Stephanie Kreiling, RN, BSN, MPH, CIC Brenda Helms, RN, BSN, MBA/HCM, CIC

Transcription

1 Stephanie Kreiling, RN, BSN, MPH, CIC Brenda Helms, RN, BSN, MBA/HCM, CIC

2 Stephanie Kreiling and Brenda Helms have nothing to disclose.

3 Briefly review infection transmission risks related to healthcare facility construction and/or renovation Describe the role of the infection preventionist (IP) during construction and renovation Discuss challenges/barriers the IP may encounter during the infection control risk assessment (ICRA) process Summarize components of a successful ICRA process to mitigate infection-related hazards and risks

4 Construction Renovation Preventive maintenance Remediation of damage to indoor spaces or building infrastructure After natural or manmade disasters

5 Air Bacillus, Legionellae, numerous fungi and molds Aspergillus o Numerous outbreaks have been described o Systematic review of 53 studies of aspergillus outbreaks: o High fatality rate 57.6% in those with severe immunodeficiency o Construction or demolition work was often considered to be the probable or possible source of the outbreak (49.1%) o Even tiny concentrations of spores have been associated with outbreaks Vonberg & Gastmeier. J. of Hosp. Infection :

6 Water Huge number of microbes in potable water and delivery systems Risks: Changes to water distribution pathways Dead ends, stagnation Disruption to water systems release of biofilms Indoor water features

7 Surfaces and patient care equipment Inanimate surfaces serve potential reservoirs Great number of different pathogens that may cause harm -- including MDROs Construction design elements can enhance infection prevention or increase transmission risk

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9 Evaluate plans/structural design Review and communicate relevant standards and regulations Facilitate and communicate essentials necessary for safe practice Provide consultation based on patient populations and care delivery systems Determine impact based on project scope Provide recommendations for optimal use of space and design Determine environmental monitoring needs Determine education necessary for internal and external contractors Develop expectations (agreements, checklists, contractor accountability) in the event of breaches in infection control practices

10 Ongoing planning and monitoring during all phases of project: Area prep Demo Construction Clean Up Return to Service Keeping work area isolated, maintaining negative pressure Providing ongoing input into design & infection control practices

11 Created out of concern that health care construction and renovation projects were causing infections: Design elements: greatest long-range impact to infection prevention Mitigation elements Short term Recommend methods to prevent transmission of contaminants by air and water during onstruction/renovation projects and in commissioning/re-commissioning of systems (HVAC, water pathways, sterilizers)

12 TIMING IS EVERYTHING! ICRA should be conducted BEFORE the construction project begins, and should continue through project completion and commissioning activities

13 Design, number and type of AIIRs HVAC, including ventilation and filtration charts Systems involving water supply/plumbing Number, type and placement of handwashing sinks Sharps disposal containers placement PPE storage Surfaces, from ceiling tiles down to floors Utility rooms: soiled, clean, instrument processing, holding and workrooms Storage of movable and modular equipment

14 Facilities Guidelines Institute (FGI) Most comprehensive guidelines available Space, risk assessment, infection prevention, architectural detail, and surface and furnishing needs Engineering design criteria for plumbing, electrical, and heating, ventilation, and airconditioning (HVAC) systems, Infection prevention is infused into every chapter

15 2014 edition: Now divided into two standards: one for hospitals/outpatient facilities and one for LTC /residential facilities Includes entire 2013 Edition of ASHRAE 170 minimum requirements for ventilation systems Updated to keep up with changing health care needs Responsive to guidance from health care providers, regulatory bodies, and designers Revisions made by consensus of the Health Guidelines Revision Committee

16 List of exceptions to help clarify when existing building systems or equipment must be updated Only altered, renovated, or modernized portions of building are required to meet the installation and equipment guidelines Safety Risk Assessment Multidisciplinary, documented assessment process Proactively identifies and mitigates hazards and risks in the healthcare built environment Includes infections, falls, medication hazards, immobility, security, etc.

17 Part 2: Hospitals Critical care patient toilet or human waste disposal rooms New requirements for hybrid ORs Part 2: Hospitals and Part 3: Outpatient facilities Guidance for hand hygiene stations serving multiple patient care stations Unsealed water features no longer permitted Surgical suite has two designated areas: semi restricted and restricted Scrub stations in surgical suites Required next to OR but can serve two ORs Substerile does not have to be between every two ORs Revised requirements for sterilization processes within surgical suite Revised Endoscopy instrument processing room requirements

18 Part 3: Outpatient Facilities Significant revisions to requirements for ORs New definitions for invasive procedures, procedure rooms, and areas that make up the surgical suite Distinction between OR and a procedure room in the ambulatory care setting No longer using outdated Class A-C levels One size minimum requirement for outpatient OR Part 4: ANSI/ASHRAE/ASHE 170: Ventilation of Healthcare Facilities

19 Knowledge deficits related to one or more aspects of construction/renovation Selection of appropriate/essential measures to mitigate risk Timely notification of projects Effective communication with applicable stakeholders Achieving and maintaining consistent adherence to ICRA recommendations Lack of support for infection prevention program Education

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21 IP notification after-the-fact or mid-project Routinely submitted projects with poor description of the work to be performed and/or no blueprints Variable and sometimes poor adherence to IP recommendations Wide variation in prescribed mitigation practices All infection prevention measures were listed together under one category in the permit Which recommendations do we select?

