9/26/18 Infection Control Risk Assessment for Healthcare - - PDF document

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9/26/18 Infection Control Risk Assessment for Healthcare - - PDF document

9/26/18 Infection Control Risk Assessment for Healthcare Construction Laura Riley, PhD, CIH Randy Ennis, RN, CIC Industrial Hygienist Infection Prevention Coordinator Northside Hospital System Northside Hospital, Cherokee Elements of the


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9/26/18 1 Infection Control Risk Assessment for Healthcare Construction

Randy Ennis, RN, CIC Infection Prevention Coordinator Northside Hospital, Cherokee Laura Riley, PhD, CIH Industrial Hygienist Northside Hospital System

Elements of the Environment

  • Water
  • HVAC (Heating, Ventilation, Air Conditioning)
  • Environmental Cleaning
  • Waste Management
  • Construction and Renovation

All of these elements should be considered in your ICRA

Industrial Hygiene – OSHA Definition

“the science and art devoted to the anticipation, recognition, evaluation, and control of those environmental factors or stresses arising in or from the workplace, which may cause sickness, impaired health and well-being, or significant discomfort among workers or among the citizens of the community.”

S o u r c e : h t t p s :/ / w w w .o s h a t r a in .o r g / c o u r s e s / im a g e s / 7 5 0 / 7 5 0 _ in t r o _ s c ie n c e .jp g
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9/26/18 2

The Role of an IH

  • Use environmental monitoring and analytical methods to detect the

extent of worker/patient exposure

  • Employ engineering, work practice controls, and other methods to

control potential health hazards

  • Spot the conditions and help eliminate or control them through

appropriate measures

Recognizing & Controlling Hazards ICRA - Definition

  • Determines level of risk to patients and defines controls to reduce risk
  • 3 step method
  • Identify type of construction (nature & scope)
  • Identify patient or staff risk group
  • Determine the level of infection control classification
  • Defines the controls that are needed to reduce or eliminate risk to patients
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9/26/18 3

The Nuts and Bolts of the ICRA: What are we really doing?

  • Identifying conditions and factors related to the

transmission of infectious disease agents that can be released during construction

  • Designing and implementing contaminant

transmission controls

  • Continuously evaluating the effectiveness of

controls

FGI Guidelines 1.2-3.2 - ICRA

  • Impact of disrupting essential services to patients and

employees

  • The specific hazards and protection levels for each

designated area

  • Location of patients according to their susceptibility to

infection and the definition of risks to each

  • Impact of movement of debris, traffic flow, spill

cleanup, and testing and certification of installed systems

  • Assessment of external and internal construction

activities

  • Location of known hazards

The following shall be addressed:

Air contaminants generated during construction

  • Inorganic particles – Aerosols
  • General construction dusts (sheet rock, fiberglass, wood

dust, concrete dust)

  • Metal fumes and metal dusts
  • Vapors – adhesives, paints, solvents
  • Organic particles – Bioaerosols
  • Fungi – Aspergillus sp., Fusarium sp., Rhizopus sp.
  • Bacteria – water systems
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9/26/18 4

ICRA Players

  • Multidisciplinary ICRA Team
  • Infection Preventionist
  • Construction Coordinator
  • Facilities Operations
  • Safety & Security
  • Environmental Services
  • Construction Project Manager
  • Architect

ICRA Steps

ICRA: Identify Type and Group

GROUP TYPE

Step 1 Step 2

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9/26/18 5

Step 1: Identify the Type of Construction Activity (Type A-D)

TYPE A

Inspection and Non-Invasive Activities

Includes, but is not lim ited to:

  • rem oval of ceiling tiles for visual inspection only, e.g., lim ited to 1 tile per 50 square

feet

  • painting (but not sanding)
  • w all covering, electrical trim w ork, m inor plum bing, and activities w hich do not

generate dust or require cutting of w alls or access to ceilings other than for visual inspection TYPE B

Small scale, short duration activities which create minimal dust

Includes, but is not lim ited to:

