Construction and renovation projects can be fun to watch as the framework and skeleton takes shape, and you anticipate the structure’s eventual unveiling and readiness for patient service.
But planning and preparations can be challenging and tedious with the understanding that sterility assurance for the facility must continue and not be compromised. This encompasses a number of areas, including environmental services, infection prevention and control and sterile processing operations.
These projects require a team of professionals, for sure, and at the center of that team resides infection control expertise.
“Any time construction crews are working in a healthcare environment, infection control needs to be involved to dictate best practice for construction barriers to the project team,” said Steve Sutton, Director, Planning and Design Group, Belimed Inc. “There needs to be clear policies and procedures for the construction crew to follow, such as, how to enter the construction area, are they passing through a controlled or restricted space, will they need to gown up? If utilities in the area need to be brought down in the construction process, what is the risk and what is the plan to maintain service and keep the staff and patients safe?”
At Norfolk, VA-based Children’s Hospital of the Kings Daughter, working inside the construction zone is regulated and managed by the project manager (hospital employee) and the general contractor under the advice of clinical and risk management leaders, according to Danny Blount, Director of Supply Chain.
“Each renovation may have a unique set of circumstances that most likely will vary from project to project,” Blount said. “For example, a simple floor tear out and industrial carpet installation may have limited impact on air quality but will affect our ingress/egress route, while a steam line re-do may not shut down a corridor but may involve removal of asbestos. The key infection prevention issues are air quality, maintaining positive/negative airflow, contact precautions, general cleanliness of the entry/exit points into/out of the construction zone, etc.”
Organizations embarking on a construction or renovation project must focus on the big picture and then hone in on specific operations, according to Christena Fournier, Technology Consultant, Mazzetti+GBA, a global provider of healthcare mechanical-electrical-plumbing engineering design and technology/information technology consulting.
“Thought must be given to how the space will be used immediately and in the future,” she said. Everything from the physical and mechanical design of the space to the selection of the [furniture, fixtures and equipment] is dependent on the proposed use of the space.
“For the physical environment, consider every factor that will have an impact on the infection control capabilities of the space, from the availability of hand washing to the choice of lighting, hard ceiling or acoustic tile and flooring to the number of air exchanges per hour,” Fournier continued. “When selecting FF&E, it is important to consider how each product will be used and by whom. Many products and finishes are now available with embedded antimicrobial properties. Stain-, moisture- and odor-resistant finishes that can withstand a variety of hospital-grade germicides should be selected. With soft goods such as bedspreads and cubicle curtains, order sufficient attic stock so that these items can be regularly changed and laundered.”
Mike Reid, Vice President, Construction, Capital and Facilities, Intalere, urged healthcare organizations not to take construction and renovation projects lightly when it comes to affecting patient care via airborne pathogens.
“The leading cause of nosocomial infections is particularly prevalent during construction periods due to the tear out of existing walls, flooring, ceilings, etc., potentially harboring pathogens that threaten the already immune compromised patient,” Reid insisted.
Expand from the center
Organizations should determine specific hazards to patient safety in adjacent spaces, movement of debris and traffic through occupied spaces, and assessment of internal/external forces contributing to hazardous conditions, according to Michael Compton, AIA, LEED AP, EDAC, Healthcare Architect at RS&H. This requires infection control barriers and entry/exit procedures. “Methods of infection control vary, but some strategies include dust barriers, air pressure control, coordinated contractor access, and the use of mobile dust/debris isolation carts outside the primary work area,” Compton noted. “In addition, by implementing construction in phases, facility operations can be maintained while providing a safe environment for patients.”
Prior to beginning any construction project within or adjacent to an open and functioning healthcare environment, an Infection Control Risk Assessment (ICRA) must be performed, according to Fournier. Typically, a committee that includes the infection control and facilities/engineering departments, project architect and the contractor complete this assessment, along with an industrial hygienist, she added.
“The ICRA team will evaluate the potential risks and make recommendations for prevention,” Fournier continued. “This usually includes the construction of a physical barrier between the construction zone and open hospital space. Depending on the duration of the construction schedule, the team will determine if the barrier is a stud and sheetrock wall or plastic and poly sheeting such as Visqueen. The team will also determine if the barrier should stop at the ceiling grid or continue to grade. A containment checklist should be developed and checked regularly for compliance.”
Fournier also recommended limiting horizontal and vertical points of entry and exit to the construction zone, installing disposable layered adhesive “sticky mats” at entry and exit points, redirecting HVAC ductwork, and deploying negative air machines or air scrubbers.
“Surface cultures and air particle counts should be taken in areas adjacent to the construction zone prior to the start of construction to establish a baseline,” she said. “Particle counts and cultures can be taken throughout the project to ensure that there is no change from the initial baseline counts.”
Fournier called for furniture and equipment vendor contracts to require suppliers to “un-box and remove their cardboard and trash at the loading dock, shell space or other area to ensure these materials do not enter the new space.”
Prior to opening a new area for patient use the facility must perform a “terminal clean” of the new space, including taking air particle counts and surface cultures, she noted. “It is important to allow enough time in the schedule between completion and first patient day for incubation of the surface cultures — 8-10 days — and re-cleaning and re-testing if the results are unacceptable,” she added.
