Andrew Streifel Hospital Environment Specialist University of Minnesota Medical Center 32 years service at U of Minnesota infection prevention. Visited over 400 hospitals & assisted in IAQ infection issues. Technical expert for ASHRAE, CDC, FGI & other organizations. Goal to provide evidence based training for prevention of infections during construction & maintenance practice. PROCESS GOING FORWARD RESOURCES: Reference Examples of ICRA Statements Infection Control Risk Assessment and Practices for the Design and Construction of the Ann & Robert H. Lurie Children s Hospital of Chicago Table of Contents I. Introduction II. Other Considerations III. Standards and Guidelines IV. Infection Control Review Committee A. Roles and Responsibilities V. Infection Control Practices During Construction A. New Construction & Renovation of Newly Constructed Work B. Infection Control Practices During Construction C. Process of Observing and Reporting Damages and Mold Damage Response Plan VI. Infection Control Practices During Commissioning VII. Infection Control Practices Post-Construction VIII. Transition and Move-in Planning Green field development Design Hazard Analysis New Construc7on Hazard analysis for cri7cal control points Recognize issues associated with design and IC Water and air emphasis Surface management for infec7ous disease Renova7on prac7ce Similar hazard analysis Pa7ent care environment occupancy cri7cal Both require owner guidance for infec7on preven7on 1
PROCESS GOING FORWARD DEFINE & AGREE on Team Members Roles & Responsibilities Owner Programming, Planning, Use & Administration Finalize the ICRA Statement IC Operations IC Specialist(s) - Guidance for Creating IC Design Specification Architects & Engineers Design in Terms of ICRA Construction Coordinate and Build in Terms of Design for ICRA Criteria Best Practice Means & Methods Commissioning Agent Validation of Special ICRA Specified Design Criteria ICRA Development Process Overview 1. Define Team, Roles & Responsibilities (IC Team) 2. Update & Maintain the ICRA On-Going (Owner) 3. Identify IC Action Items & Assess ICRA as it Affects Design & Construction (IC Team) 4. Create & Maintain Status Matrix of Actions for Design By Project Phase (IC Team) 5. Incorporate IC Driven Facility Requirements in Design (Design Team) 6. Enact IC Driven Construction Requirements (Contractor) 7. Commission of IC Requirements (Contractor) 8. Operate the Facility in Accord with IC Requirements (Owner) ICRA Team Members Project Manager Infec7on Control Contact Building Official Architect MEP Design Engineer Commissioning Tes7ng Agency General Contractor MEP Contractor Owner/Department Contact OWNER Plant Opera7ons Contact Telecommunica7ons Contact Environmental Services Contact Regular Safety Meetings -Place holder for Infection Control -Owners representative for IC attends as needed -Essential participation as building is sealed and pressurized -air -water 2
PROCESS GOING FORWARD RESOURCES: Reference Examples of ICRA Statements UNIVERSITY OF MINNESOTA CHILDREN S HOSPITAL, FAIRVIEW REPLACEMENT HOSPITAL & ANCILLARY RENOVATION INFECTION CONTROL RISK ASSESSMENT (ICRA) Interface with existing building I. The Infection Control Risk Assessment II. Internal collaboration and consideration III. Recommendations and Regulatory Resources to be incorporated: External IV. Recommendations and Regulatory Resources to be incorporated: Internal V. Operational Issues VI. Areas Requiring Infection Control Sign off for Design and Specifications VII. Communication: Technical Review User Group VIII. Construction IX. The UMMC Infection Control ICRA Planning and Design Elements for Consideration and Discussion PROCESS GOING FORWARD RESOURCES: Commissioning Guidelines IC Audit Checklist Questions Item No. 1 2 3 4 5 Date Infection Control Issue 9/25/2007 Chlorine Injection System vs. Copper-Silver Ionization ICRA - Infection Control Risk Assessment issue Dedicated Stair between IR, 9/25/2007 Major, Minor procedure floors 9/25/2007 Service Elevators - Clean/Dirty usage 9/25/2007 P-Tube: Single Station with clean and dirty counter vs. separate p-tube stations Owner s responsibility PROCESS GOING FORWARD PERFORM: Hazard Analysis of Critical Control Points Construc7on Responsibili7es Created by: Owner Architect Contractor Infec7on Control Risk Assessment Team approach Owner Driven Develop Mi7ga7on Plans Specifica7on Development for Control Points Internal External 3