  • installation of telephone and com puter cabling
  • access to chase spaces
  • cutting of w alls or ceiling w here dust m igration can be controlled

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies

Includes, but is not lim ited to:

  • sanding of w alls for painting or w all covering
  • rem oval of floor coverings, ceiling tiles and casew ork
  • new w all construction
  • m inor duct w ork or electrical w ork above ceilings
  • m ajor cabling activities
  • any activity w hich cannot be com pleted w ithin a single w ork shift

TYPE D

Major demolition and construction projects

Includes, but is not lim ited to:

  • activities w hich require consecutive w ork shifts
  • requires heavy dem olition or rem oval of a com plete cabling system
  • new construction

Step 2: Identify the Patient Risk Group

GROUP 1 LOW RISK GROUP 2 MEDIUM RISK GROUP 3 HIGH RISK GROUP 4 HIGHEST RISK Office areas Areas not engaged with patient care activities. All patient care units not covered under group 3 & 4 Outpatient Areas Public Corridors Cafeteria Dietary Emergency room Radiology/MRI Post-anesthesia care units Labor and delivery Newborn nurseries Nuclear medicine Admission/discharge area PT – hydro therapy tank areas Laboratories Perinatal High Risk Perinatal Unit Microbiology lab Cancer Center/Radiation Oncology Operating rooms; Sterile Processing Labor&delivery OR rooms Cardiac catheterization & angiography areas Dialysis Oncology Units Transplant Unit (BMTU) Anesthesia All endoscopy areas Pharmacy admixture All Oncology areas All Intensive Care Units Outpatient invasive procedure rooms Special Care Nursery Depts that care for BMTpatients Infusion Center Radiology Special Procedures Stem Cell Lab

We can’t see dust less than 50 um diameter

Aspergillus spore diameter about 2 microns

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9/26/18 6

Step 3: Matrix

  • Infection Control Plan: floor plan, IC procedures, waste removal,

cleaning/clothing requirements, tear-down procedures

Step 3 (cont): Description of Requirements

Class I During Construction Project: 1. Execute work by methods to minimize raising dust from construction operations. 2. Immediately replace any ceiling tile displaced for visual inspection. Upon Completion of Project

  • 1. Cleanup and disposal in accordance with defined procedures wiping surfaces within work site with

disinfectant at completion of job. Class II During Construction Project 1. Provide active means to prevent air-borne 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. Upon Completion of Project

  • 1. Wipe surfaces with disinfectant as needed to maintain cleanliness and at completion of job.
  • 2. Contain construction waste before transport in tightly covered containers with clean wheels.
  • 3. HEPA Vacuum all surfaces or wet mop periodically and at completion of project to reduce dust.
  • 4. Upon completion, restore HVAC system where work was performed.

Class III Date Initial During Construction Project 1. Remove or Isolate HVAC system and return in area where work is being done to prevent contamination of the duct system. 2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement use of dust mist containment unit before project begins. 3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units. – NAM exhausting into non-WA 4. Contain construction waste before transport in tightly covered containers with clean wheels. 5. Cover transport receptacles or carts. Tape covering unless solid lid. Upon Completion of Project:

  • 1. Do not remove barriers from work area until completed project is inspected by the Safety

Department and 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. Upon completion, restore HVAC system where work was performed.

Class IV Date Initial During Construction Project: 1. Isolate HVAC system in area where work is being done to prevent contamination of duct system. 2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement dust mist containment unit before construction begins. 3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units. 4. Seal holes, pipes, conduits, and punctures appropriately. 5. Construct anteroom and require all personnel to pass thru this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or wear bunny suits that are removed when leaving work site. 6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area. 7. Do not remove barriers from work area until completed project is inspected by the Safety Department and Infection Control Department and thoroughly cleaned by the Environmental Services Department. Upon Completion of Project:

  • 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. Tape covering unless solid lid.
  • 4. Vacuum work area with HEPA filtered vacuums.
  • 5. Wet mop area with disinfectant
  • 6. Upon completion, restore HVAC system where work was performed.

