Infection Control Risk Assessment (ICRA) Developed and ... · 10/16/2019  · Infection Control...

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Infection Control Risk

Assessment (ICRA)

Developed and Presented by:

Wisconsin Healthcare

Engineering Association

Primun non nocere

Image from: http://www.bernardmansheim.com/first-do-no-harm-hippocratic-oath-guides-medical-practice-ethics/

Surgery was shut down for a

week.

‘The 7,000-square-foot sterile

processing distribution room,

which houses multiples of 3,700

pieces of equipment in the

bowels of the hospital, has

been cleaned and restocked

with new surgical supplies.’

A cleaning procedure is

suspected of causing the dust,

although a gasket on a light

fixture also was found to have

deteriorated..

What is an ICRA?

An Infection Control Risk Assessment (ICRA) is multidisciplinary, organizational, documented process that after considering the facility’s patient population and program:

• Focuses on reduction of risk from infection,

• Acts through phases of facility planning, design, construction, renovation, facility maintenance, and

• Coordinates and weighs knowledge about infection, infectious agents, and care environment, permitting the organization to anticipate potential impact.

The infection control risk assessment and

mitigation processes are important entry points for

the active participation by the infection

preventionist into the design and oversight of

healthcare construction and renovation projects to

provide input addressing infection risks to

patients, healthcare personnel, and visitors.

What is an ICRA?

Infection Control Risk Assessment

Establish a multidisciplinary team that

includes infection-control staff to

coordinate demolition, construction, and

renovation projects and consider proactive

preventive measures at the inception;

produce and maintain summary statements

of the team's activities (1,9,11--16,38,48--

51). CDC-Category IB, IC (AIA: 5.1)

Infection Control Risk

Assessment (ICRA)

Not Just for “Construction”

FGI 2018 Guidelines include Infection Prevention

guidelines in the design phase as well as

during the actual construction phase– Planning

– Design

– Construction

– Mitigation

– Monitoring

Infection Control Risk

Assessment (ICRA)

Design Phase

• Finishes & surfaces

• Number, location and type of Airborne

Infection Isolation (AII) rooms

• Protective Isolation rooms

• HVAC

– Surgery

– Endoscopy

– Laboratories

– Pharmacy

• Water systems

http://www.ashe.org/resources/pdfs/cdc/CDCfullbookDIGITAL.pdf

Hand Hygiene InfrastructureSink design

• Intended use– Hand hygiene

– Specimens

– Food prep

– Instrument washing

• Location

• Quantity

• Temperature control

• Aerators

• Faucet handle style

• Hands free– Motion sensors

– Foot activated

– Kick plates

• Basin size & depth

• Integral backsplash

• Emergency power

• Water treatment– ozonated water

• Drain location

• Trap disinfection system

Planning of Diagnostic, Surgical and Interventional Spaces

Parvizi, Javad, et al. "Environment of care: is it time to reassess microbial contamination of the operating room

air as a risk factor for surgical site infection in total joint arthroplasty?." American Journal of Infection Control

45.11 (2017): 1267-1272.

A person may shed 3,000-

50,000 organisms/minute

Class Level of

Invasiveness

Risk of

Infection

ACH MERV Number

of Staff

Amount of

Equipment

Min.

Square

Footage

1 Minimal Low 4-6 8/12 Low Low 80-120

2 Limited 15 130-160

3 Highly High 20 14 High High 255-270

OP

400 IP

Laminar flow of empty surgical suite

Sadrizadeh, Sasan, and Sture Holmberg. "Surgical clothing systems in laminar airflow operating room: a

numerical assessment." Journal of infection and public health 7.6 (2014): 508-516.

Impact of

door

opening

Sadrizadeh, Sasan, et al. "Airborne particle dispersion to an operating room environment during

sliding and hinged door opening." Journal of infection and public health 11.5 (2018): 631-635.

Traffic Patterns

During Surgery

Palmer, Gary, et al.

"Realizing improved

patient care through

human-centered operating

room designa human

factors methodology for

observing flow disruptions

in the cardiothoracic

operating room." The

Journal of the American

Society of

Anesthesiologists 119.5

(2013): 1066-1077.

Planning Phase

Layout issues as it relates to traffic

patterns

• Determine appropriate alternate

routes from the risk assessment.

• Designate areas (e.g. hallways,

elevators, entrances/exits) for

construction worker use.

• Do not transport patients on the same

elevator with construction materials

and debris.

Planning Phase

Determine location of dustproof partitions

and entry site.

• Use prefabricated plastic units or plastic

sheeting for short-term projects which

would generate minimal dust.

• Use durable rigid barriers for ongoing

long-term projects which would generate

minimal dust.

PARK NICOLLET METHODIST

HOSPITAL: CAFETERIA RENOVATION

Planning Phase

• Determine storage area for supplies

to minimize water damage and

control fire/safety hazards.

