1. Infection Control during Hospital Renovation and Construction Policies, Procedures and Strategies To Protect Patients and Workers Laborers’ Health and Safety Fund of North America

2. Infection Control during Hospital Renovation and Construction Course Objectives: Provide background on hospital infections Describe opportunistic infections Discuss elevated risks due to construction Discuss control measures to reduce risks  Work practices, barriers and ventilation Show how to identify and respond to mold Describe measures to protect workers Discuss the responsibilities of the hospital’s ICRA staff 2

3. Hospital Nosocomial Infections Opportunistic Cause about 99,000 deaths each year  5% of these infections are due to hospital construction and maintenance activities 3

4. Opportunistic Infections Uncommon in healthy people Caused by a medical condition that limits the ability of the patient’s immune system to fight back 4

5. Hospital Patients are Likely Immunocompromised Hospital patients are usually ill, weak or elderly Some hospital patients may be taking drugs that lower their immune system 5

6. Microbic Pathogens Microrganisms Associated with Airborne Hospital Infections FungiBacteriaViruses Numerous Reports in Heath-Care Facilities AspergillusTuberculosisMeasles virus Mucorales (Rhizpous) Varicella-zoster virus Atypical, Occasional Reports AcremoniumAcinetobacterSmallpox FusariumBacillusInfluenza PseudoallescheriaBrucellaAdenovirus SporothrixStraphylococcusNorwalk-like Virus ScedosporiumStreptococcus 6

7. Mold and Fungal Pathogens Aspergillosis and other fungal microbes are ubiquitous Found naturally in soil, old leaves, compost, carcasses, plaster, drywall, ceiling tiles, dust and concrete powder Proliferate in wet conditions Some fungi can also be airborne 7

8. How Do Fungi and Molds Affect People? Among people sensitive to molds, exposure can cause:  Nasal stuffiness  Eye irritation  Wheezing  Skin irritation 8

9. How Do Fungi and Molds Affect People? People with serious allergies to molds may have more severe reactions:  Fever  Shortness of breath The immunocompromised and people with chronic lung illnesses may develop deadly pulmonary mold infections 9

10. Fungi Vehicle – DUST! Easily disturbed and sent airborne during indoor and outdoor construction Carried on dusty clothes and shoes Spread by dusty tools and tool carts Damp conditions help fungi grow 10

11. The Concern Indoor and outdoor construction activities produce airborne dust and debris that can carry microorganisms into patient areas 11

12. Hospitals Deaths Associated with Construction Activities OrganismPlaceActivity AspergillusAcute LeukemiaFireproofing insulation Bone Marrow Transplant (BMT)Road construction, window air conditioner NeonatalFalse ceiling Intensive care unit (ICU)ICU renovation, elevators Cancer-melanomaTiles, air filters, cell incubators GeneralCarpeting Chronic obstructive pulmonary disease Air filters PenicillinBMTRotted wood cabinet Operating roomVent duct, fiberglass insulation RhizopusBMTConstruction ScedosporiumHematologyConstruction LegionellaImmunosuppressedSoil, water Adults, employeesCooling towers PseudomasICUPotable water StreptococcusMaternityShower heads MycobateriumEndoscopyPotable water Stachybotrys atraInfantsWater damaged homes AcremoniumAmbulatory surgeryVent system humidifier 12

13. General Patient Welfare – Noise-Induced Stress Sleep disruption Patient falls Confusion Decreased oxygen saturation Decreased rates of wound healing Elevated blood pressure levels Higher incidences of re-hospitalization Increased medication and restraint use 13

14. Noise Controls Buy/rent quieter equipment Find quieter alternative work methods Use damping materials, silencers and mufflers Keep noisy machines away from sensitive areas Keep machinery under regular maintenance Keep machinery covers and panels closed and well fitted Make sure bolts and fasteners are tightened to avoid rattles Line barriers with sound absorbing material 14

15. Noise-Induced Stress Noise-induced stress is contagious among patients and hospital staff, making everyone unhappy Its important that contractors and workers keep the volume down 15