PROCESS GOING FORWARD COMPLETE: Matrix of Tasks and Responsibilities Itemize & Resolve IC Concerns: Medical Planning, Surfaces, Materials, Building Systems, Operations & Processes, Etc. Item No. Date Infection Control Issue Comments Ball in Court [12/19/07][11/28/07] Hot water system needs to be a recuirculation system. Needs to generate water at 140 F Chlorine Injection System vs. Copper-Silver 1 9/25/2007 and recirculate it at 120 F to 128 F. No dead legs. Recirculation back to water heaters. Pairs of water heaters Ionization for Bed Tower and D&T floors. Water test for ions at farthest point on system. [11/28/07] Copper-Silver ionization needed ONLY on the hot water system and ONLY for the Bed Tower floors (13 through 22). [11/9/07] Use copper-silver ionization. No chlorine injection system needed. Check City water quality and combined chlorine vs.free available chlorine ICRA - Infection Control Risk Assessment 2 Limit dead-end pipe legs - cut and cap pipes at risers issue ZGF indicates that the communicating stair is included - subject to Fire Department Approval. Dedicated Stair between IR, Major, Minor 3 9/25/2007 ZGF reviewing opportunity for a scissor stair connection between the OR and Proceedure floors that would be procedure floors dedicated and semi-restricted 4 9/25/2007 Service Elevators - Clean/Dirty usage Elevator shaft is similar to a vertical corridor therefore conclusion is that both clean and dirty materials can be transported on the same elevator, even at the same time as long as materials are in closed containers and all protocols are followed. [11/28/07] Reviewed plan submitted by ZGF - approved. AEI noted that when a carrier arrives at the p-tube P-Tube: Single Station with clean and dirty 5 9/25/2007 station a puff of air is released above the ceiling. Andy Streifel noted that this was not a problem since the air counter vs. separate p-tube stations within the system is filterred. [11/9/07] - Must provide a clean and dirty side. Does not have to be large. Any exception MUST come back to the IC committee for review. Single station is OK - need to establish clear protocols to follow - double bag dirty materials - Blowers should be located in a filtered room 6 9/25/2007 Carpet in NICU area [1/25/08] Conference call with Dr. Shulman & Sherri Ewing: Dr. Shulman reiterrated IC's requirement that there be no carpet in patient care corridors including NICU. IC/ZGF Phases of Construction * Baseline Preliminary Review & Program Analysis *Pre design *Schema7c Design *Design Development *Construc7on Documents *Construc7on Implementa7on *Facili7es Commissioning *Occupancy What infection control principals need to be developed? -ventilation -plumbing -airborne infection isolation -surgery -immune suppression -disaster planning Identify locations for need. -user group collaboration Construction methods -water damage management -construction methods -validation process *Cer7fica7on for Use AIA 2010 Guidelines for Design And Construc7on of Hospitals & Health Care Facili7es Latest in an over 60 year series of guidelines specific for design and construc7on of hospital and other health care facili7es Nursing Facili7es; Outpa7ent Facili7es Rehabilita7on Facili7es; Psychiatric Hospital Mobile, Transportable, and Relocatable Units Hospice Care; Assisted Living Adult Day Care Facili7es Glossary Tables ASHRAE Std 170 Ven7la7on for HCF inclusion 4
Design Guidelines Design criteria Facili7es Guidelines Ins7tute Centers for Disease Control & Preven7on Uniform Building Code Interna7onal Building Code Na7onal Fire Protec7on Associa7on Plumbing code Electrical code Mechanical code Pharmacy code USP 797 other Specific Design Issues Opera7ng rooms Airborne infec7on isola7on rooms Protec7ve environments Procedure rooms Emergency department Wai7ng areas Morgue Surfaces Ven7la7on parameters Climate condi7ons Air intake loca7ons Hand washing access Sharps control Pest control Water damage management Area with water damage poten7al should be water resistant. Janitor s closets Dish rooms Bathrooms 5
