Environmental Control/Aspergillus Protocol IC/373/10

BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST Environmental Control/Aspergillus Protocol IC/373/10 Owner Name Hazel Gray Job Title Senior Infection Control Nurse Final approval Name Infection Control Committee committee Date of meeting 25 August 2009 Authoriser Name Dr Nicki Hutchinson Job title Director of Infection Prevention and Control Signature Date of authorisation 09/03/2010 Review date (maximum 3 years from date March 2013 of authorisation) Audience (tick all that apply) Trust staff Contractors NHS General public Standards Standards for Better Health NHSLA Executive Summary The aim of this policy is to give guidance to Trust staff on the required actions when building work is being carried out to protect vulnerable patients from potentially fatal aspergillus infections. Any building work can lead to contamination of the air with Aspergillus spores and it is important to contact the infection control team prior to this work starting so preventative measures described in this policy can be implemented. Page 1 of 14

Implementation Plan Summary of changes New policy Action needed and owner of action Infection Control Team MUST be involved in all phases of any building work where there is a risk to patients. All contractors must have Health and Safety/Infection Control Training before commencement of a project. The Infection Control Team will review progress of construction in order to identify any potential problems at the earliest opportunity. Clinicians will be asked to report clinical cases of suspected hospital acquired fungal infection to the medical microbiologists. Purpose To give guidance to Trust staff when building works is being carried out to reduce the risk of contamination of the air with Aspergillus spores. Policy Statement: It is the policy of Basingstoke and North Hampshire NHS Foundation Trust that the following recommendations are adhered to when building work is being undertaken, either during construction, demolition or renovation of buildings where increased airborne particles originating from dry soil, dust or fragmenting building materials are common. Trust Application: Trust wide. Read in Conjunction with: Health and Safety Policy Contractors Policy Page 2 of 14

Table of Contents Page No 1. Introduction 4 1.1 Aspergillus species 4 1.2 Inhalation 4 1.3 Primary route of infection 4 1.4 Diagnosis 4 1.5 Diameter of spores 4 1.6 Construction and renovation activities 4 1.7 Infection prevention and reduction 4 2. Role of the Infection Control Team 5 3. Areas requiring special environmental conditions 5 4. Risk assessment 5 4.1 Patients at most risk of invasive aspergillosis 5 4.2 Use of negative pressure 5 4.3 Precautions during building work 6 5. Infection control precautions to be instituted during building works 6 5.1 Prior to commencement of build 6 5.2 Physical barriers 6 5.3 Traffic control 6 5.4 Ventilation 6 5.5 Waste 6 5.6 Builders clothes and equipment 7 5.7 Health and safety of staff during renovation/construction 7 5.8 Protection of high risk patients 7 5.9 Monitoring 7 5.10 Clinical Monitoring 8 5.11 Microbiological Surveillance 8 6. Equality and Diversity 8 Appendix I: Infection Control Construction Recommendations 9 Appendix II: Infection Control Construction Checklist 10 Appendix III: Risk Assessment for Aspergillus during 11 Renovation/Construction Appendix IV: Audit 13 Appendix V: References 14 Page 3 of 14

