Appendix 1 Infection Control Risk Assessment for Minor Repairs and

Policy for Prevention of Aspergillosis and other Environmental Pathogens during Demolition and Building Work Classification: Policy Lead Author: Dr Adam Jeans Additional author(s): N/A Authors Division: Clinical support & Tertiary medicine Unique ID: TC1(09) Issue number: 1.7 Expiry Date: July 2017 Contents Section Page 1 Who should read this document 2 2 Key messages 2 3 Background & Scope 2 4 What is new in this version 3 5 Policy 3 6 Explanation of terms/ Definitions 8 7 References and Supporting Documents 8 8 Roles and Responsibilities 8 Appendix 1 Infection Control Risk Assessment for Minor Repairs and 10 Maintenance 2 Infection Control Risk Assessment for Building & Demolition 11 3 Nosocomial Aspergillosis Prevention Group Terms of Reference 16 Document control information (Published as separate document) Document Control Policy Implementation Plan Monitoring and Review Endorsement Equality analysis Page 1 of 16

1. Who should read this document? Team leaders in patient care areas, laboratories, sterile processing areas and pharmacy. All facilities staff. 2. Key Messages Outbreaks of invasive aspergillosis may occur as a consequence of construction, demolition or renovation activities in or near areas of the hospital accommodating immunocompromised patients. Any proposed building or demolition work, including renovation, redecoration or maintenance work that may involve disturbance to the fabric of the building, must be risk assessed and appropriate infection control measures put in place before work is commenced. 3. Background & Scope Aspergillus species are ubiquitous fungi that commonly occur in soil, water, and decaying vegetation. Aspergillus species and other fungi associated with invasive disease produce spores which can persist in the environment and remain suspended in the air for a significant period of time. It is recognised that outbreaks of nosocomial invasive aspergillosis may occur in association with construction, demolition or renovation activities in or near hospital wards accommodating immunocompromised patients. Invasive aspergillosis is a cause of severe illness and mortality in these patients. In addition, construction and related activities can lead to increased contamination of the hospital environment with dirt and dust which increases the risk of the environment acting as a reservoir for hospital pathogens such as Clostridium difficile, Methicillin resistant Staphylococcus aureus (MRSA), Glycopeptide resistant enterococci (GRE) and Acinetobacter species. There are a number of strategies that can be adopted to prevent invasive fungal infection: Identification of at-risk groups High index of suspicion in at-risk patients, particularly at times when levels of spores in the environment are likely to be high Provision of HEPA-filtered air Other environmental measures including dust containment and control Targeted antifungal chemoprophylaxis This policy focuses on environmental measures; in particular those to be implemented when building and renovation work are being carried out, when levels of Aspergillus and other fungal spores are likely to be high. Page 2 of 16

This policy provides guidance to ensure construction/renovation activities within the Trust are managed in such a way as to minimise the risk of infection to patients. 4. What is new in this version? Risk assessment proforma layout changed to improve clarity. Classification of at-risk patients section updated. Reference section added. Terms of Reference for SRFT Nosocomial Aspergillosis Prevention Group added. 5. Policy 5.1 Classification of at-risk patients Patients at risk of invasive fungal infection as a consequence of demolition and building work may be categorised as follows: GROUP 1 - No evidence of risk Staff members, service providers and contractors All patients not listed in Groups 2 4 below (NB these patients may still be placed at increased risk of infection with other pathogens because of building work; discuss all proposals with the infection control team). GROUP 2 - Increased risk Patients on prolonged courses of high dose steroids or receiving other immunosuppressive drugs, particularly those hospitalised for long periods Severely immunosuppressed AIDS patients Patients undergoing mechanical ventilation Patients having chemotherapy who are not neutropenic Dialysis patients Patients undergoing plasma exchange GROUP 3 High risk Neutropenia for less than 14 days following chemotherapy Adult acute lymphoblastic leukaemia (ALL) on high dose steroid therapy Solid organ transplantation Intensive immunosuppressive therapy e.g. treatment for vasculitis Chronic Granulomatous Disease of Childhood (CGDC) Neonates in intensive care units GROUP 4 - Very high risk Allogeneic bone marrow transplantation o During the neutropenic period o With graft versus host disease Page 3 of 16

