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Infection Control

A Contractors perspective towards achieving ICRA compliance

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PresentersATI Healthcare Environmental Division

Dena Kaul Regional Account Executive, San Diego Gary Tilton Project Manager, San Diego

Oscar Rodriguez- Project Manager, San Diego

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AgendaATI Company IntroductionEvolution of ICRA (2001 Standard)Joint Commission - Environment of Care StandardICRA Risks and Mitigation MeasuresMulti-Disciplinary Team ApproachThe WhyBarriers Negative Pressure Isolation/ Monitoring/ VerificationILSM Communication Measures & Challenges[ 2 ]

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Who We Are American Technologies, Inc. is a leader in restoration, environmental and reconstruction services with over 700 full-time employees in 15 offices regionally located throughout the United States.Based in Orange, CA, ATI is comprised of three major divisions; Environmental, Restoration/Reconstruction and Healthcare Environmental Services. Within these divisions, we provide comprehensive recovery services following natural and man-made disasters including:24-Hour Emergency Response Environmental Remediation for Asbestos, Lead, Mold and Biohazards Contents Cleaning and Restoration Reconstruction Duct Cleaning/HVAC/Kitchen Hood CertifiedElectronics RecoveryDocument Restoration

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[ 4 ]Territories

= Regional Offices= ATI Presence

HIAZCAFLILINIAKYLAMIMNMSMTNVNMNYOHORTNTXMexicoUTNCWAWISCMAMEVTNHARNESDIDCTRIPANJMDDEVAWVGAALMOKSOKWYCONDAK

SacramentoSan FranciscoSan JoseLos AngelesOrangeRiversideSan DiegoLas VegasPhoenixChicago

New England

DallasTucsonAlbuquerque

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Joint Commission 2009 Environment of Care Standard Requirements

EC02.06.05EP 1. When planning for new, altered or renovated spaces the hospital uses design criteria, state rules and regulations, AIA Guidelines (2001), other reputable standards or guidelinesEP 2. The hospital conducts preconstruction risk assessments for air quality, infection control, utility requirements, noise, vibration and other hazards that affect care, treatment and servicesEP3. The hospital takes action based on its assessment to minimize risks during demolition, construction or renovation

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Joint Commission 2010

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Joint Commission 2010

Facility GuideIines Institute 2010 http://fgiguidelines.org/

PCRA (ICRA) Team RequiredInfection PreventionDirect Patient Care - clinical, from impacted department(s)Facility Knowledge HVAC, MEP, Scope of ProjectOther(s) as dictated by scopePCRA done (started) during planningOwner or 3rd party conducts monitoring of risk mitigation measures for the duration

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THE WHYScripps Memorial Hospital La Jolla should have done more to protect seriously ill patients from exposure to a potentially lethal fungus that thrived during remodeling. A cluster of patients at the hospital tested positive for the common fungus, aspergillus, from Oct. 28 to Jan. 28, a time during which the hospital was remodeling. Six of the patients died (Los Angles Times March 31, 2000).The parents of three young leukemia patients say their children died because the Hospital failed to protect them from mold stirred up during an expansion at the hospital.All three developed infections from aspergilla's, which is a type mold (Tom Brennan February 5, 2009)

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THE HOWASSESS THE PROBLEMDEVELOP A TEAMESTABLISH THE PLANCOMMUNICATE THE PLANEXECUTE THE PLAN

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10Updated PCRA Form

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11Multi-Disciplinary Team Approach

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12Roles and ResponsibilitiesSubcontractorsEC02.06.05 Noise, Vibration, AQInstall containment and engineering controlsWill know chemicals and methods to be used (noise and vibration issues)Schedule and duration3 people, 3 days or 4 people, 2 long shifts, etc.Need to know where to exhaust, how to enter and exit the work areaSometimes the first time the superintendent sees the work plan is the day s/he arrives on the job

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13Roles and ResponsibilitiesOwnerResponsible to conduct the PCRAInfection Control Professional (aka Infection Prevention)EC 02.06.05 Infection ControlIdentifies (or confirms) the risk group(s) impacted by the projectTypically a clinical professional, on hospital staffMay be the required signatory for the permitVarying degrees of construction project expertise Can be our most ardent supporter