• Where will welding and other

obnoxious tasks be done?

Control Water Damage

• Mold mediation

• Make provision for dry

storage.

• Do not install wet, porous

building materials.

• Replace water damaged

building materials.

Planning Phase

• Determine break etiquette

• Determine delivery route of

construction materials.

Planning Phase

Determine if areas above, below or along side construction area must be protected

Consider:

• Ventilation

• Plumbing

• Cable pulls

• Water intrusion

• Elevators

• Vibration

Planning Phase

• Develop a demolition and construction

phasing plan.

– Disruption of inhabitants/pests

• Specify any necessary after-hours

construction.

• Determine need to seal windows, provide

additional air intake filters or turning off

air-handler units.

Particle Counter

• Use airborne-particle sampling

as a tool to evaluate barrier

integrity (CDC- Category II)

– Laser particle counter

– Calibrated on annually or as

recommended by manufacturer.

– Two channels to count particles

0.5 microns and one other size.

Define Expectations Priorto Starting Project

• Define barriers

• Types and locations

• Who is responsible to construct

• Who is responsible to maintain

• Define when erected

• Define when can be removed

Projects That Require Barrier Structures

• Demolition of walls.

• Removal of flooring.

• Working with sinks and plumbing.

• Exposure of ceiling spaces.

• Crawling into ceiling spaces.

• Work in elevator shafts.

• Repairing water damage.

Image from https://www.abatement.com/aire-guardian-mobile-dust-containment-cart-model-ag8000.html

Clarify Expectations

• Work methods

• Negative pressure verification

• Dust/debris control and removal process

• Define cleaning methods/frequencies

• How to turn off/on systems

• Time Schedules

• Noise/vibrations

• Closures/system shut downs

Operational Phase

• Convene a preconstruction meeting

• Educate construction workers regarding

infection control requirements.

• Hold project team meetings.

• Monitor compliance with construction.

• Identify responsibilities of hospital

personnel.

Process Measurement

Elements

• Conduct risk assessment prior to

construction.

• Conduct ventilation assessments r/t

construction barrier assessments.

• Establish and maintain pressure

differentials for special care units.

Construction –– Impact to occupants, work flow, safety, egress

– Who will occupy the space

– Future renovation should be considered

– Emergency Management build in

– Utilities disruptions – when – the least disruption

– Contingencies in place – in budget

Infection Control Risk

Assessment (ICRA)

Follow Plan

⚫ Request a copy of the Infection Control Risk

Assessment

➢ Implement measures as defined to limit liability

➢ Monitor barriers/measures for protection of patients

➢ Review the plan as the project progresses

➢ EVERYONE on the jobsite should know and follow

the plan – Post Plan

➢ Every person, every task, every day!!

Post Plan

⚫ Best practice to have

the plan posted

⚫ Prominent location

⚫ Highly visible

⚫ Contacts

⚫ Signature

⚫ Date

Infection Control Risk

Assessment (ICRA)

Mitigation –– What do you do to protect occupants,

– Activities to prevent infections related to construction

– Educate construction team and sub contractors on

requirements

Infection Control Risk

Assessment (ICRA)

Monitoring –– How will you continuously

monitor compliance

– Who is responsible for

monitoring

– How often will monitoring

be done

– Process if there is a failure

and work is stopped

– Who can do this

When is an ICRA Needed?

➢ Pre-construction

➢ Demolition

➢ Intra-construction

➢ Post construction and cleanup activities

➢ Educational and monitoring needs, before, during and after construction/renovation.

Do Small Projects Need an

Assessment?

All maintenance and small construction projects

need to be assessed and performed with the

same level of attention to the ICRA.

Small projects may also require an assessment

for interim life safety, noise and vibration,

asbestos and essential services disruption.

Problem Areas for Small

Projects or Maintenance

1. Not conducting an ICRA

2. Inadequate negative pressure system

3. Conducting renovations on “off-hours”

4. Improper barrier and anteroom design

5. Failure to follow industry protocol for mold

Step One: Level Activity

⚫ What Type of activity will you be performing

➢ Type A – Inspection or noninvasive activities

➢ Type B – Small scale, short duration which create

minimal dust

➢ Type C – Work that generates a moderate to high

level of dust or requires demolition or removal of

any fixed building components or assemblies

➢ Type D – Major demolition and construction projects

ICRA Matrix – Step One

Step Two: Patient Risk Group

“Group 1, 2, 3, or 4”

• Identify the Patient Risk Group that will be

affected by the project.

Restricted Areas

• Attire restrictions when working in

restricted areas

Step Three: Identify the Classification

• This defines the Construction Project

Protection Class – “Class I, II, III or IV”

• Use Class information to define measures

to be implemented during the project and

after completion.