Autologous bone marrow transplantation, i.e. during the neutropenic period Peripheral stem transplantation, i.e. during the neutropenic period Non-myeloablative transplantation Children with severe combined immuno-deficiency syndrome (SCIDS) Prolonged neutropenia (for > 14 days) following chemotherapy or immunosuppressive therapy Aplastic anaemia patients The Infection Control Team will, in conjunction with the relevant clinical team(s), identify the highest risk group affected by every building scheme (as defined below) at the earliest possible point in the planning process and if there are any changes to the affected patient population for the duration of works. 5.2 Minor repairs and maintenance Minor repairs and maintenance includes activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection. Examples include, but are not limited to: o painting (but not sanding) o wall-covering o electrical trim work o minor plumbing o drilling small holes for the fixation of small or light items to walls o removal of ceiling tiles for visual inspection (limited to 1 tile per 50 square feet) Minor repairs and maintenance may proceed with the permission of the person in charge of the department, provided there are no group 2 or 3 increased risk or high risk patients in the same room (see section 5.1). Note this policy applies to risks of infection only, other health and safety risks must be assessed separately. No work should be carried out in areas containing group 4 very high risk patients without discussion with the infection control team. Before any minor repairs or maintenance are undertaken in any clinical area the member of facilities staff or contractor must discuss the proposed work with the person in charge of the department. Facilities staff and contractors will carry a copy of Appendix 1 which they will show to the person in charge of the department when seeking permission to carry out the work. Page 4 of 16

If the person in charge of the department is unsure, having reviewed Appendix 1, as to whether the work should proceed they must contact the Infection Control Team for advice. 5.3 Building and demolition work infection control risk assessment A formal infection control risk assessment must be performed for all building work other than minor repairs and maintenance (as defined in section 5.2). For the purposes of this policy, building work includes any renovation, redecoration or maintenance work that may involve disturbance to the fabric of the building such as the removal of ceiling tiles. The risk assessment must be carried out by the infection control team in conjunction with senior representatives from Estates department and, where applicable, from Trust contractors/project managers well in advance of any building/renovation work. A proforma for this assessment is included in Appendix 2. Once construction/ re-development project teams have become aware of any proposed building work within the Trust, they must inform infection control immediately, complete section A of the proforma and send it to a member of the infection control team. A member of the infection control team must be invited to initial planning meetings. It is the responsibility of the named facilities representative to ensure that contractors and subcontractors have read a copy of this policy and ANY completed risk assessments. 5.4 Infection control measures for building and demolition work Necessary measures will depend on the individual project, and will be determined by the infection control risk assessment. High-risk areas refers to any area containing patients in groups 3 or 4 (see section 5.1). If the proposed building work is to take place at a location very near to patients at high risk of aspergillosis (groups 3 or 4) consideration must be given to decanting patients to an alternative area until the work has been completed. Robust, dust-proof barriers, with airtight seals must be constructed between patient-care areas and construction areas to prevent ingress of dust and other material which may be contaminated with fungal spores. Barriers should be of solid construction wherever possible. Only where this is not possible should double layer plastic or polythene sheeting be used. Page 5 of 16

The infection control team must inspect barriers before building work commences. Any deficiencies in barriers as identified by the infection control team must be rectified before work can begin. Barriers must be inspected on a daily basis by the construction project manager to ensure their fitness for purpose. Particular attention must be paid to the seals around plastic sheeting. Barriers must only be removed after post-building work cleaning has been completed and has been approved by infection control personnel. Consideration should also be given to employing additional dust containment measures such as the use of water sprays by contractors to dampen down dust plumes. Regular vacuuming using HEPA filtered vacuum cleaners must also be performed, to remove dust as it is created. If building work takes place adjacent to service ducts in high-risk areas, these must be sealed. Ventilation ducts within the building must be protected. Every effort should be made to provide dedicated access points to the works area for building site workers and for transport of construction materials and debris. These must be sited as far away as possible from patient care areas. Debris chutes should be avoided, especially near highrisk areas. If there is a water leak within the construction site, or leakage of water from the construction area which affects adjacent areas, cleaning and repair must be undertaken as soon as possible as damp materials are highly conducive to fungal growth. If cleaning/repair cannot be undertaken within 72 hours of the incident, affected fabric and materials must be assumed to be contaminated with fungi and must be dealt with/disposed of accordingly. When building work takes place on upper floors, consideration should be given to designating stairs for the sole use of construction workers and building material. Construction workers whose clothing might be contaminated with sporebearing materials must not have contact with non-construction clinical areas. They must not enter high-risk areas. Painters dust sheets must be disposable. Staff, patients and visitors must not enter construction areas. In construction areas sited within high-risk areas of the hospital, air should be exhausted to the outside of the building if possible. Page 6 of 16