Class IV Date Initial During Construction Project: 1. Isolate HVAC system in area where work is being done to prevent contamination of duct system. 2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement dust mist containment unit before construction begins. 3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units. 4. Seal holes, pipes, conduits, and punctures appropriately. 5. Construct anteroom and require all personnel to pass thru this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or wear bunny suits that are removed when leaving work site. 6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area. 7. Do not remove barriers from work area until completed project is inspected by the Safety Department and Infection Control Department and thoroughly cleaned by the Environmental Services Department. Upon Completion of Project:

  • 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. Tape covering unless solid lid.
  • 4. Vacuum work area with HEPA filtered vacuums.
  • 5. Wet mop area with disinfectant
  • 6. Upon completion, restore HVAC system where work was performed.
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9/26/18 7

Interrupt Transmission Pathways

SOURCE PATHWAY PATIENT

HVAC Pressure Differentials

  • Negative
  • Anterooms
  • Airborne isolation rooms (AII)
  • Construction areas next to occupied

patient care areas

  • Decontam (dirty) rooms
  • Positive
  • ORs
  • Interventional procedure rooms
  • Protective anterooms
  • Bone marrow transplant units

Ventilation of the Construction Zone

  • Dedicated ventilation/exhaust system for

the construction area

  • Negative air (and validation)
  • -0.03” water in high risk areas (crit care, ED,

L&D, BMT/Onc, NICU, Surgery)

  • -0.01” water elsewhere
  • Locations of exhaust discharge, sealing of

existing air ducts

  • Ductwork should be kept capped/clean

during demo and dust-generating construction

Diffuser panel exhausting HEPA- quality air out of the space

Visual Validation

BE WARY OF TYING IN TO EXISTING EXHAUST DUCTS!

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9/26/18 8

Negative air machine (NAM) inside construction space Construction air is taken in through a HEPA filter HEPA-quality air is exhausted

  • ut of the barrier into non-

construction space

Get Creative! There are usually many more

  • ptions than you think (or are told).

There is ALWAYS a way. You are in charge of the

  • ICRA. Don’t

let them tell YOU that it can’t be accomplished!

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9/26/18 9

Plenum vs Ducted Air

This is preferred!

Walls and Ceilings Dust in the ceiling cavity

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Firewall = wall goes completely to deck What you typically see above ceiling

When to require “barriers to deck”:

  • If working extensively above ceiling

and there is a potential for contaminant migration (ie: plenum return)

  • Long duration of work
  • Difficult and time-consuming to

achieve Pressure differentials are much more important! Consider the surrounding area’s patient population.

Source controls: Containment barriers – 3 main types

Environmental Containment Unit (ECU) Non-rigid containment barrier Rigid containment barrier

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9/26/18 11

Sealing off unused areas

Interrupt Transmission Pathways

SOURCE PATHWAY PATIENT

Conditions and Factors of Contaminant Transmission

Contaminant Source Transmission Pathway to patient Controls Personnel clothing Fall off walking through corridors Airborne and re- entrainment Shared traffic route Vacuum clothing Bunny suit ensemble Night/weekend Equipment (ladder) Fall off during movement Airborne and re- entrainment Shared traffic route Vacuum and then wipe clean with disinfectant Night/weekend Ceiling tiles/access panels Damage during removal and placement Airborne and re- entrainment Shared traffic route Containment cube with HEPA filtered negative air machine Ceiling cavity Pressurized cavity Airborne (small particle diameter) Shared traffic route Containment cube with HEPA filtered negative air machine

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9/26/18 12

Wi Wiped clean Co Cover ered ed and wipe e wheel eels St Staging large materials Ta Tacky mats

Frequent mopping or vacuuming traffic route

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9/26/18 13

Anything wrong here? What about here? Problems here?

It needs to be plugged in to be effective!