What Should The Outside of the Building Do for Infec7on Control? It should not leak water or air Brick versus panel installa7on weep hole plugs architectural gaps and gaske7ng Mi7gate infiltra7on of water and air by design? How do you keep the weep holes from plugging?? How do you prevent architectural gaps from occurring on panel curtain walls? Infec7on Control Issues per Owner Review Landscaping Sprinkler adjustment spray on wall Slope of earth Sterile processing Rinse water Sterilizer processing Water treatment Laboratory Kidney dialysis Cooling towers Water source management Maintenance Water proofing Chutes Trash Linen Water treatment equipment 6
Infec7on Control Issues per Owner Review Pandemic isola7on Surge capacity Employee safety Immune compromised pa7ent ven7la7on Protec7ve environment? Less stringent control measure pa7ent units (Oncology) Emergency Department Ven7la7on & isola7on Surge capacity Finishes & surfaces Furniture Disinfec7on Hand cleansing Water less Sinks Ac7va7on method Infec7on Control Issues per Owner Review General clinical areas func7onal performance tes7ng Filtra7on valida7on Pressure, air exchanges and filtra7on Water chlorina7on Residual disinfectant Special ven7la7on Airborne infec7on isola7on Protec7ve environment Valida7on of ven7la7on parameters Cleanliness for occupancy Surface cleaning standard Ven7la7on systems Horizontal surfaces Visual or microbiological? Test methods Interpreta7on of data Negative Pressure Room for Airborne Infection Isolation monitor corridor Intended Usages: Procedure/Treatment Rooms Bronchoscopy Autopsy Emergency Rooms 7
Positive Pressure Room Control for Protection From Airborne Environmental Microbes monitor corridor Intended Usages: Immune Compromised Patient Rooms Operating Rooms CDC EIC MMWR JUNE 6, 2003 AIA & ASHRAE DESIGN GUIDELINES FOR VENTILATION Airborne Infection Isolation Room with Anteroom ante room monitor bathroom normal corridor immune compromised neutral ante room monitor bathroom corridor immune compromised ante room monitor bathroom corridor pressure differential @ 2.5 Pascal's or 0.01"w.g., sealed room with about 0.1cfm/ft^2 greater than 125 cfm airflow differential Supply vs Exhaust. clean to dirty airflow, monitoring >12 air exchanges per hour new or 6 ac/hr renovation anteroom airflow patterns 8
CEILING REAL ESTATE CEILING PROPERTY FILLS UP FAST TO PROVIDE MULTI FUNCTION OF THE CEILING COMPONENTS SCHEMATIC DESIGN DOES NOT ALLOW FOR CEILING COMPONENT UNLESS PREPLANNING OCCURS Room Leakage Areas Airflow leakage occurs around: plumbing connections medical gases electrical/video connection lighting ceilings windows/doors door cracks in wall mounted fixtures Room Seal Necessary for Special Ventilation Management Cracks can result in room air leakage. Supply air volume differential allows for airflow direction control. Low pressure differential can result in airflow reversal. Substantial room pressure design should provide a sealed vessel. Design criteria are necessary for control. 9
IC CONSIDERATION EXAMPLES IC Design Assessment TOOL: Computer Simulation of Patient Room Airflow PE Room 0.120% Low wall return Concentration kg_c / kg 0.100% 0.080% 0.060% 0.040% 0.020% 0.000% Low wall return Ceiling return Ceiling return Where should the return/exhaust be located ceiling or low wall? ICRA Mi7ga7on Process Means and methods development do not tell the contractor how to do a job but ask them how they will do it Documenta7on water damage & other issues mold cleanup valida7on Commissioning guidelines for infec7on control ven7la7on parameters dialysis & lab water quality municipal water Infection Control Risk Assessment Mitigation Response Notification Process areas affected work description start & finish date work hours notification/permits information included noise & vibration contractor Sub and Sup phone meeting time 10
Plan Review can be confusing? When to. What to look for.. What can you do.. How do you know.. What to say When to say it Be a team! Temporary Post Anesthesia Airborne Isolation Room Exhaust What needs to be done to protect workers? signage communication expedite move train IC CONSIDERATION EXAMPLES Construction Management issues Proac7ve and reac7ve response to water damage. Water & mold resistant gypsum board Sanita7on Break areas 11