Waste material and debris must be removed in such a way as to minimise dispersal of dust e.g. bagging of waste, covering of skips, etc. When building work takes place at a site outside high-risk areas, or is within the hospital at a site adjacent to a high-risk ward and the site cannot be sealed off completely, windows in the high- risk area must be sealed for the duration of the work and for a period of at least one week following completion of the work. Sealing of windows, particularly during the summer, may lead to uncomfortable conditions for both patients and staff. Patients and relatives should be made aware of the reasons why sealing of the windows is necessary and the steps being taken to mitigate any discomfort. Minor building work must not be carried out in rooms that are occupied by patients. This should be deferred until the room becomes vacant. Rooms must be thoroughly cleaned before new patients are admitted. During building work arrangements must be made to increase the frequency of cleaning in areas adjacent to sites where the work is taking place. Newly constructed or refurbished areas must be cleaned and disinfected thoroughly before high- risk patients are allowed to enter. Infection control personnel must inspect areas at least 48 hours before patients are expected. This will allow re-cleaning to be carried out should infection control deem the cleanliness of the area to be sub-optimal. When building/renovation work has taken place within a high-risk unit, the ventilation direction of airflow and room pressurisation, where appropriate, must be tested and adjusted if necessary before patients are allowed to enter. Air sampling will also be required for fungal air counts and will be arranged by the infection control team. Severely immunocompromised patients must not leave protective isolation unless medically essential in which case the patient should wear a mask. The type of mask will depend on tolerance and may require fit testing; each situation should be discussed and agreed with the infection control team. The robustness of environmental measures must be monitored on a daily basis by either facilities staff or the infection control team. Identification of a documented, or strongly suspected, case of aspergillosis must prompt a complete review of the environmental control measures adopted for a given project. Page 7 of 16

6. Explanation of terms & Definitions Terms explained in document. 7. References and Supporting Documents 1. Department of Health. Health Building Note 00-09: Infection Control in the Built Environment. March 2013. www.gov.uk/government/publications/guidance-for-infection-control-in-thebuilt-environment 2. National Disease Surveillance Centre, Ireland. National Guidelines for the Prevention of Nosocomial Invasive Aspergillosis During Construction/Renovation Activities, 2002. www.hpsc.ie/a- Z/Respiratory/Aspergillosis/Guidance/ 3. Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for Environmental Infection Control in Health-Care Facilities, 2003. www.cdc.gov/hai/prevent/prevent_pubs.html 8. Roles and responsibilities The Executive Director of Nursing and Medical Director (DIPC) on behalf of the Chief Executive will ensure that the Clinical Directors take clinical ownership of the policy. The Clinical Directors on behalf of the executive directors of nursing and medicine (DIPC) will: ensure that all health care workers comply with this policy The Senior Nurses and Matrons on behalf of the Executive Director of Nursing and the Clinical Directors will: ensure that all health care workers comply with this policy The Infection Control Team will: Liaise with Estates and Capital Development regarding planned construction/refurbishment work Ensure that a suitable assessment of the infection control risk from any building/refurbishment is made and managed appropriately Lead on and provide expert advice to the Hospital Infection Control Committee and Nosocomial Aspergillosis Prevention Group Monitor the implementation of this policy within clinical areas Regularly review and update the policy Page 8 of 16

