Hospital construction: stirring up trouble

Engineered Systems, July, 2007 by Judene Bartley

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Whether the project is a new facility or a retrofit--and whether the project involves ceiling tiles in an OR or simply giving a nearby room a coat of paint or new computers--risks arise for infection. The 2007 Infection Control Risk Assessment provides critical guidance for precautions to take, depending on the scope of work, to protect a hospital's delicate procedures and especially vulnerable populations.

Patients can leave the hospital sicker than they arrived if construction crews don't use established precautions to control infection during new construction or major renovations. How can hospital-acquired infections (HAI) and the estimated 5,000 deaths associated with construction-related infections each year be prevented?

The Centers for Disease Control (CDC) recommends comprehensive preventive actions. (1) The recommendations are strongly enforced in health care construction standards published by the American Institute of Architects (AIA) to ensure construction-related infections don't occur. The AIA's 2006 Guideline for Design and Construction of Health Care Facilities (2) mandates an "infection control risk assessment" or ICRA before beginning any new construction or major renovation project. Federal enforcement (CMS) or accrediting agencies (Joint Commission) require an ICRA if the health care organization receives Medicare/Medicaid funding.

So, what is an ICRA? Who is responsible for it? How is it done? Which areas of a health care facility are more susceptible to HAI's and need to be most vigilant during construction*

THE WHAT

An ICRA might be compared to an environmental impact statement. That is, what is the impact or risk of infectious agents released from the dust and dirt stirred up during construction activity on vulnerable patients in health care facilities? Can dust and dirt carry bacteria and mold into patient areas during minor or major construction and lead to serious infection?

The answer is a resounding "yes." A large body of published peer-reviewed evidence has demonstrated over several decades that indeed, patients can, and have been infected with numerous infectious agents leading to illness and death.

The infections were the result of inadvertent exposure to fungi or mold released for example, from contaminated ceiling tiles, fireproofing insulation, contaminated HVAC systems, rotted wood cabinets, and contaminated equipment. (1, 3) The ICRA as described in the AIA guidelines requires that before any project begins there is planning that considers a) the degree of dust and dirt that may be generated in or near the facility; and b) the degree of susceptibility for infection in the patient population near the construction site.

That is, are they fairly healthy patients on medical units hospitalized for testing, or are they bone marrow transplant (BMT) patients in special protected units, or in operating rooms where their sterile tissue will be exposed to the air? Determining the potential risk of transmission of various infectious agents in the facility permits the facility to adopt preventive or control measures throughout all phases of construction or renovation.

WHO IS RESPONSIBLE?

Clearly the ICRA needs to be started at the earliest possible stage of new hospital construction or renovation. The Guidelines describe who is involved, elements of the ICRA that must be considered and clarifies accountability. The owners are ultimately responsible, but the ICRA process must translate into workable documentation for the owner, the architects and contractors (internal and external).

Although the ICRA must begin during the planning, design and construction/renovation stages--it continues as a process throughout the project right through commissioning and hand-off to the owner. A multidisciplinary panel of experts on infectious diseases, ventilation, engineering, facility design and construction, epidemiology, and safety performs the assessment and provides various types of documentation regarding the assessment. It is frequently part of bid documents but commonly includes a permit posted on the site stating the level of risk that was determined by the ICRA and the precautions to take during construction.

The ICRA also complements federal OSHA or state occupational health and safety requirements for worker safety. The process reduces time and the cost of rework because issues are addressed with state review agencies before the blueprint approval stage. All health care organizations--not just hospitals--have to consider issues ranging from air handling to power management to traffic flow and include the following:

* The impact of disruptions of essential services on patients and staff

* Patient placement or relocation

* Placement of effective barriers to protect patients from airborne contaminants such as Aspergillus species

* Air handling and ventilation needs for surgical services, airborne infection isolation (AII), and protective environment (PE), laboratories, local exhaust system for hazardous agents and other special areas