16. Review: Exercises and Video Exercises Describe nosocomial infections Discuss why they are hazardous to the hospital patients Describe opportunistic pathogens and how they are everywhere but not a problem to the healthy Discuss the role of dust in the spread of infections Video Site Specific video or Building on the Plan – Infection Prevention for Construction Workers (DVD) 16

17. Infection Control and Risk Assessment Everyone is responsible for preventing the spread of diseases The hospital’s ICRA staff is charged with risk assessment and developing a plan for infection control from project conception to completion 17

18. Infection Control and Risk Assessment The Hospital’s ICRA staff should:  Coordinate demolition, construction and renovation projects  Educate both the construction team and healthcare staff of immunocompromised patient care areas 18

19. Infection Control and Risk Assessment ICRA staff is responsible for relocating patients based on:  Their immune status  The scope of the project  The potential for generation of dust or water aerosols and what methods are being used to control these aerosols 19

20. Infection Control and Risk Assessment ICRA staff should work with construction crews to:  Designate entrances, corridors and elevators for worker use  Provide essential services (e.g., toilet facilities) and convenience services (e.g., vending machines) for worker use 20

21. Worker Risk Assessment The ICRA staff must determine potential hazards to workers, for example:  Project’s proximity to TB patients  Exposure to duct dust  Sudden outbreaks of an unidentifiable illnesses Determine worker protection measures:  Vaccinations  Respirators  Hazard training 21

22. Infection Control Risk Assessment Types of Work TYPE A Inspection and Non-Invasive Activities Includes, but is not limited to:  Removal of ceiling tiles for visual inspection limited to one tile per 50 square feet painting (but not sanding)  Wallcovering, electrical trim work, minor plumbing and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection TYPE B Small scale, short-duration activities which create minimal dust Includes, but is not limited to:  Installation of telephone and computer cabling  Access to chase spaces  Cutting of walls or ceiling s where dust migration can be controlled TYPE C Work that generates a moderate to high level of dust or requires demolition or removal of fixed building components or assemblies Includes, but is not limited to:  Sanding of walls for painting or wall covering removal of floor coverings, ceiling tiles and casework  New wall construction  Minor duct work or electrical work above ceilings  Major cabling activities  Any activity which cannot be completed within a single work shift TYPE D Major demolition and construction projects Includes, but is not limited to:  Activities which require consecutive work shifts  Requires heavy demolition or removal of complete cabling systems  New construction 22

23. Infection Control Risk Assessment Patient Risk Categories Low RiskMedium RiskHigh RiskHighest Risk Office areasCardiology Echocardiography Endoscopy Nuclear medicine Physical therapy Radiology/MRI Respiratory therapy CCU Emergency room Labor and delivery Laboratories (specimen) Newborn nursery Outpatient surgery Pediatrics Pharmacy Post anesthesia care unit Surgical units Any area caring for immunocompromised patients Burn unit Cardiac cath lab Central sterile supply Intensive care units Medical unit Negative pressure isolation rooms Oncology Operating rooms including c-section rooms 23

24. Infection Control Risk Assessment Match the type of work category to the patient risk group to determine the precaution class Type AType BType CType D Low Risk Group III III/IV Medium Risk Group III IV High Risk Group IIIIII/IVIV Highest Risk Group IIIII/IV IV 24