• *Reference ASHE, AIA Guidelines and

EUA/ASHE Matrix

• Using the Activity Level (Step 1) and the Risk

Group (Step 2):

• Match Construction Activity with Risk Area to

define the Construction Class

Step Three: Identify the Classification

Step Four: Implementation

• Requires Infection Control Review and

approval prior to start of project.

• Requires implementation of measures as

determined by the ICRA.

• Required monitoring and documentation of

monitoring with corrective action

documented for deficiencies noted.

Class I

• Schedule utility interruptions during low

activity.

• If plumbing, flush lines prior to reuse,

observe for discolored water, verify water

temperatures, ensure gaskets and

materials do not support Legionella,

report any noted leaks.

CL

AS

S I

1. Execute work by methods to minimize

raising dust from construction operations.

2. Immediately replace a ceiling tile

displaced for visual inspection

1. Clean work area upon completion of

task.

During Construction Project Upon Completion of Project

Class II

• .

CL

AS

S I

I

1. Provide active means to prevent

airborne dust from dispersing into

atmosphere.

2. Water mist work surfaces to control

dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Place dust mat at entrance and exit of

work area

6. Remove or isolate HVAC system in

areas where work is being performed.

1. Wipe work surfaces with

cleaner/disinfectant.

2. Contain construction waste before

transport in tightly covered

containers.

3. Wet mop and/or vacuum with

HEPA filtered vacuum before

leaving work area.

4. Upon completion, restore HVAC

system where work was performed.

During Construction Project Upon Completion of Project

Inside the containment

Class IIIC

LA

SS

III

1. Remove or Isolate HVAC system in area

where work is being done to prevent

contamination of duct system.

2. Complete all critical barriers i.e. sheetrock,

plywood, plastic, to seal area from non work

area or implement control cube method (cart

with plastic covering and sealed connection to

work site with HEPA vacuum for vacuuming

prior to exit) before construction begins.

3. Maintain negative air pressure within work

site utilizing HEPA equipped air filtration

units.

4. Contain construction waste before transport in

tightly covered containers.

5. Cover transport receptacles or carts. Tape

covering unless solid lid.

1. Do not remove barriers from work area

until completed project is inspected by the

owner’s Safety Department and Infection

Prevention & Control Department and

thoroughly cleaned by the owner’s

Environmental Services Department.

2. Remove barrier materials carefully to

minimize spreading of dirt and debris

associated with construction.

3. Vacuum work area with HEPA filtered

vacuums.

4. Wet mop area with cleaner/disinfectant.

5. Upon completion, restore HVAC system

where work was performed.

During Construction Project Upon Completion of Project

HVAC Protection

Temporary Exhaust Systems

HEPA Filtering

Air Differential

Pressure Monitor

Class IV – During ConstructionC

LA

SS

IV

1. Isolate HVAC system in area where work is being done to prevent contamination

of duct system.

2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from

non work area or implement control cube method (cart with plastic covering and

sealed connection to work site with HEPA vacuum for vacuuming prior to exit)

before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA equipped air

filtration units.

4. Seal holes, pipes, conduits, and punctures.

5. Construct anteroom and require all personnel to pass through this room so they

can be vacuumed using a HEPA vacuum cleaner before leaving work site or they

can wear cloth or paper coveralls that are removed each time they leave work

site.

6. All personnel entering work site are required to wear shoe covers. Shoe covers

must be changed each time the worker exits the work area.

Posted ICRA Permit

Anteroom

Ante Rooms and HEPA Unit

Class IV – Upon CompletionC

LA

SS

IV

1. Do not remove barriers from work area until completed project is

inspected by the owner’s Safety Department and Infection Prevention

& Control Department and thoroughly cleaned by the owner’s

Environmental Services Dept.

2. Remove barrier material carefully to minimize spreading of dirt and

debris associated with construction.

3. Contain construction waste before transport in tightly covered

containers.

4. Cover transport receptacles or carts. Tape covering unless solid lid.

5. Vacuum work area with HEPA filtered vacuums.

6. Wet mop area with cleaner/disinfectant.

7. Upon completion, restore HVAC system where work was performed.

Completion Phase

• Thoroughly clean renovated area.

• Re-verify integrity of utility and safety

systems.

• Conduct post construction walk-through.

Legionella

• Remove dead legs

• Avoid collection tanks and long pipes that allow water to

stagnate

• Consider hyperchlorinating or superheating stagnant

potable water (especially if Legionella is already present

in potable water supply)

• Flush water lines at construction or renovation site and

adjacent patient care areas before patients are

readmitted

• Test water line

Strategy for Monitoring

• Gather baseline samples

– 3 samples of 1 minute duration counting at 0.5

microns or larger

– Include outside air samples

– Compare counts during construction and after

terminal cleaning process

– Suggest investigating any counts more than 2 x

the baseline

Containment of Particles

Use an Air Scrubber

Questions?