1 Introduction 1.1 Aspergillus species are fungi found in soil, water and decaying vegetation. They have also been isolated from unfiltered air, ventilation systems, false ceiling dust, contamination dust dislodged during hospital renovations and construction, horizontal circulars, food, spices, dried flowers and plants. Other reported reservoirs include contaminated fire proofing materials, damp wood, indwelling catheters, in plant and contaminated bandages. Due to their size Aspergillus spores remains suspended in air for long periods of time. Once introduced into the environment the spores can persist for many months. 1.2 Aspergillus species are inhalated into the nasopharynx. In patients with severe neutropenia Aspergillus species can cause lower airway infections and brain abscess. Patients with chronic lung conditions are also pre-disposed to colonisation of the lower respiratory tract and subsequent invasive pulmonary and/or disseminated infection/disease. Cultures of both surveillance and diagnostic samples are practically always negative for Aspergillus species. It rarely infects non immuno-suppressed hospital patients and staff. While this policy refers to aspergillus the same principles apply for the prevention of infection due to other moulds, which may be released into the environment during building work. 1.3 The primary route of infection is by inhalation of fungal spores which colonise the lungs and can spread via the bloodstream to other major organs. Infection is also believed to occur directly into deep wounds during surgery, however due to the hygiene standards in theatres and the relatively short exposure times involved, this rarely poses a significant risk. 1.4 The diagnosis of Aspergillosis is often difficult involving invasive procedures. Treatment is lengthy and costly and mortality is still high despite new therapies, thus making prevention a high priority in the management of all at-risk patients. 1.5 Aspergillus spores have a diameter of between 2.5 and 3.5 microns. In practice this makes the only effective ventilation filtration system to be High Efficiency Particulate Air (HEPA) quality EU12 or above. 1.6 When hospital construction and renovation activities are in the planning stage, it is important to implement a strategy that attempts to protect patients at high risk from aspergillosis and minimise exposure to high ambient air spore levels. This will necessitate creating and maintaining an environment as free of Aspergillus spores as possible. 1.7 Infection can be prevented or reduced by: i. Identifying at risk patients ii. Surveillance using settle plates for Aspergillus species iii. Nursing high risk patients in an isolation cubicle with hepa-filtration iv. Prevention of Aspergillus inhalation by nasal amphotericin B spray v. Staff hygiene precautions and environmental cleaning Page 4 of 14

2 Role of the Infection Control Team (ICT) The ICT must be involved in: All phases of any building work where there is a risk to patients e.g. of aspergillus or other fungal spores, whether demolition, construction or internal refurbishment from planning to final hand over of the project. Planning, agreement of work programme and duration. Documentary evidence must be completed. Undertaking a risk assessment for the area involved. Education sessions for contractors. Attending all Estates progress meetings and will be available for advice and consultation throughout the project. The provision of written documentation on precautions, which need to be instituted. 3 Areas requiring special environmental conditions i. Operating Theatres ii. Clinical areas with Hepa filtration iii. PICU, NNSU, TSSU, Oncology Department, Pharmacy, Cyto-toxic Suite, CIVAS iv. Any other areas identified by risk assessment to have immunosuppressed patients All maintenance work or renovation in the above clinical areas must be discussed to the ICT prior to implementation. A formal risk assessment should be carried out by the ICT in conjunction with the appropriate Facilities Project Manager and Estates Manager prior to all renovations/construction (See Appendix I and II). 4 Risk Assessment 4.1 Patients at most risk of invasive aspergillosis are those who are immunocompromised or immunosuppressed for extended periods of time. These include the following patients: Haematopoietic stem cell transplant Solid organ transplant Oncology Haematological malignancy patients especially those with acute leukaemia SCIDS (Severe combined immunodeficiency syndrome) Other patient groups who are at an increased level of risk are: ICU/PICU Patients on high dose steroids Burns HIV positive patients Patients after major surgery if other factors are present Taking into account the prevalence of aspergillus in the environment and the patients that require protection a two stage protocol is required: 4.2 Use of negative pressure in the construction area, exhausted outside if possible and away from clinically susceptible patient areas. Hepa filtration will be considered depending on level of risk. Page 5 of 14

4.3 Precautions during building work; these are detailed below and involve minimising the release of spores into the environment and methods to reduce contamination of the patients environment. 5 Infection control precautions to be instituted during building works 5.1 Prior to commencement of build Before any building work is undertaken all contractors must have an education session with the Health and Safety and Infection Control Team. (Please refer to BNHFT Contractors Policy) 5.2 Physical Barriers These are required to minimise spores contaminating clinical areas and may include: Plastic sheeting: Fire-rated with a > 2 feet overlap for entry. Rigid barriers i.e. White washable plywood, which is dust-proof and fire-rated. Provision of an entry vestibule for change of clothing, tool storage etc. Sealing of windows with adhesive strips. Sealing of the area of building work if possible. Sealing of doors. Sealing of roof space. Taking care to minimise dust when dismantling barriers. Controlling of dust accumulation by regular damping down with water. 5.3 Traffic Control This can also reduce the dissemination of spores by: Directing patients, staff and visitors away from construction area. (Ensure signage is clear and visible). Designated entry/exit for contract staff. Using separate routes for patients, staff and visitors including separate lifts if appropriate. Using routes for removal of building materials and waste which are away from clinical areas. For immunocompromised patients, planning journeys avoiding potentially heavily contaminated areas and considering additional precautions e.g. face masks, for patients moving around and visiting the hospital. Contractual staff must only use designated routes to work area and change before accessing trust communal catering areas 5.4 Ventilation The direction and movement of air as a vehicle for dissemination of aspergillus spores needs to be considered including the following: Use of a negative pressure in the construction area, exhausted outside if possible and away from clinically susceptible patient areas. Direct airflow should go from clean to dirty areas. Protection of the ventilation units of clinical areas: Most important for high risk areas with immunocompromised patients or specialised units. Enhance plant maintenance will be put in place.. 5.5 Waste Spore contaminated waste may also pose a risk. This can be minimised by: Page 6 of 14