25. Required Infection Control Precautions by Class partial listing During Construction ProjectUpon Completion Class I 1. Execute work by methods to minimize raising dust from construction operations. 2. Immediately replace ceiling tiles displaced for visual inspection. Class II 1. Provide active means to prevent airborne dust from dispersing into atmosphere. 2. Water mist work surfaces to control dust while cutting. 3. Seal unused doors with duct tape. 4. Block off and seal air vents. 5. Place dust mat at entrance and exit of work area. 6. Remove or isolate HVAC system in areas where work is being performed. 1. Wipe work surfaces with disinfectant. 2. Contain construction waste before transport in tightly covered containers. 3. Wet mop and/or vacuum with HEPA-filtered vacuum before leaving work area. 4. Remove isolation of HVAC system in areas where work is being performed. Class III 1. Remove or isolate HVAC system in area where work is being done to prevent contamination of duct system. 2. Use critical barriers (i.e. sheetrock, plywood, plastic) to seal areas from non-work areas or implement control a cube method (i.e., a cart with a plastic covering and a sealed connection to the work site with a HEPA vacuum to clean the area prior to exit from the area) before construction begins. 3. Maintain negative air pressure within the worksite using HEPA-equipped air filtration units. 4. Contain construction waste before transport in tightly covered containers. 5. Cover transport receptacles or carts, if the cover is not solid the cover must be taped closed. 1. Do not remove barriers from work area s until the completed project is inspected by the Infection Control Department and thoroughly cleaned by the Environmental Services Department. 2. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction. 3. Vacuum work area with HEPA-filtered vacuums. 4. Wet mop area with disinfectant. 5. Remove isolation of HVAC system in areas where work is being performed. Class IV 1. Isolate HVAC systems in areas where work is being done to prevent contamination of duct system. 2. Use critical barriers (i.e. sheetrock, plywood, plastic) to seal areas from non-work areas or implement control a cube method (i.e., a cart with a plastic covering and a sealed connection to the work site with a HEPA vacuum to clean the area prior to exit from the area) before construction begins. 3. Maintain negative air pressure within work site using HEPA-equipped air filtration units. 4. Seal holes, pipes, conduits and punctures appropriately. 1. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction. 2. Contain construction waste before transport in tightly covered containers. 3. Cover transport receptacles or carts, if the cover is not solid the cover must be taped closed. 4. Vacuum work area with HEPA-filtered vacuums. 5. Wet mop area with disinfectant. 6. Remove isolation of HVAC system in areas where work is being performed. 25

26. Contamination Control Safe Work Practices Daily Safety Briefings Local Exhaust/Vacuuming Debris Removal Traffic Control Clean Clothing and Tools Worksite Cleaning Monitoring Engineering Controls Ventilation and Environmental Control  Creating Negative Pressure Environments Barrier Systems  Dust and Debris Control Contamination Control 26

27. Daily Pre-Job Safety Briefings Conduct daily pre-job safety briefings to clearly specify responsibilities and expectations Conduct weekly toolbox talks to discuss work hazards 27

28. Dust Control and Vacuuming Drilling, cutting, grinding and other sources of vibration have the potential to create and dislodge dust collected above suspended or false ceilings Use equipment with local exhaust Vacuum affected areas before re-occupancy 28

29. Debris Removal Debris must be removed in carts with tightly fitted covers, using designated traffic routes Restrict use of elevators and transport during the lowest periods of activity Debris must be removed daily 29

30. Debris Removal If chutes are used to direct debris outside, HEPA-filtered negative air machines must be used Chute openings should be sealed when not in use 30

31. Debris Removal Filters should be bagged and sealed before transport out of the construction area Exit paths should be free of debris Walk-off mats should be used to minimize tracking of heavy dirt and dust from construction areas 31

32. Traffic Control Designated entry and exit procedures must be defined Designated elevators should be restricted to scheduled times Only authorized personnel should be allowed to enter construction zones 32

33. Worksite & Traffic Control Signage should direct pedestrian traffic away from the construction area and materials Storage areas should be designated for construction use only and away from patient traffic Access should be limited to workers with photo ID badges Permits should be issued for restricted work areas 33

34. Clean Clothing and Tools Construction worker clothing should be free of loose soil and debris before leaving construction areas If protective apparel is not removed, a HEPA- filtered vacuum should be used to remove dust from clothing before leaving construction areas 34

35. Clean Clothing and Tools Workers entering sensitive areas should be provided with disposable head/shoe coverings and jump suits Tools and equipment should be damp wiped before entry to and exit from work areas 35

