Services, Inc. Roles and Responsibilities Environmental Health and Safety Professional –EC , Air Quality, Other hazards, perhaps IC –Review the PCRA, procedures and monitoring methods –May understand containment, engineering controls, work practices, etc. –May be knowledgeable on testing methods and interpretation of data –Often participates in Environmental Tours –May be aware of other hazards (chemicals, biologicals) –May provide information on in-house policies, documentation requirements –May be tasked with assigning risk groups –May have access to asbestos inspection reports 10

Copyright © Forensic Analytical Consulting Services, Inc Roles and Responsibilities Facility Manager/Building Engineer –EC , Utilities; LS , Life Safety Systems –Excellent source for utilities related issues –Can provide information on HVAC system, medical gas line locations, confined spaces, above ceiling access requirements, water features, shut offs, etc. –Can help determine where vibration impact will travel –May provide input on in-house policies for HVAC and plumbing re- commissioning (testing, flushing, treatment) –Sometimes knows the scope of work –May also have access to asbestos inspection reports –Often difficult to get to a meeting

Copyright © Forensic Analytical Consulting Services, Inc Roles and Responsibilities Construction Project Manager –EC all elements; LS –Knows the scope and phasing –May know the methods of the subcontractors –May understand the EC requirements –May understand testing methods and data interpretation –May have contractual requirements to implement (and monitor) risk mitigation measures –May have forms that can be used to document conditions or findings (meeting minutes, logs)

Copyright © Forensic Analytical Consulting Services, Inc. Roles and Responsibilities Architects/Design Engineers –EC all elements; LS –Know the scope and phasing Water systems, HVAC shut downs or tie-ins –May have knowledge of impacted departments well in advance –May provide advance warning for impact on utilities, need for above ceiling inspections –May include testing in specifications without clear understanding of impact (cost, timing, data interpretation/acceptance criteria) 13

Copyright © Forensic Analytical Consulting Services, Inc. Roles and Responsibilities Subcontractors –EC Noise, Vibration, AQ –Install containment and engineering controls –Will know chemicals and methods to be used (noise and vibration issues) –Schedule and duration 3 people, 3 days or 4 people, 2 long shifts, etc. –Need to know where to exhaust, how to enter and exit the work area Sometimes the first time the superintendant sees the work plan is the day s/he arrives on the job 14

Copyright © Forensic Analytical Consulting Services, Inc. Roles and Responsibilities Medical Staff/Clinicians –EC Infection Control, Noise –Assign risk groups, provide important input on the impact of noise, vibration or patient relocation –Department Managers have department specific information AIIR’s, hand washing locations, schedules for procedures) –Can provide information, support and education on infection risks based on department/history –May have input on analytical/lab methods Desired data, level of analyses, air, surface, water 15

Copyright © Forensic Analytical Consulting Services, Inc Roles and Responsibilities Environmental Services (EVS) –EC IC, other –Most likely will conduct pre-occupancy (terminal) cleaning and need to know where work impacted the environment –Can provide information on preferred (or prohibited) cleaning agents –Know where sharps and biohazard waste containers are located and should be the ones removing them prior to construction

Copyright © Forensic Analytical Consulting Services, Inc Roles and Responsibilities Industrial Hygienists –EC all elements; LS –Understand construction, building functions, regulatory requirements, environmental sampling. –Provide expert level consultation on applicability, benefits and limitations of testing methods and data interpretation. –Can provide third support for the owner and avoid conflict of interest issues –Can provide independent communication support Town hall meetings, PIO –Help build confidence between the construction side and the clinical side

Copyright © Forensic Analytical Consulting Services, Inc Noise Risks Volume may not be the only noise-related issue Beyond just volume risks can include: Interference with ability to hear people or devices Power tools or other construction and/or demolition activities may generate sounds similar to audible alarms Some people just talk softly Agitation of patients, family members Evaluate impact to patients and staff

Copyright © Forensic Analytical Consulting Services, Inc. Risks and Mitigation Measures Noise and Vibration Who can identify the sources of noise and vibration? - Project Manager, General Contractor, Subcontractors, others? Who can identify the noise risks to the environment and/or patients? others? - Clinical staff, Biomedical Engineering, others? 19

Copyright © Forensic Analytical Consulting Services, Inc Risks and Mitigation Measures AIR QUALITY/INFECTION CONTROL

Copyright © Forensic Analytical Consulting Services, Inc Risks and Mitigation Measures Air Quality Who will evaluate the impact on the Environment? –Clinical staff Procedure schedules, path of travel, special requirements (gowning, hand hygiene) Patient risk groups –Plant Ops Air balances, HVAC component and locations, Med gas, steam –Subcontractors Locations of containment, controls and exhaust locations –EH&S, Industrial Hygienists Testing methods Environmental Monitoring, Data interpretation

Copyright © Forensic Analytical Consulting Services, Inc. Benefits of the Multi-Disciplinary Team Approach Meets the recommendations set forth in CDC and AIA/FGI Guidelines (referenced by EC standard) Includes multiple experts to ensure risks are adequately considered and appropriately managed Builds confidence in the team –Helps avoid complaints from impacted departments –Helps avoid clinical disruptions –Helps avoid project disruptions –Minimize impact on the Environment of Care –Prevents HAIs related to construction projects 22

Copyright © Forensic Analytical Consulting Services, Inc Case Study 1 – OR Suite Flooring Replacement Risk – Dust (Aspergillus)

Copyright © Forensic Analytical Consulting Services, Inc. Case Study 1- Project Goals Phased removal of flooring and some walls in ORs while others remain functional Control impact of dust, noise and vibrations during project activities Maintain critical air balances for the duration of the project 24