Removing waste through a designated route avoiding clinical areas as far as practically possible. Removing debris in tightly sealed, lidded container. Heavy duty Bags may need to be used. Alternatively, cover it with a suitable covering e.g. tarpaulin. Removing waste regularly, at least on a daily basis. Do not allow waste to accumulate remove at quiet times e.g. end of day, end of session. If construction activity is above ground level, remove bagged waste in a sealed lidded container. 5.6 Builders Clothing and Equipment Construction workers and their equipment should be free of debris and dust on exiting the building area, particularly if they are passing through clinical areas. The use of the following strategies may be recommended: Hoovers containing a HEPA filter for clinical areas. Change of clothing in an airlock if available. Overshoes to be put on when entering a construction area and removed on leaving. Overalls. Tacky mats. Wiping down equipment before it leaves the area. 5.7 Health and Safety of staff during renovation/construction Aspergillus species is not normally a risk to healthy staff. However, due to the likelihood of the increase of dust and possible inhalation, masks such as PRF95, should be provided for any staff that may come into contact with areas where they are likely to inhale dust. Temperature regulation of areas or windows may have to be sealed should also be considered and any renovation/construction work should be avoided in summer wherever possible. 5.8Protection of High-Risk Patients The risk for individual patients needs to be considered including: The possibility of delaying admission, admitting elsewhere or deferring elective immunosuppression if the patient cannot be nursed in a clean environment. This needs to be discussed between the named Consultant, Infection Control and the patient. Planning movements of susceptible patients, including access to hospital for outpatients and admission of inpatients, to avoid high risk areas if possible. The use of high efficiency face masks if the patient may potentially be exposed to dust. Prophylactic antifungal agents (itraconazole) may be considered in extremely vulnerable patients. If water supply may be compromised, consider the risk to patients. Ensuring appropriate physical barriers are in place. Seal windows, doors and ceiling space. (Solid ceilings are preferred to false ceilings in units with high risk patients). 5.9 Monitoring During construction, the ICT will review its progress in order to identify any potential problems at the earliest opportunity. Inspection will include considerations such as: Dust and debris. Traffic control. Barriers. Cleanliness of adjacent sites. Formal monitoring may be appropriate under some circumstances e.g. Airflow. Page 7 of 14

Air sampling. Particle counting. Water testing. Temperature. Humidity. A construction monitoring form will be used by the Infection Control team. A thorough check of the area by Infection Control and Estates will be made at the time of commissioning. Following completion of the work, a project appraisal should be completed within 1 month. 5.10 Clinical Monitoring Clinicians will be asked to report clinical cases of suspected hospital acquired fungal infection to the medical microbiologists. The ICT will then investigate possible causes. 5.11 Microbiological Surveillance During the summer months (01.04-31.09) transmission of Aspergillus species is higher compared with the winter months. Both settle plates and air sampling is required to monitor the level of Aspergillus species contamination. 6. Equality and Diversity The Trust is committed to an environment that promotes equality and embraces diversity both within our workforce and in service delivery. This policy should be implemented with due regard to this commitment. Page 8 of 14

