Putting infection control into practice
Hospitals are under competitive pressure to continually upgrade and expand their facilities. Aging infrastructure, new technologies, and the growing demand for more patient-friendly facilities create a constant need for construction and repair.
Any of these activities has the potential to release dust, bacteria, and mold spores into the air. Some of the more common microbes that can be spread through construction activities include Stachybotyrs atra, Penicililum funiculosum, and Aspergillus fumigatus, a thermophilic fungus often found in construction dust. See Figure 1 for a list of common potentially harmful organisms found in hospital settings. (Figure 1).
The Centers for Disease Control (CDC) publishes guidelines designed to manage the potential health impact of construction activities. These guidelines include resources for understanding modes of disease transmission, ventilation, environmental monitoring, and infection control.
While the CDC recommendations were designed primarily with patient populations in mind, they are fully applicable as recommendations for the protection of the workforce.
The next section looks at how Frankford Hospitals incorporates these recommendations, as well as many of its own disease management solutions, into its infection control program.
Frankford Hospitals
Founded in 1903, Frankford Hospitals operates three hospitals and three outpatient centers in Northeast Philadelphia and Bucks County, Pennsylvania. With a mix of older infrastructure and newer facilities, it is not unusual to have multiple construction projects underway at the same time. These range from simple repairs to complex renovations, such as building a new heart center or converting an operating room to accommodate new equipment.
Disturbing any building material, even something as simple as replacing a damaged ceiling tile, has the potential to release mold and dust. Patients, especially the immunosuppressed, can become ill from exposure to these infectious agents in the ventilation system or drinking water supply. Sick patients can transmit disease to workers, or workers can become directly ill from contaminants. Therefore, each project must be considered for its potential health impacts.
To manage this risk, Frankford has developed procedures for infection control during construction projects. These include: 1) regular meetings of a construction management team, 2) standardized risk assessments for construction projects, 3) ongoing infection control training for construction personnel and suppliers, 4) quality testing of the air and environmental monitoring, and 5) guidelines for communicating with personnel in a timely and accurate manner.
These procedures are briefly described below:
1. Construction management team:
The team meets weekly to review current construction activities and communicate with staff. The committee includes representatives from the laboratory, engineering, environmental services, administration and risk management. Depending on the complexity of the project, meetings may also include architects, design engineers, contractors, and construction managers.
2. Risk assessment:
An Infection Control Risk Assessment (ICRA) is conducted for construction projects to determine the potential risk to patients and staff, as well as to inform the appropriate regulatory agencies of ongoing activity. In Pennsylvania, these include the Department of Health and the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations – JCAHO).
The ICRA compares the complexity of construction activities with their proximity to patient populations to determine what controls are needed. In addition, the ICRA process results in recommendations for the safety of construction personnel, such as wearing personal protective equipment, maintaining negative air pressure in the construction area, or constructing an anteroom to prevent the spread of dust.
Frankford developed his own ICRA form which was later adopted by the Pennsylvania State Division of Plan Review. An example of this can be seen in Figure 2 (See Figure 2).
3. Training:
Hospital staff, contractors, and subcontractors are required to be familiar with infection control procedures. Contractors and subcontractors must pass a two-hour infection control course offered by Frankford. Some of the topics covered in the course include tuberculosis control, the dangers of asbestos, and the safety of bloodborne pathogens. Contractors unfamiliar with these procedures are not eligible to bid for projects.
4. Environmental monitoring:
Environmental monitoring involves two types of activities: 1) daily physical monitoring of activities to ensure that building activities and ICRA barriers meet safety and infection control standards, and 2) air quality tests to assess whether ICRA barriers are preventing the entry of construction dust into active areas of the hospital. Air quality testing generally includes real-time particulate testing and may also include samples of culturable fungi and bacteria.
Environmental and Engineering Solutions, Inc. (EES) assists Frankford with its environmental monitoring program by providing weekly monitoring of ICRA barriers and contractors. EES also conducts weekly air quality tests during construction activities. Both baseline measurements are made in areas away from construction and on-site measurements of areas close to construction zones.
Air quality testing, lab time, and reporting add cost, so facilities must review their budgets and targets to make the best decisions about ICRA monitoring. These services are generally prioritized for situations where:
o There is evidence of water damage or water in an affected area
o Mold growth is observed
o Construction activity will generate dust
o The project has the potential to affect the domestic water supply.
o The ventilation system can be affected by construction activity.
5. Communication:
Construction management team meetings are used to keep affected departments informed of ongoing construction activities. The information is then disseminated through a variety of means including departmental meetings, memos, and email.
There are also standard procedures for communication between the construction team and hospital administrators. For example, if a potential hazard is discovered, the facility design and construction manager is involved immediately. Additional steps may be required to keep staff informed.
The following section describes an instance where Frankford procedures were implemented to address an infection control situation.
Put the plan into action
Frankford was converting an operating room into a new central sterilization room. The workers had removed an autoclave, exposing the wall behind it. During a weekly air quality test, EES discovered large patches of mold on the wall.
We immediately reported to Frankford’s director of design and facilities management, who ordered a suspension of construction. Based on our recommendation, he also had the area quarantined and ordered that staff whose work areas were near the building be relocated until we could determine if the mold was toxic.
Next, Environmental and Engineering Solutions took bulk samples to identify the type of mold and the extent of contamination and to determine if there was any danger to hospital personnel or construction employees. Frankford management also informed staff working in the area that they had found the mold.
Unfortunately, several of his employees were upset and concerned that their health would be affected. In this day of instant communications, the situation had the potential to escalate, so Frankford’s management was eager to allay people’s fears.
Fortunately, the lab report was negative for toxic mold, bacteria, or harmful particles. These results were made known to the staff at a special meeting. Employees were allowed to read a copy of the report to validate our findings.
Using these results, we also made recommendations to Frankford regarding the remediation steps that needed to be taken and what protective measures were required for the workers. We then conduct a visual inspection before giving the green light to resume construction activities.
These steps were repeated several other times for other non-construction related mold issues. Investigations included visual inspection, sampling and analysis for mold and bacteria, interviews with affected employees, and recommendations on remediation.
Conclution
Hospitals will continue to build new facilities and upgrade old ones. Planners must address the impact of these construction projects on the health of workers and patients alike.
By focusing on infection control, hospitals can warn of potentially dangerous situations and reduce risks to patients and staff. Communication, environmental monitoring and training, as well as adherence to strict infection control procedures, are all essential steps in the process. With advance planning, training, and active communication, hospitals can manage risk and keep construction schedules running with confidence.