Copyright © Forensic Analytical Consulting Services, Inc Identifying and Managing Risk Temporary/localized pressure changes impact sensitive design requirements –Engineering? Poorly controlled dust from activities has adverse impact on patient safety and operations –Infection Prevention, EVS, EH&S, Hygienist Perceptions and communications –Who will be impacted –Who will communicate, when and how

Copyright © Forensic Analytical Consulting Services, Inc Considerations What engineering controls, where, and when Phases?, Exhaust locations?, Ante rooms? Pressure differentials, air changes, path of travel Establish monitoring methods, criteria, documentation, and communications Testing schedules Include indoor control locations when possible Team in agreement prior to mobilization

Copyright © Forensic Analytical Consulting Services, Inc. Case Study 1- Events and Actions Code Blue announced via overhead paging system (12:45am), Project already in demo phase Pressure differential and particle counting data collected immediately after hearing the announcement Data analysis showed acceptable criteria at all data points Construction crew notified of code call 27

Copyright © Forensic Analytical Consulting Services, Inc Patient Transported passed Work Area Entrance (~1:20am)

Copyright © Forensic Analytical Consulting Services, Inc Patient in Room

Copyright © Forensic Analytical Consulting Services, Inc. Case Study 1 - Events and Actions Pressure differential and particle counting data collected immediately after patient is taken passed the work area Data collected again at patient OR threshold after patient was in the room Data analysis showed acceptable criteria at all data points 30

Copyright © Forensic Analytical Consulting Services, Inc. Case Study 1 Results Particle data showed hall outside contained work area had lower particle counts than indoor control locations and other hall locations in the suite Particle data showed path to, hall outside OR with patient remained in baseline ranges Pressure differential data confirmed that work area containment was under negative pressure Pressure differential data confirmed that OR where patient was treated remained under positive pressure in relation to the adjacent hall 31

Copyright © Forensic Analytical Consulting Services, Inc. Case Study 1 Summary Instruments and observations helped document that controls were effective but without data… –Do we have proof?, Are we defensible? Data collection offered real time analysis of indoor conditions (real time data is not always attainable) Events and data reported to Department Manager next morning (via attachments) Construction team congratulated for a job well done Confidence built between construction and clinical teams Data in hand to prove effectiveness of controls 32

Copyright © Forensic Analytical Consulting Services, Inc Case Study 2 – 4-phase Sterilizer Replacement Project Risk – Dust, Maintaining Pressures

Copyright © Forensic Analytical Consulting Services, Inc Special Work Practices and Controls (SPD Mgr, Contractor, Engineering) Install barriers (Locations and timing) –Gowned whenever passing through clean side spaces Establish negative pressure –Bridged Clean and Decon Sides (Engineering)2 zones become 3; HVAC registers impacted (Engineering) (EH&S / IH) –Onsite validation (EH&S / IH) Conduct work in controlled environment –Put on new clean gowns prior to walking back into clean side

Copyright © Forensic Analytical Consulting Services, Inc Other Work Practices Clean work area after work is completed –Damp wipe and HEPA vacuum –No cleaning chemicals planned for contractor cleaning (EVS / SPD Mgr) Phased barrier removal (Contractor / EH&S / IH) EVS terminal Cleaning (EVS / SPD Mgr) Significant coordination, timing and communication demands (full team)

Copyright © Forensic Analytical Consulting Services, Inc Exhausting to an Adjacent Space The plan pulled air from the work area and exhaust the highly filtered air into the wrap and pack side. –Allows to maintain negative pressure in the work area, ensure positive pressure in clean side

Copyright © Forensic Analytical Consulting Services, Inc Containment and Negative Pressure Phase 1 Decon side containment Wrap and Pack side containment

Copyright © Forensic Analytical Consulting Services, Inc Containment and Negative Pressure Phase 1 HEPA Filtered Neg Air Machines Decon Chamber/ Ante Room

Copyright © Forensic Analytical Consulting Services, Inc Phase 2 HEPA Filtered Neg Air Machines Decon Chamber/ Ante Room

Copyright © Forensic Analytical Consulting Services, Inc Phase 3 Decon Chamber/ Ante Room HEPA Filtered Neg Air Machines

Copyright © Forensic Analytical Consulting Services, Inc Phase 4 HEPA Filtered Neg Air Machines Decon Chamber/ Ante Room

Copyright © Forensic Analytical Consulting Services, Inc. Final Details Approved Path of Travel HVAC supply and return registers inside work areas –Proposed to be protected with filters (not sealed) Phone tree for emergencies Decon entry/exit locations 42

Copyright © Forensic Analytical Consulting Services, Inc. Case Study 2 Summary Baseline testing indentified problems with air balances before the project started Conditions during and after project were better than before Work flow and process modifications minimized production losses Department staff learned impact of propping open doors Improved confidence and communication between Construction Team, Infection Prevention and Clinical 43

Copyright © Forensic Analytical Consulting Services, Inc. Two Examples of Team Driven Success But … 44 “My time is valuable” $$$ Someone needs to lead/manage the team

Copyright © Forensic Analytical Consulting Services, Inc. Recap Regulations require Risk Assessment –Joint Commission EOC Standard Multi-disciplinary Team Approach –Best Practice, Effective Tools available to Guide the Team Common Mitigation Measures include –Containment with Negative Pressure –Controlled traffic patterns QUESTIONS? 45

Copyright © Forensic Analytical Consulting Services, Inc. Thank You John Martinelli Forensic Analytical Consulting Services, Inc. Right People, Right Perspective, Right Now