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14Multi-Disciplinary Team ApproachMultiple experts to:Help identify risksAssign risk mitigation measuresDetermine methods to evaluate effectivenessWhich of the experts knows about:Infection Control? The buildings MEP systems?The scope of the project?Mold?Noise?What does Air Quality mean?How to test, when to test?How to interpret test data?Generally no single person knows all of the issues

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15Roles and ResponsibilitiesEnvironmental Health and Safety ProfessionalEC 02.06.05, Air Quality, Other hazards, perhaps ICReview the PCRA, procedures and monitoring methodsMay understand containment, engineering controls, work practices, etc. May be knowledgeable on testing methods and interpretation of dataOften participates in Environmental ToursMay be aware of other hazards (chemicals, biologicals)May provide information on in-house policies, documentation requirementsMay be tasked with assigning risk groupsMay have access to asbestos inspection reports

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16Roles and ResponsibilitiesFacility Manager/Building EngineerEC 02.06.05, Utilities; LS01.02.01, Life Safety SystemsExcellent source for utilities related issuesCan provide information on HVAC system, medical gas line locations, confined spaces, above ceiling access requirements, water features, shut offs, etc.Can help determine where vibration impact will travelMay provide input on in-house policies for HVAC and plumbing re-commissioning (testing, flushing, treatment)Sometimes knows the scope of workMay also have access to asbestos inspection reportsOften difficult to get to a meeting

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17Roles and ResponsibilitiesConstruction Project ManagerEC02.06.05 all elements; LS01.02.01Knows the scope and phasingMay know the methods of the subcontractorsMay understand the EC requirementsMay understand testing methods and data interpretationMay have contractual requirements to implement (and monitor) risk mitigation measuresMay have forms that can be used to document conditions or findings (meeting minutes, logs)

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18Roles and ResponsibilitiesArchitectsEC02.06.05 all elements; LS01.02.01Know the scope and phasingWater systems, HVAC shut downs or tie-insMay have knowledge of impacted departments well in advanceMay provide advance warning for impact on utilities, need for above ceiling inspectionsMay include testing in specifications without clear understanding of impact (cost, timing, data interpretation/acceptance criteria)

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19Roles and ResponsibilitiesMedical Professionals (Doctors, Nurse Managers)EC02.06.05 Infection ControlAssign risk groups, provide important input on the impact of noise, vibration or patient relocationDepartment Managers have department specific information(AIIRs, hand washing locations, schedules for procedures)Can provide information, support and education on infection risks based on department/historyMay have input on analytical/lab methodsDesired data, level of analyses, air, surface, water

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20Roles and ResponsibilitiesEnvironmental Services (EVS)EC02.06.05 IC, otherMost likely will conduct pre-occupancy (terminal) cleaning and need to know where work impacted the environmentCan provide information on preferred (or prohibited) cleaning agentsKnow where sharps and biohazard waste containers are located and should be the ones removing them prior to construction

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21Roles and ResponsibilitiesConsultantsEC02.06.05 all elements; LS01.02.01Understand construction, building functions, regulatory requirements, environmental sampling.Provide expert level consultation on applicability, benefits and limitations of testing methods and data interpretation.Can provide third support for the owner and avoid conflict of interest issuesCan provide independent communication support Town hall meetingsHelp build confidence between the construction side and the clinical side

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22Benefits of the Multi-Disciplinary Team ApproachMeets the recommendations set forth in CDC and AIA/FGI Guidelines (referenced by EC standard)Includes multiple experts to ensure risks are adequately consideredBuilds confidence in the teamHelps avoid complaints from impacted departmentsHelps avoid clinical disruptionsHelps avoid project disruptionsMinimize impact on the Environment of Care

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23Certificate Training for Consultants and ContractorsSome require prerequisite training and/or experienceNot allDemonstrate commitment to learningVoluntaryNo standards requiring certification for HealthcareSome local policies starting to include requirements for education and/or certification

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24Standard HVAC System

24This is a normal HVAC supply and exhaust system.

Creating a Negative Air Environment Using Existing Ducts25

Exhaust register zoned offExhaust register zoned off

This is standard protocol to Isolate the HVAC System and exhaust HEPA filtered negative air utilizing existing exhaust ducts.