Appendix I Environmental Control/Aspergillus Protocol INFECTION CONTROL CONSTRUCTION RECOMMENDATIONS Class I Execute work by methods to raising dust from cons. Ceiling tiles: Immediately replace tiles displaced for visual inspection Traffic: Visitor traffic routes should contact with pts Class II In addition to points for Class I above: Class III In addition to points for Classes above: Class IV In addition to points for above Classes: Water: mist work surfaces when cutting HVAC s: Air vents blocked & sealed before starting Monitor need to change or clean filters during const Area contained to 1 room with walls from floor to ceiling: Close door & duct tape frames & door Debris: covered, sealed & taped shut during transport No elevators used for debris removal Infection Control Specialist consulted Educate staff regarding risks Examine design of operational laundry/trash chutes for potential transmission Dust Minimization: partitions must be installed prior to starting (including construction in ceilings) Dust partitions must be sealed from floor to ceiling Debris: Transport debris during activity period (night best) Site thoroughly cleaned before pt admittance: remove blockage of air vents & wet mop with disinfectant frequency of cleaning adjacent areas Barriers: Dampers closed temporarily to circulation of contaminated air Assure adjacent air filtering systems are functioning Thoroughly clean new area before pt admit Airtight plastic barrier from floor to ceiling or drywall barrier covered or sealed Plastic seams must be sealed with duct tape Remove barriers carefully: spread of dust/dirt Barriers considered debris at disposal Ceiling: Openings from removed tiles covered in plastic & sealed until replaced Infection Control Specialist consulted Relocate patients to area remote from const. areas Transportation route or storage for clean supplies not near contaminated materials Traffic: Pt movement: exposure of pts to construction Water: Schedule interruptions during low activity Dust: wet-mop & place door mats at entrance Holes in walls not exposed > 4 hrs. Cover if more. Ceiling: access panels without barriers must be closed when unattended Ceiling Tiles, Porous: Remove & replace if wet Nonporous: Remove, clean with dilute hypochlorite & dry before replacement Maintain negative pressure in construction area Increase air filter change frequency Fresh air intakes 25 feet from exhaust outlets of vent system, combustion equip. stacks, med/surg vacuum system, plumbing vents, or area near vehicular exhaust or other fumes Vent system cleaned & balanced after completion of construction Page 9 of 14

Appendix II Environmental Control/Aspergillus Protocol INFECTION CONTROL CONSTRUCTION CHECKLIST Location of Construction: Project Start Date: Estimated Duration: Project Manager: Name of Contractor: ICS: P.M. Phone #: Contractor Phone #: ICS Phone #: Yes No Construction Activity. See Section A Below Yes No Infection Control Risk Group See Section B Below Type A: Inspection, non-invasive activity Group 1: Least Risk Type B: Small scale, short duration, minimal dust generating Group 2: Medium Risk activity. Type C: Activity that generates moderate to high levels of dust, requires greater than one work shift for completion Type D: Major duration and construction activities requiring consecutive work shifts. Page 10 of 14 Group 3: Medium/High Risk Group 4: Highest Risk CONSTRUCTION ACTIVITY/INFECTION CONTROL MATRIX TO DETERMINE CLASS **ICS must be consulted when the tool indicates that Class III or Class IV protocols are necessary. Construction Activity Risk Level Type A Type B Type C Type D Group 1 I II II III/IV Group 2 I II III IV Group 3 I III III/IV IV Group 4 III III/IV III/IV IV A) CONSTRUCTION ACTIVITY TYPES: Type A Type B Type C Type D Inspection and Non-Invasive Activities, Includes, but is not limited to, removal of ceiling tiles for visual inspection limited to 1 tile per 50 square feet, painting (but not sanding), wall covering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection. Small scale, short duration activities which create minimal dust. Includes, but is not limited to, installation of telephone and computer cabling, access to chase spaces, cutting of walls or ceiling where dust migration can be controlled. Any work which generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies. Includes, but is not limited to, sanding of walls for painting or wall covering, removal of floor coverings, ceiling tiles and casework, new wall construction, minor duct work or electrical work above ceilings, major cabling activities, and any activity which cannot be completed within a single work shift. Major demolition and construction projects. Includes, but is not limited to, activities which require consecutive work shifts, requires heavy demolition or removal of a complete cabling system, and new construction. B) INFECTION CONTROL RISK GROUPS Group 1 Group 2 Lowest Medium Office areas All other patient care units (Ex: Cardiac, Rehab, Neuro) General Medicine Laboratories Group 3 Medium High Emergency Room Radiology/MRI Post Anaesthesia Care Units (PACU) Outpatient Surgery All ICU s Nuclear Medicine Admission/Discharge units PT - tank areas Echocardiography Outpatient Group 4 Highest All OR s Sterile Processing Areas Cardiovascular Recovery All Cardiac Cath & Angiography Areas Dialysis Units Transplant Units Oncology Cardiology Anaesthesia All Endoscopy Areas Pharmacy Labour and Delivery Newborn Nurseries