Sutton recommended that in the sterile processing area, “terminal disinfection needs to be done after every phase of construction before the space can be recommissioned for reprocessing instrumentation. Dust and dirt can be contained using construction barriers with negative pressure being maintained in the construction space relative to the rest of the area. Typically, the air is measured for contaminants at different intervals as agreed to by the hospital. When a particularly dusty part of the work is to occur this can be done during off-hours, and environmental services can be coordinated to clean in and around the area at the completion of this work.”
William Stitt, CMRP, FAHRMM, CHFP, Chief, Supply Chain Management at University of Mississippi Medical Center, and Principal and Chief Operating Officer, Credibility Healthcare LLC, echoed concern for thorough measures.
“Controlling dust and debris, airflow, waste removal and secondary surface contamination are all things that come to mind,” Stitt said. “An organization should have protocols in place that govern construction projects, and regular rounds that include plant operations/facilities, environmental services and infection control should take place to ensure those are being met. Other things, like proper infection control barriers, appropriate signage and training for construction staff, are also necessary [for] a safe and clean environment during any project.”
Early team building needed
Recruiting the right professionals to participate early enough can make a tremendous difference, according to James Dickow, President, Dickow Consulting Group LLC, Milwaukee.
“The sterility and cleanliness requirements should be addressed throughout the design process,” Dickow said. “Although some of these requirements are subject to interpretation, many are little more than common sense, and the infection control group should be consulted throughout the project.”
Ric Goodhue, CMRP, Equipment Planner and Capital Coordinator, CaroMont Health, Gastonia, NC, concurred. “[Infection control professionals] have the background and knowledge of the regulatory requirements as it pertains to limiting or eliminating the potential exposure to staff and patients of hazardous materials that affect the safety and well-being of both,” he said. “This includes requirements for air monitoring, wall barriers, floor mats, additional air filtering systems, PPE requirements and frequent monitoring of compliance of general contractors.”
Blount acknowledged the teamwork that takes place in his facility.
“Our facilities and construction managers work closely with infection prevention to ensure all the environmental hazards are mitigated during project work,” he said. “We utilize tacky floor mats for construction site entry points, portable HEPA filter devices for indoor air quality, temporary wall partitions, HVAC duct closings, and a variety of other mechanisms to prevent environmental hazards. All projects located in an occupied building are handled through a permitting process, which included our [Infection Prevention Executive, who is a registered nurse].”
The assessment team must plan and account for a wide variety of situations that may occur.
“Although a project may be on the second floor of the facility, the demolition debris may be transported on an elevator that’s shared with staff, patients, food service, etc., so there are certain requirements to ensure the safety and well-being of everyone that uses that elevator or there may be alternatives identified to minimize the exposure,” Goodhue added.
“Controlled access to the area(s) is one of the main things,” Stitt said. “Also being aware of what is in close proximity and how it has the potential to be affected — in advance — is very important. Engaging Infection Control from the onset of the process is essential, and taking their feedback and input throughout the process as the project evolves also makes a huge difference. Cross contamination of areas continues to be a major problem in construction, especially when renovating areas. Cleaning of adjacent areas adjacent to construction locations is sometimes an afterthought, but actually requires a heightened level of focus from an infection control perspective, and must be top of mind to everyone involved.”
Knowing the materials in your space is crucial, indicated Bryce Stuckenshneider, Vice President, Marketing, Clarus Glassboards. “Many pieces of furniture or equipment contain porous surfaces where bacteria can hide and multiply,” he said. “This is one reason we are particularly passionate about glass boards as ideal for the patient room as glass surfaces are completely non-porous and were proven in a recent study to carry three times less bacteria than traditional whiteboards.”
But wiggle room may be needed, Dickow noted.
“A clear distinction should be made between requirements that have a significant impact on either capital and operating expense,” he noted. “The interpretation required when converting general requirements into bricks and mortar and/or operating procedures can be areas for discussion.” Dickow cited the following examples:
- What constitutes a “cardboard box” (external shipment packaging versus product packaging) should be addressed on an individual basis and may include contacting the government and/or professional standard of cleanliness for clarification.
- Sterility integrity and/or control of either vendor-provided or hospital-sterilized disposable or reusable products.
- Both short- and long-term storage space environmental requirements of small and large diagnostic and treatment equipment.
Dickow further indicated that enforcing design criteria must be flexible enough to incorporate “back-up alternative strategies and operational workarounds.”
Goodhue emphasized that infection control on any project is critical to the safety and well-being of staff and patients alike.
“Supply Chain, Facility Services and Construction cannot do it alone,” he said. “Any successful project is based on communication, collaboration and coordination of a variety of service lines. Clinical must acknowledge non-clinical. Support services must understand the needs of the clinicians. Bringing the team together and creating a collaborative mindset is necessary if we are to achieve the ultimate goal of ‘improved patient outcomes’ as noted in the [Institute of Healthcare Improvement’s] Triple Aim Initiative.”