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9/26/18 14

Interrupt Transmission Pathways

SOURCE PATHWAY PATIENT

Patient control systems

  • Patient relocation
  • Unit closures
  • Work Hours
  • Day-time or night-time
  • Workers do not ride in elevators

with patients

  • Designated elevator

Separate patients and construction area by:

  • Distance
  • Time

Two levels of cleaning at turnover

Construction cleaning before barrier removal EVS Terminal Clean after barrier removal Remove all dust and debris Surfaces will be visibly clean Disinfect all surfaces

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9/26/18 15

Inspections: Visual validation of infection controls

  • Clean clothing
  • Clean equipment
  • Clean carts
  • Clean ladders
  • Proper waste removal
  • Tacky mat use
  • Dust suppression methods
  • Depressurized

containments

Inspections: Quantified validation of infection controls

  • Directional airflow
  • Pressure differentials
  • Environmental monitoring
  • Particles
  • Bioaerosols – fungi

Project #1:

  • Need to replace millwork and

cabinets at central nurse’s station in PACU

  • Sunday work – there may be

patients depending on emergency cases

  • Note: Millwork can also

include floors and molding since those are technically produced in mills

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9/26/18 16

Step 1: Identify the Type of Construction Activity (Type A-D)

TYPE A

Inspection and Non-Invasive Activities

Includes, but is not lim ited to:

  • rem oval of ceiling tiles for visual inspection only, e.g., lim ited to 1 tile per 50 square

feet

  • painting (but not sanding)
  • w all covering, electrical trim w ork, m inor plum bing, and activities w hich do not

generate dust or require cutting of w alls or access to ceilings other than for visual inspection TYPE B

Small scale, short duration activities which create minimal dust

Includes, but is not lim ited to:

  • installation of telephone and com puter cabling
  • access to chase spaces
  • cutting of w alls or ceiling w here dust m igration can be controlled

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies

Includes, but is not lim ited to:

  • sanding of w alls for painting or w all covering
  • rem oval of floor coverings, ceiling tiles and casew ork
  • new w all construction
  • m inor duct w ork or electrical w ork above ceilings
  • m ajor cabling activities
  • any activity w hich cannot be com pleted w ithin a single w ork shift

TYPE D

Major demolition and construction projects

Includes, but is not lim ited to:

  • activities w hich require consecutive w ork shifts
  • requires heavy dem olition or rem oval of a com plete cabling system
  • new construction

Step 2: Identify the Patient Risk Group

GROUP 1 LOW RISK GROUP 2 MEDIUM RISK GROUP 3 HIGH RISK GROUP 4 HIGHEST RISK Office areas Areas not engaged with patient care activities. All patient care units not covered under group 3 & 4 Outpatient Areas Public Corridors Cafeteria Dietary Emergency room Radiology/MRI Post-anesthesia care units Labor and delivery Newborn nurseries Nuclear medicine Admission/discharge area PT – hydro therapy tank areas Laboratories Perinatal High Risk Perinatal Unit Microbiology lab Cancer Center/Radiation Oncology Operating rooms; Sterile Processing Labor&delivery OR rooms Cardiac catheterization & angiography areas Dialysis Oncology Units Transplant Unit (BMTU) Anesthesia All endoscopy areas Pharmacy admixture All Oncology areas All Intensive Care Units Outpatient invasive procedure rooms Special Care Nursery Depts that care for BMTpatients Infusion Center Radiology Special Procedures Stem Cell Lab

Step 3: Matrix

  • Infection Control Plan: floor plan, IC procedures, waste removal,

cleaning/clothing requirements, tear-down procedures

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9/26/18 17

Step 3 (cont): Description of Requirements

Class III Date Initial During Construction Project 1. Remove or Isolate HVAC system and return in area where work is being done to prevent contamination of the duct system. 2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement use of dust mist containment unit before project begins. 3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration

  • units. – NAM exhausting into non-WA

4. Contain construction waste before transport in tightly covered containers with clean wheels. 5. Cover transport receptacles or carts. Tape covering unless solid lid. Upon Completion of Project:

  • 1. Do not remove barriers from work area until completed project is inspected by the

Safety Department and 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. Upon completion, restore HVAC system where work was performed.