The Nosocomial Aspergillosis Prevention Group will: Convene as appropriate in preparation for planned major work schemes (see Appendix 3 Nosocomial Aspergillosis Prevention Group Terms of Reference). Plan measures to minimise the risk of aspergillosis as a consequence of the work and monitor their implementation. Report to the Hospital Infection Control Committee The Facilities Manager will: Ensure the ICT are aware, in a timely manner, of all construction/refurbishment work Partake in the risk assessment of the work as per this policy Ensure all facilities staff are aware of and adhere to this policy Ensure that contractors comply with measures in line with this policy All Trust staff including all clinicians will: Comply with this policy Inform the infection control team about any issues or concerns relating to construction/refurbishment work Page 9 of 16

Appendices Appendix 1 Infection Control Risk Assessment for Minor Repairs and Maintenance 1. Member of facilities staff or contractor - report to the person in charge of the department, inform them of the proposed minor repair or maintenance and request they read sections 5.1 and 5.2 before authorising the work to continue. 2. Person in charge of the department consider the room(s) where the proposed work is to take place. Does the room (or any adjacent space that cannot be separated by fully closed doors and/or windows) contain any: a. Patients on prolonged courses of high dose steroids or receiving other immunosuppressive drugs b. Severely immunosuppressed AIDS patients c. Patients undergoing mechanical ventilation (or with tracheostomy/et tube in situ) d. Dialysis patients e. Patients undergoing plasma exchange f. Patients undergoing chemotherapy, whether or not neutropenic g. Prolonged neutropenia (for >14 days) following chemotherapy or immunosuppressive therapy h. Bone marrow transplantation, during the neutropenic period or with graft versus host disease i. Peripheral stem transplantation, during the neutropenic period j. Non-myeloablative transplantation k. Adult acute lymphoblastic leukaemia (ALL) on high dose steroid therapy l. Aplastic anaemia patients m. Solid organ transplantation n. Intensive immunosuppressive therapy e.g. treatment for vasculitis o. Children with severe combined immuno-deficiency syndrome (SCIDS) p. Chronic Granulomatous Disease of Childhood (CGDC) q. Neonates in intensive care units 3. If YES either move these patients to another room or delay the work. If necessary discuss with infection control 4. If NO allow the work to proceed 5. If the person in charge is in any doubt they should contact the Infection Control Team for advice Page 10 of 16

Appendix 2 Infection Control Risk Assessment for Building & Demolition SECTION A: Building & Demolition Project Summary Location of Construction: Project Start Date: Estimated Duration: ICT member: Project Manager: Estimated Duration: Area Risk Group (see section B below) Area Group 1: Least Risk Area Group 2: Medium Risk Tick Building & Demolition Activity (see section C below) Type A: Inspection, non-invasive activity Type B: Small scale, short duration, minimal dust generating activity Tick Area Group 3: Medium High Risk Type C: Activity that generates moderate to high levels of dust, requires greater than one work shift for completion Area Group 4: Highest Risk Type D: Major duration and construction activities requiring consecutive work shifts SECTION B: Building & Demolition Area Risk Groups Area Group 1 Area Group 2 Lowest Medium Office areas Laboratories Area Group 3 Medium High Radiology/MRI Outpatient minor Surgery Nuclear Medicine Admissions unit Outpatient dept. All other patient care areas Area Group 4 Highest Theatres Sterile processing areas Theatre recovery, Critical Care, MHDU, HCU, H3 Ward areas with neutropenic patients All endoscopy areas Pharmacy Aseptic prep rooms Page 11 of 16

SECTION C: Building & Demolition 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. SECTION D: Matrix to determine Class of Infection Control Precautions for Use During Building & Demolition Building & Demolition Activity Area Risk Group 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 Refer to Section E for guidance on precautions for each class of construction project Page 12 of 16

SECTION E: Infection Control Precautions for Building & Demolition Note: Not all precautions will be relevant to all schemes/works, each planned scheme/work will be individually risk assessed and the relevant precautions applied. Class I Carry out work using methods to reduce raising dust from construction Ceiling tiles: Immediately replace tiles displaced for visual inspection Traffic: Visitor traffic routes should contact with patients Patient movement: exposure of patients to construction Transportation route and storage for clean supplies kept away from contaminated materials Water: Schedule interruptions during low activity Class II In addition to actions for Class I above: Water: Dampen work surfaces when cutting Air Conditioners: Air vents blocked & sealed before starting Monitor need to change or clean filters during construction Area contained to one room with walls from floor to ceiling. Close door & duct tape frames & door. Debris: Covered during transport No elevators used for debris removal Vacuuming of affected area Reduce Dust: Wet-mop & place door mats at entrance Holes in walls not exposed >4 hours. Cover for longer exposure times. Ceiling: Access panels without barriers must be closed when unattended Ceiling Tiles: o Porous: remove & replace if wet o Nonporous: remove, clean with dilute hypochlorite & dry before replacement Class III In addition to actions for Classes I & II above: Educate staff regarding risks Page 13 of 16