36. Worksite Cleaning Construction areas must be wiped down, swept, mopped or HEPA-vacuumed daily or more frequently to minimize dust Adjacent areas must be damp mopped daily or more frequently as needed 36

37. Monitoring Project infection control staff should regularly:  Inspect all work areas  Evaluate inspection results  Follow-up to ensure that any hazards found are corrected 37

38. Monitoring Checklists are very helpful and important, but simple visual cues are also instructive:  Accumulation of visible dust  Footprints  Opened doors/windows  Presence of insects and flies  Wet ceiling tiles  Workers in patient areas 38

39. Monitoring Adjacent Areas Barriers around construction should protect in-use patient care areas Patient doors adjacent to construction areas must be kept closed with appropriate traffic control methods employed 39

40. Exercises Put students into groups to develop a pre-job safety briefing, a toolbox talk or dust control briefing Potential Topics:  Debris removal  Workplace cleaning  Traffic control strategies  Tool and clothing cleaning Exercise: Review checklist and additional missing metrics 40

41. Video Building on the Plan: Infection Prevention for Construction Personnel 41

42. Ventilation and Environmental Control Creating Negative Pressure Areas 42

43. Creating Negative Pressure Areas The air within constructions area must be negative with respect to surrounding areas (i.e., the airflow should be into the construction area) 43

44. Creating Negative Pressure Areas Construction area air exhaust handling device must be directed outside with no recirculation 44

45. Ventilation Requirements Measures Standards Pressure Differentials>-2.5Pa (0.01” water gauge) Air Changes per Hour≥ 12 (for renovation or construction) Filtration EfficiencySupply: 90%; Return: 99.97%@ 0.3µm (HEPA) Room Air Flow Direction Into the room Ideal Pressure Differential >-2.5 Pa (0.01” water gauge) 45

46. Air Handling Unit Capacity ACH = 12 Volume = room L x W x H cubic feet per minute (cfm) = volume x ACH / 60 Refer to owner’s manual for unit’s capacity in cfm What size unit is needed for this room? Perform additional exercises 46

47. Portable Pressure Differential Sensors Portable measuring instruments Compact, durable, lightweight battery- operated, backlit and designed for one- handed operation 47

48. Barrier Systems: Dust and Debris Control Small, short-term projects with little dust may use fire-rated plastic sheeting Sealed at full ceiling height with at least two-foot overlapping flaps for access to entry 48

49. Barrier Systems: Dust and Debris Control Any project that produces moderate to high levels of dust requires rigid, dust- proof and fire-rated barrier walls (e.g., drywall) with caulked seams for a tight seal 49

50. Barrier Systems: Dust and Debris Control Large, dusty projects need an entry vestibule for clothing changes and tool storage The entry area should have gasketed doorframes; tight seals must be maintained at the full perimeter of walls and wall penetrations 50

51. Barrier Systems: Dust and Debris Control An interim plastic dust barrier may be required to protect the area while a rigid impervious barrier is constructed 51

52. Environmental Containment Rooms ECU 128 Video Ready Wall Video 52

53. Exercises Have students:  Explain why negative pressure is important  Explain why different levels of barrier protection are needed  Come up with measures to determine whether a room is in negative pressure when a sensor is not available Play the Building on the Plan – Infection Prevention for Construction Workers DVD 53

54. Exercise: Hands-On Air Handling and Containment Units Show students:  A portable air scrubber  How to operate an air scrubber and how to dismantle it for service  Grill masks and sticky mats and demonstrate their use  How to poly criticals 54

55. Exercise: Building Containment Units Have students:  Construct a negative air containment system using 4- and 6-ml polyethylene and duct tape  Set up negative air filtration units and duct them to the outside of the containment  Set up portable and zip wall containment areas (time and materials permitting) 55

56. Conclusion and Review Nosocomial infections from construction activities pose significant hazards to immunocompromised patients Approximately 75% of hospital construction involves remolding, upgrading or expanding existing structures It is important that hospitals and construction contractors comply with infection control procedures 56