Project #2

  • Signage needs to be installed in medsurg hallways
  • Requires drilling screw holes
  • 5 signs total

Options to consider when containment is not feasible

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9/26/18 18

Project #3

  • Water leaked down the wall in a Bone Marrow Transplant patient room
  • Affected drywall will need to be removed and replaced
  • CDC Guidelines for Environmental Infection Control in Health-Care Facilities

Step 1: Identify the Type of Construction Activity (Type A-D)

TYPE A

Inspection and Non-Invasive Activities

Includes, but is not lim ited to:

  • rem oval of ceiling tiles for visual inspection only, e.g., lim ited to 1 tile per 50 square

feet

  • painting (but not sanding)
  • w all covering, electrical trim w ork, m inor plum bing, and activities w hich do not

generate dust or require cutting of w alls or access to ceilings other than for visual inspection TYPE B

Small scale, short duration activities which create minimal dust

Includes, but is not lim ited to:

  • installation of telephone and com puter cabling
  • access to chase spaces
  • cutting of w alls or ceiling w here dust m igration can be controlled

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies

Includes, but is not lim ited to:

  • sanding of w alls for painting or w all covering
  • rem oval of floor coverings, ceiling tiles and casew ork
  • new w all construction
  • m inor duct w ork or electrical w ork above ceilings
  • m ajor cabling activities
  • any activity w hich cannot be com pleted w ithin a single w ork shift

TYPE D

Major demolition and construction projects

Includes, but is not lim ited to:

  • activities w hich require consecutive w ork shifts
  • requires heavy dem olition or rem oval of a com plete cabling system
  • new construction

Step 2: Identify the Patient Risk Group

GROUP 1 LOW RISK GROUP 2 MEDIUM RISK GROUP 3 HIGH RISK GROUP 4 HIGHEST RISK Office areas Areas not engaged with patient care activities. All patient care units not covered under group 3 & 4 Outpatient Areas Public Corridors Cafeteria Dietary Emergency room Radiology/MRI Post-anesthesia care units Labor and delivery Newborn nurseries Nuclear medicine Admission/discharge area PT – hydro therapy tank areas Laboratories Perinatal High Risk Perinatal Unit Microbiology lab Cancer Center/Radiation Oncology Operating rooms; Sterile Processing Labor&delivery OR rooms Cardiac catheterization & angiography areas Dialysis Oncology Units Transplant Unit (BMTU) Anesthesia All endoscopy areas Pharmacy admixture All Oncology areas All Intensive Care Units Outpatient invasive procedure rooms Special Care Nursery Depts that care for BMTpatients Infusion Center Radiology Special Procedures Stem Cell Lab

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9/26/18 19

Step 3: Matrix

  • Infection Control Plan: floor plan, IC procedures, waste removal,

cleaning/clothing requirements, tear-down procedures

Step 3 (cont): Description of Requirements

Class IV Date Initial During Construction Project: 1. Isolate HVAC system in area where work is being done to prevent contamination of duct system. 2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement dust mist containment unit before construction begins. 3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units. 4. Seal holes, pipes, conduits, and punctures appropriately. 5. Construct anteroom and require all personnel to pass thru this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or wear bunny suits that are removed when leaving work site. 6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area. 7. Do not remove barriers from work area until completed project is inspected by the Safety Department and Infection Control Department and thoroughly cleaned by the Environmental Services Department. Upon Completion of Project:

  • 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. Tape covering unless solid lid.
  • 4. Vacuum work area with HEPA filtered vacuums.
  • 5. Wet mop area with disinfectant
  • 6. Upon completion, restore HVAC system where work was performed

Thank You! Questions?

Laura Riley, PhD, CIH Laura.riley@northside.com 404.851.6388 Randy Ennis, RN, CIC Randy.ennis@northside.com 770.224.2466