Pop a few Dramamine before proceeding any farther because there is so much to consider when beginning construction of a new facility or renovation of an existing one that it will make your head spin. And we’re only examining the infection control (IC) aspect.

Caught in the crossfire
Make no mistake: IC professionals should be involved in all phases of new projects. It’s their job to ensure that staff, patients and visitors are protected against unnecessary exposure to nosocomial infections so it follows that it’s their job to identify infection risks the project may introduce, to plan how to minimize those risks, and to educate hospital staff and construction workers on how the project impacts IC.

Infection control professionals need to be on top of city, county, state and federal regulations, as well as certain regulatory and accrediting agencies’ standards. They need to ensure that construction or renovation contracts are in compliance with these regulations. They need to inspect the site routinely to make sure IC recommendations are being followed by workers.

They must ensure that staff will have what is needed to follow IC practices during the project. They must ask myriad questions – from how the space will be used to how patient safety is ensured to what the budget will stand. They must work with engineers, nurse managers, administrators, risk managers, environmental services personnel, architects, physicians, materials managers — and others — before, during and after the construction project. They must make decisions on design, space, and products, and sometimes they get caught in the crossfire of people or departments who have their own agendas.

Meeting IC challenges
During construction or renovation projects, IC practices may have to be altered; a simple, routine IC procedure such as hand washing may present a challenge. Traffic patterns may need to be altered for safety’s sake but also to cut down on dust and dirt. Fungi or bacteria in dust and dirt can contaminate air-handling and water systems, which can disseminate the pathogens to already sick people whose immune systems may be incapable of fighting off one more infection. Air-handling and water systems may have to be disrupted for modifications or additions, giving Aspergillus and Legionella the perfect opportunity to rear their ugly heads. Aspergillus clings to dust, and Legionella grows in warm, stagnant water; they cause pneumonia.

Levels of nosocomial airborne and waterborne infections should be monitored and measured against baseline levels taken before the new project begins. Action plans for how to handle potential disasters, particularly failure of ventilation or water systems, must be formed in advance and kept conveniently on file.

The CDC’s "Guideline for Environmental Infection Control in Health-Care Facilities" outlines three major topics to consider before starting new projects: (1) design and function of the new structure or area; (2) assessment of environmental risks for airborne disease and opportunities for infection; and (3) measures to contain dust and moisture. The guideline gives the third measure particular attention: "The focus of a properly implemented infection-control program during interior construction and repairs is containment of dust and moisture."

Air-handling system
Air sampling should be conducted to determine air quality, flow velocity, how well dust-control measures are working, filter efficiency and particle counts. Humidity level and number of air exchanges per hour should be monitored. If they don’t meet IC requirements, dripping water could contaminate sterile items or cause mold growth.

The CDC’s "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Facilities" (MMWR 1994;43[RR-13]:1-132) offers detailed information on requirements for room air exchanges for new or renovated isolation rooms. Other special requirements for hospital air circulation and purity are detailed in the American Institute of Architects’ Guidelines for Design and Construction of Hospitals and Healthcare Facilities. Also check out the American Society of Heating, Refrigerating, and Air Conditioning Engineers for related information.

Placement of air intakes is critical. During and after construction, IC personnel should inspect air-intake and exhaust sites to make certain the design meets IC published requirements. For instance, air intakes should not be placed near cooling towers, trash compactors, loading docks, heliports, incinerators, or biological safety hoods, among other things. There are similar considerations for exhaust.

Air quality should be monitored, particularly in areas where immunocompromised patients, such as transplant patients, AIDS patients, and premature babies, are located. A seemingly harmless action such as threading wiring through the ceiling can stir up dust containing Aspergillus spores. High-efficiency particulate (HEPA) air filters can help to reduce dust and microbes. Air ducts and ceiling spaces should be cleaned with a HEPA-filtered vacuum before even starting the work.