Recycling & Waste Management Plan Iden7fy loca7on Owner, owner s rep, construc7on mgr & architect Develop communica7on plan Training contractor and sub contractors Compliance expecta7ons Sor7ng bin coordina7on Recycle & Waste Mgmt Procedures Salvage Source separated recycle Mixed debris recycle Disposal (recycle not feasible) Goals & Objec7ves Pre construc7on On going recycling Post construc7on Value Engineering During Construc7on What process do you have for VE Who approves the decision Is infec7on control involved where appropriate What VE proposals are not acceptable and must be discussed Water proofing Warranty issues Ven7la7on compromise Surfaces Air Intakes May Need Altera7on Do: extend air intake to avoid fumes Don t: choke off the airflow Charcoal pre filters will help to reduce fumes from roofing, welding or delivery trucks. Careful not to impede airflow 12
PROCESS GOING FORWARD RESOURCES: Case Studies EXAMPLES IC CONSIDERATION EXAMPLES Water Damage & Mold Proactive Response Reactive Response What is the difference in these shaft walls? -Luck? -Better materials? -Construction Implementation? -All of the above? IC CONSIDERATION EXAMPLES Construction Management issues Water damage will happen! 13
IC CONSIDERATION EXAMPLES Construction Management issues Why should the specification for gypsum board installation include keeping it off the slab? Keep porous material less than 20% water content and relative Humidity < 95%. Because it keeps the gypsum board dry! Best Practice Consider code and noise issues with caulk under the gypsum board Keep the rock off the slab! Specifica7on: Do not install wet GB Protect GB from WD & Extreme climate Storage of gyp board should provide protection from water damage IC CONSIDERATION EXAMPLES Construction Management Issues Some organizations require cleaning floor rails in certain areas during new construction. Will such an effort help keep mold under control? 14
IC CONSIDERATION EXAMPLES Design Concerns MOLD SOURCES ARE COMMON CONTROL PREVENTS INFECTION & OTHER ISSUES IC CONSIDERATION EXAMPLES Moisture detectors are useful decision makers for water detection & drying Keep moisture content <20% &<90%RH Maintain air movement Remove moisture physically or by evaporation Infrared technology IC CONSIDERATION EXAMPLES Ventilation Control in Hospitals - Commissioning SPECIAL VENTILATION ROOMS Conduct Performance Analysis for Validation of Specification Particle counter air quality Outside vs other areas Lowest levels in the cleanest locations Pressure monitoring Airflow from cleanest to cleaner to clean Pressurized environment Filtration and Air exchanges Dilution ventilation with purified air 15
IC CONSIDERATION EXAMPLES Construction Management & Commissioning issues Parameters should be kept stable and should be checked when changes or adjustments in the HVAC system occur. Particle counters tell the rank order Pressure gauges give air velocity Balancing hoods verify air exchanges Owner s Acceptance Criteria Air quality clinical applica7on Water quality clinical applica7on drinkable These require specific objec7ve informa7on for JCI and Baseline data Cleanable surfaces Control of the environment for pa7ent safety University of Minnesota Medical Center Amplatz Children s Hospital Children s Hospital -102 Bed acute care facility -Cancer center -Bone Marrow Transplant-20 Bed -Solid Organ transplant Current Programs -Behavior Health -Birth Center -Neonatal ICU -Active Orthopedic Surgery & Rehab -Advanced Diagnostic & Therapeutic Radiology Facility Challenge -discovery of existing conditions -marriage of building at Surgery and NICU sites 16
UMCH Replacement Hospital: Infection Control Risk Assessment (ICRA) The ICRA mad be modified throughout the Project. Page 1: Patient Assess ment. Page 2: Management of the Envi ronment N ot ifica tion #: 99R Project or Phasing: Start Date: 7/24/13 Pr oject Lo cato n: I nc lu d e sh or t d escrip tion : Level 3 OR Project Manager / Owner's Representative: Pat Stockhaus Ph on e #'s: See Master List of Key Contacts KA: Project / Phasing Manager: Chris Patraw UMCH Uni t / De par tmen t M ana ger : 1. Patie nt gr ou ps that may be impacted by the project. (Example: On co log y, BM T, OB ) OR 2. Proce dures that may be impacted by the project. (Example: OR, ER, Laser ): Identified by Unit or Departm ent Ma nager as needed. OR 3. Le vel and Group of R isk. Lev el 1, 2, M inim al Du st. This project is a Level: M inim al dust Group #: 4 Meduim - High Risk 1. Office Areas Group 1 Low Risk G rou p 2 M ed ium 1. All patient care units (Example: Cardiac