22 Patient risk matrix: no delineation between lower risk patient care areas and higher risk patient care areas (patient care areas were lumped into one group) Construction matrix: listed some activities that could generate dust but that did not require a permit Limited direction selecting appropriate barriers for work above ceiling IP recommendations sometimes marginalized Budget constraints, urgency to complete projects, lack of recognition of importance Lack of consistency, burdensome ICRA requirements for lower risk projects

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25 Should engineering/construction be allowed to raise and inspect ceiling tiles without a dust buggy or other containment barrier? In which areas? What precautions are required to adjust VAV? For wet tile removal/replacement? What tasks, if any, could be safely performed above ceiling without a dust buggy or other containment barrier? Do other facilities use standardized, pre-approved permits? Clean dust buggies after use? Options for dust containment when cutting into a wall to install a box? Should there be differentiation between types of high risk areas, such as ICU vs. BMTU? Should construction crews be allowed into common areas such as the cafeteria? Should the kitchen be designated as a high risk location? Rounding during major construction/renovation: should it be more prescriptive? Approval process after barriers are in place? Before barriers come down?

26 Issues/challenges were presented to the IP Council and Environmental Safety for their input and feedback System-level team was convened Safety Infection Prevention Engineering/building maintenance Project managers/construction leadership Healthcare system leaders (support/sponsorship)

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28 Evaluation/classification of patient risk groups Low: areas where no patients, patient care supplies and/or equipment passes through or were housed Medium: areas where patients, patient care supplies and/or equipment passes through or were housed High: High risk areas as designated on High Risk Locations Matrix

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31 Safety/Engineering provided expertise and recommendations to: Revise/add and delineate activities that generated no dust from those that generated moderate or high levels of dust, and Create better distinction between minor construction/renovation projects from major construction/renovation projects Infection Prevention provided science on infection risks related to construction/renovation

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33 o For data, power and voice line cable pulls in low and medium risk areas o Statement of approval from Safety and IP&C at the bottom of the permit o Does not require prior Epi review & signature provided it is used in non-high risk areas and in adherence to the required precautions o Face-to-face meeting and/or approval process not required, as long as permit is complete and posted in the work area o Cable pulls in high risk locations must still be approved by Epidemiology/ Infection Prevention and Control

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35 o Consider the flow of air: Where does the air go? o What is above, below, and adjacent to a work site? o What kind of patients are nearby? o What is the scope of the project? o How dusty is the work?

36 o High risk patients + Dust - generating work: o The department must be closed to patients OR o Barriers must be airtight with correct airflow

37 o Cleanliness of equipment o Clean shoes and clothing o Dust buggy o Tools/tool cart o Waste/trash transport o Lids/Covers o Safe exit paths o o o o Tacky mats Shoe covers Bunny suits Anteroom

38 Divided into 3 specific levels (classes) of protection Class selection based on patient risk and type of activity Less guesswork for the inexperienced IP Ensured minimal required measures of protection Types of barriers listed on bottom of permit

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40 o Use of barrier/requirement for IP notification versus written ICRA permit requirement o VAV adjustments and caulking of penetrations may occur without a barrier in low and medium risk areas in certain conditions o Class II construction permit required in high risk areas for removal of 3 or more tiles

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42 o High Risk Departments Matrix o General Epi Permit for Cable Pulls o Ceiling Tile Risk Assessment Matrix o Construction Matrix o Epidemiology Construction Permit: o 3 specific levels of protection 42

43 Safety reviewed/revised onboarding and annual competencies for all workers performing construction/renovation activities Mandatory stakeholder education provided jointly by Safety and Infection Prevention New tools/revised ICRA process Importance of partnerships/collaboration Requirements Timely project submission Detailed description/blueprints Posting of permits Infection Prevention education of all workers Empowerment of IP to shut down projects as needed

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45 Added power to types of cable pulls on the Construction Matrix and on General Cable Pull Permit Added labels (A, B, C, etc.) to different barrier types on permit Added section on top of permit to add an extension date Added check boxes on Class II section of permit for selection of HEPA vacuum and/or HEPA- filtered air scrubber Removed requirement for inspection by infection prevention and control from Class III section of permit Removed wording Project may start from bottom of permit

46 Added check box for wearing of appropriate PPE to Class III section Added more comment lines to Class I, II, and III permit sections and a few comment lines to the bottom of the permit Removed instructions that workers must be vacuumed with HEPA vacuum from the Class III section of the permit Updated High Risk Locations Matrix

47 Standardized checklist for rounding during projects Ceiling Tile Risk Assessment Matrix: review for further revision Formally survey applicable stakeholders What isn t adequately addressed in our current processes? What is working well, where are the current challenges? How is compliance? Evidence of infection transmission related to projects?

48 Bartley JM. APIC state-of-the-art report: the role of infection control during construction in health care facilities. Am J Infect Control 2000 Apr;28(2): Cotton, B. Construction and renovation. In Grota, P., et al, eds. APIC Text Online Facilities Guidelines Institute Guidelines for Design and Construction of Hospitals and Outpatient Facilities. Washington, DC, The American Institute of Architects Press, 2014 Vonberg & Gastmeier. J. of Hosp. Infection :

49 Thank you!