Controlling dust and dirt
Controlling dust and dirt goes a long way toward preventing contamination of patient-care surfaces, supplies and equipment. Barriers are vitally important. For small, short-term projects, it might be as simple as plastic sheeting sealed with duct tape. For long-term projects, durable, rigid barriers are needed; one option is framed sheetrock sealed with duck tape or spackling, with a door for construction workers. Local fire codes can help to determine what type of barrier is required for your project.

Some other measures used to control dust, dirt, and the pathogens that cling to them are outlined in the table on this page.

Traffic patterns may need to be altered to reduce the amount of dust and dirt tracked in. IC personnel should help to determine the best routes by which to detour visitors, patients, and staff to lessen the incidence of exposure to nosocomial pathogens or construction hazards. Questions to consider when detouring foot traffic include but are not limited to the following:

• Can housekeeping maintain the new route?

• Can surgical personnel move about without contaminating their scrubs?

• Can food, linens, medical supplies and equipment, and janitorial supplies and equipment be moved (in closed containers) in and out of storage areas with a minimal risk of contamination?

• Should construction/renovation work be performed during off hours or weekends instead of during usual working hours?

• Do some departments or storage areas need to be relocated during the construction project?

Storage areas
Temporary storage areas may have to be small, but should permit staff to:

• Monitor supplies (e.g., be able to see expiration dates)

• Store sterile items separately from soiled items

• Store clean/sterile supplies away from sinks to prevent wetting

• Store contaminated waste outside of patient-care areas

• Have enough space to move items without placing them on the floor

• Be clean, free of pests, and have adequate temperature and humidity control

Keeping medical supplies free of fungal or bacterial contamination is extremely important, because when packages are opened the contents can be contaminated, too. This can be very bad news to a burn patient, for example, because if their open wounds come into contact with a contaminated bandage, pathogens could be directly inoculated into their wounds. Consequently, they may not be able to survive the infection.

Water Supply
IC personnel should have plans in place for how to handle disruption of water supply, whether planned or accidental, for at least two reasons: Water is vital to many IC practices and contaminated water can spread disease. When service is restored, water-pressure "shock" can cause debris and scale, containing microorganisms, to be loosened; flushing the water system can help to clear it.

Keeping water contaminant-free is an ongoing concern for healthcare facilities. Water disinfection methods include hyperchlorination, ozone, superheat and flush, ultraviolet light, and copper-silver ionization. Hyperchlorination can corrode pipes, and hot-water flushing may lose its effectiveness as it reaches higher floors because the water cools down, rendering it unable to kill pathogens; however, hospitals have used all water-decontamination methods successfully, and the CDC does not recommend one method over the other. IC personnel need to be informed as to which water-disinfection method is practical for their institution.

Don’t forget…
IC professionals need to make informed decisions on isolation rooms; handwashing facilities, such as types of faucets and sinks and their location; location of sharps containers; human-waste disposal; appropriate type of, and location for, ice dispensers; and finishes such as floor and wall coverings, countertops, and ceiling tiles.

Additional Resources:
Carter CD, Barr BA. Infection control issues in construction and renovation. In: Herwaldt LA, Decker MD, eds. A Practical Handbook for Hospital Epidemiologists. 1st ed. Thorofare, NJ: SLACK Inc; 1998;317-330. Also published in Infect Control Hosp Epidemiol 1997;18:587-596.

Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, et al. Guidelines for environmental infection control in health-care facilities: recommendations from the CDC and the Healthcare Infection Control Practices Advisory Committee, (HICPAC). MMWR 2003;52(RR-10):1-42.

Centers for Disease Control and Prevention. Guidelines for prevention of health-care–associated pneumonia, 2003: recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR 2004; 53(RR-3):1-36.

Noskin GA, Peterson LR, Centers for Disease Control and Prevention. Engineering infection control through facility design. http://cdc.gov/ncidod/eid/vol7no2/noskin.htm. Last updated 12/22/01.

The APIC Curriculum for Infection Control Practice, vol. II. Soul BM, ed. Dubuque, IA: Kendall/Hunt Publishing Co; 1983.

American Institute of Architects Academy of Architecture of Health. Guidelines for Design and Construction of Hospitals and Healthcare Facilities. Washington, DC: American Institute of Architects; 2001. HPN