Dust Minimization: Partitions must be installed prior to starting (including construction in ceilings) Dust partitions must be sealed from floor to ceiling (if ceiling is not solid discuss with infection control team) Airtight plastic barrier from floor to ceiling or drywall barrier covered or sealed Remove soft furnishings and send curtains for laundering Adjacent ward windows kept shut during external construction Construction staff clothing must be free of loose soil and debris when entering hospital areas Debris: Chutes for debris removal must be discussed with Infection Control Team. Minimise dust plumes from chutes Transport debris during activity period Increase frequency of cleaning adjacent areas during construction Remove blockages from air vents & clean before patients admitted Thoroughly clinically clean site before patients admitted Clinical clean inspected by Infection Control Team No additional work to be undertaken during or after clinical clean Extent of clinical clean to be agreed with Infection Control Team Barriers: Dampers closed temporarily to circulation of contaminated air Assure adjacent air filtering systems are functioning and monitor regularly Plastic seams must be sealed with duct tape Remove barriers carefully: spread of dust/dirt Ceiling: Openings from removed tiles covered in plastic & sealed until replaced Maintain relative negative pressure in construction area where at all possible Increase air filter monitoring and change frequency Ventilation system cleaned & balanced after completion of construction Water: Mains, branch mains, risers and branches to a group of fixtures have stop valves Water lines flushed at site & adjacent areas before patient occupation Class IV In addition to actions for Classes I, II & III above: Relocate patients to area remote from construction areas No work to be undertaken with patients in the immediate area Work in HEPA filtered rooms to be planned in advance and room sealed during work Air must flow from clean to dirty area Recheck airflow following work Page 14 of 16

Appendix 3 Nosocomial Aspergillosis Prevention Group Terms of Reference 1.0 Definition (Constitution) The Nosocomial Aspergillosis Prevention Group (NAPG) has been established to minimise the risk of cases of aspergillosis occurring as a consequence of construction, demolition or renovation activities within the Trust. 2.0 Purpose and Powers (Duties) The NAPG will: Convene as appropriate in preparation for planned major work schemes. Plan measures to minimise the risk of aspergillosis as a consequence of the work, using the Trust policy Prevention of Aspergillosis and other Environmental. Monitor the implementation of the plan with ongoing review and amendment as necessary. Report to the Hospital Infection Control Committee. 3.0 Frequency of Meetings The NAPG will convene in preparation for planned major work schemes, with further meetings held as appropriate. 4.0 Membership Consultant Microbiologist Assistant Director of Nursing Infection Control Head of Estates Head of Facilities Representative from Balfour Beatty/contractor Critical Care Consultant Haematology Consultant Renal Medicine Consultant Respiratory Medicine Consultant Infection Control Nurses The Chairman may also when required co-opt, at his or her discretion, those with a specialist interest/expertise and able to support the activities of the group. 5.0 Chairmanship The Chair of the NAPG will be a consultant microbiologist. In the event of his or her absence the meeting will be chaired by the Assistant Director of Nursing for Infection Control or another consultant grade member. Page 15 of 16

6.0 Quorum A quorum will exist if the chair or deputising chair and at least 3 other members are in attendance, with not less than 2 consultant grade staff and not less than 1 representative from Estates. 7.0 Conduct of Meetings The meeting will follow the following format: Recording of those present and apologies Confirmation of previous minutes Matters arising Progress / update of building work Progress / update of preventative measures Identification of high risk patients Communications issues Any other business Date and time of next meeting 8.0 Reporting The NAPG will report to the Hospital Infection Control Committee Page 16 of 16