Rehab) G rou p 3 Group 4 Medium - High High 1. Emergency Room 1. Transplant Unit 12. Cardiac Unit 2. Radiology/MRI 2. OR, PACU, & Pre-induction 13. All Endoscopy Areas 3. Labor & Delivery 3. Sterile Processing 14. Pharmacy 4. Newborn Nurseries 4. ICU's 5. Pediatrics 5. Labor & Delivery - OR 6. Nuclear Medicine 6. Cardiac Catheterization & Angiography Areas 7. Admission/Discharge Area 7. Pulmonary Function 8. PT (tank areas) 8. Dialysis Areas 9. Cafeteria/Kitchen 9. Oncology Unit 10. Special Procedures - Radiology 10. BMT 11. Laboratories 11. Radiation Oncology Identified areas surrounding the project to consider for potential impact. Un it Belo w Un it Above Lateral Lateral B e hin d Front Risk Group Risk Group Risk Group Risk Group Risk Group Risk Group Scope of work: -remove walls -three phases -premium hours -two air handlers -barriers and HEPA Preconstruction Notification: Establish monitoring for infection control -subjective-visual -objective-pressure and particle counts Interpretation guidelines must be established -if contractor using particle counts -if owner s representative using particle counts -baseline versus problem Patient present or not -rules -noise and vibration -particle levels and airflow direction (intensity) Clearance Guidelines -baseline levels -comparison 17
With barrier layers and local HEPA the particles are optimally captured. Operating rooms remained pressurized to assure dilution ventilation and controlled airflow direction. Tricky part involved winter breakthrough of exterior wall. 18
Build a temporary barrier during winter to get project started before fully enclosed. This area will be the tie in for the operating rooms. Four additional operating rooms and intervention will be built later but the process requires building in the winter. Remove outer layer brick two layers. Risks: Noise & vibration Patient safety if doing surgery Particle count and pressure monitoring were required for quality assurance -Training for scope of work -What to look for in particle management of work -Stoppage guides for particle & noise/vibration 19
Draping walls important for containment in OR demolition Some barriers were left open to assure controlled airflow and pressure. Monitoring conducted to assure appropriate levels of particle and pressure. As the wall came down winter required heating the space but water condensation forces outside combustion to control water vapor. Existing condition monitoring 1/8/10 PARTICLES Pascal's AIR FLOW COMMENT Particle sampling Fairview Riverside Medical Center OPERATING ROOM p/ft^3 press diff direction out 1 4200 8.3 6 people case 2 550 6.8 out empty Pressure measured with a Digital Pressure Gauge 3 1500 6.8 out 1 setting up Particle counter measured particles greater than 0.5µm 4 11000 3.7 out 7 people case 5 1100 9.3 out Divinci case 5 people 6 75 5.4 out empty 7 120 4.5 out empty 8 0 5.1 out empty 9 0 3.6 out empty 10 0 4.9 out empty 11 1950 2.8 out 1 setting up 12 4200 8.3 out setting up 14 820 8.3 out 3 people patient prep corridor out 2700 4.5 traffic OR desk 33000 4 people outside 130000 anest wk rm 64000 above ceiling 400000 minus to 1.8 variable from negative 0.3 to positive airflow 20
Unknown factors must be anticipated Cutting in doors for clean core access to new operating rooms. Unknown mechanical under window required plumbers and electricians to remove abandon lines to expedite project. Clearance Monitoring for Infection Control Particle counts for clearance Similar to pre construction Alias particles can cause concern Vapors can affect particle counts Validate other OR s on same fan to assure Low counts in non affected OR s assured Particle counts were from vapor not dust Operating room protection and assurance Plastic barriers protect wall mounted equipment. Portable filters open returns and particle counts assure safety. 21
30 OR Pressure Differential (in Pascals) 25 20 15 2/3/09 2/14/09 2/15/09 10 5 0 OR 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 10 OR 11 OR 12 OR 14 North Door South Door particles (>0.5µm)/ft^3 Outside particle counts from 54000 to 74000 particles/ft 3 particles (>0.5µm)/ft^3 22
Lessons Learned Determine sampling protocol Set limits: usually rate of increase Communicate Include user group and coordinate Project manager key individual Quality monitoring prevented surgery delay 23