Appendix III RISK ASSESSMENT FOR ASPERGILLUS DURING RENOVATION/CONSTRUCTION 1. Instruction for completion 1.1 Once EFM Department are aware of any proposed renovation/construction and work in the Trust they must complete Section A prior to sending it to the Infection Control Nurse or other member of the Infection Control Team. This included proposed work on ducting, ventilation systems and false ceiling work. 1.2 The Infection Control Nurse will complete Section B and forward completed copy to named EFM project representative. 1.3 It is the responsibility of the named EFM project representative to ensure contractors see a copy of both the MRSA Policy and completed risk assessment. Section A (for completion by facilities project representative) Date proposed renovation/construction due to commence:... Name of facilities project representative completing form:... Contact number:... Brief description of proposed renovation/construction work: Description of proposed renovation/construction area:. Any additional comments:. Page 11 of 14

Section B (to be completed by Infection Control Nurse/Member of Infection Control Team) Date form received from EFM project representative: Date.../.../... Section B completed by:... Date.../.../... High risk areas identified by Infection Control Team: (1) (2) (3) Other at risk areas identified: (1) (2) (3) (4) Comments: Appropriate Operational Manager of high risk areas informed: (1) (2) (3) (4) Have above been given/sent policy on Aspergillus: Yes ( ) No ( ) Other hospital services informed: (1) (2) (3) Microbiology informed of proposed work: Yes ( ) No ( ) Previously yearly Aspergillus spp. Data reviewed by Infection Control Nurse Yes ( ) No ( ) Appropriate clinicians informed of any prophylaxis necessary during work. If yes who? Yes ( ) No ( ) Date arranged for Infection Control Nurse and facilities project officer to visit proposed site of renovation/construction if appropriate: Date:../../.. Additional comments: Page 12 of 14

Appendix IV: Audit TOPIC: OUTCOME: Cleaning during building, upgrading and demolition work in health care premises Dust and building debris is kept to a minimum to reduce the risk of hospital acquired infection STATEMENT AUDIT CRITERIA YES NO N/A The additional cleaning requirements are clearly defined prior to the commencement of any building, upgrading or demolition work. TARGET.. ACTUAL.. VARIANCE.. Formula for calculating actual performance Number of Yes responses divided by number of applicable responses multiplied by 100 equals percentage of actual performance. 1. A risk assessment is carried out prior to work commencement, involving the Infection Control Team, Domestic Services Manager and Estates Department. 2. There is written communication of the requirement for additional cleaning during building or demolition work. 3. The Domestic Services Manager monitors the provision and standard of the additional cleaning. 4. Responsibility for clear communication is defined prior to the commencement of work. 5. The standard of cleanliness, agreed following the risk assessment, is maintained during the building, upgrading or demolition work. 6. The Domestic Services Manager documents deficiencies in the standard of cleanliness. 7. There is evidence to show that action to remedy deficiencies in the standard of cleanliness has been taken. Action plan (including timescales) 1. 2. 3. Signature of Auditor: Job Title: Location of Audit: Date of Audit: Review Date: Date of Follow up Audit: Page 13 of 14

Appendix V References Ayliffe G.A.J, Lowbury,E.J.L., Gedds, A.M. Williams GD 1992, Control of Hospital Infection 3rd Edition. Chapman and Hall Medical, London. Page 184-185. Centres for Disease Control 1994. Issues on Prevention of Nosocomial Pneumonia. American Journal of Infection Control Volume 22, Page 247-292. Fitzpatrick F Prowt S, Gilleec, E.A. Fenlan LE, and Murphy OM, 1999, Nosocomial Aspergillus During Building Work - Multi-disciplinary approach (letter). Journal of Hospital Infection Volume 42 No. 2 Page 170-171. Wenzel RP, Hospital Environment for Higher Risk Patients, Prevention and Control of Nosocomial Infection. Williams and Wilkins 3rd Edition 1997, Pg 463 489. Advisory Committee on Dangerous Pathogens. Department of Health Control of Substances Hazardous to Health Regulations 2002 Health and Safety at Work Act 1974 Management of Health and Safety at Work Regulations Page 14 of 14