This is a last resort scenario First option would be to exhaust out a window or doorPlan B would be to exhaust into an adjacent space or hallwayPlan C would be the above illustration with authority having jurisdiction approval (IC, Facilities etc.)25

Negative Air Exhaust26

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Scripps Mercy HospitalFourth Floor Renovation27

28Scope of Work

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Phasing Plan

ICRA Barriers/ Construction Path of Travel30

BAD BARRIERS

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Monitoring Checklist32

THE ATI DIFFERENCE[ 33 ]

PRE AND POST BARRIER CHECKLIST

ILSM Communication Measures34

ICRA Isolation35

WHERE ATI CAN TAKE YOU

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ICRA Isolation37

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NAM used to supply Cool Air38

Monitoring Containment39

KNOWLEDGE IS POWER

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Air Pressure Verification41

ILSM Communication Measures42

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43Challenges to ComplianceLife Safety Code3 of top 10 violations in 2010 were LSCHallways obstructionsDocumentation missing, not believable (e.g. 12 projects audited, no LSC impact)Egress paths altered, no ILSMs in place Contractor not knowledgeable of code or facilityICRA/PCRA not done, not done rightOne permit for the entire 3 month project, all phases, all areasRequired experts not engaged.Done but not updated as project evolvesStarts as a Class 3, ends up a Class 2 or vice versa

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Challenges to Compliance44

Mobile Containment UnitKONTROL KUBE

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HVAC/Duct Cleaning in a Hospital Environment

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Neglected HVAC EquipmentFilters/Belts get replaced during PMs

HVAC- Supply Registers Preventive Maintenance

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Dirty register with heavy lint debris attached to louvers causes for low air flow and reduces the air exchanges.Quarterly cleaning program for a more efficient HVAC System.

HVAC- VAV Box Cleaning[ 48 ]

Fiberglass insulation deteriorationNew Foil Insulation installed

HVAC Black Fiberglass Insulation deterioration from moisture causing microbial growth on surface.

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White microbial coating on the fiberglass surface

Fiberglass Insulation removed and new foil Insulation Installed

Deteriorating HVAC Piping mold and condensation source

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Eliminate any future issues with mold and water damage losses.Survey HVAC supply/return lines for damage from contractors and deterioration.

( 51 )ATI Advantage24-Hour Emergency Services

Infection Control Assistance

Duct Cleaning

Environmental Mitigation

Containments

Restorative Drying

Records Recovery

Bio-Decontamination TechnologyHydrogen Peroxide VaporUltraviolet Nosocomial Outbreak Prevention/ HAIsPackaged Consumables Decontamination

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FINANCIAL SECURITY

Insurance and Bonding Summary:General Liability Insurance National Union Fire Insurance Company, Best Rated A (XV)$1 Million each Occurrence, $2 Million General Aggregate$10 Million Umbrella Liability Occurrence BasisContractors Pollution Liability includes coverage for Asbestos/ Lead/ Mold Abatement

Bonding CapacityInternational Fidelity Insurance Company, Best Rated AVIII$5 Million per project - $25 Million aggregate

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AWARDS AND ACCOLADES[ 53 ]

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Questions ?

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800-400-9353www.amer-tech.com

FULL SERVICERESTORATIONENVIRONMENTALRECONSTRUCTIONEXPERTS

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Area of Work 6,935 SF

Contractor Elevators 151 SF

03 Mercy Floor Plans 4th Floor.pdf (98% of Scale); SMH 4th Floor Renovation; PBG-Projects; 2/25/2011 09:24 AM

Demo- Existing Sink & Fixtures, Cap Plumbing 1 EA

Demo- Lower Cabinet 59 SF

Demo- Upper Cabinets 14 SF

Demo- Water Damaged Plaster 23 LF

Demo- Existing Sink & Fixtures 10 EA

Replace 12x12 Ceiling Tiles 1,870 SF

Remove Battery Operated Smoke Detectors (Salvage) 13 EA

Remove Signage at Room Doors (Salvage) 13 EA

Remove Paint from Existing Terrazzo Base 851 LF

Remove Existing Rubber Base 120 LF

Remove Transition / Threshold @ Hallway (Salvage) 7 LF

Remove Towel Racks (Salvage) 10 EA

Remove Vinyl Lettering at Vision Lites 1 EA

Demo- Existing Carpet and Scrape Subfloor 3,659 SF

05 Mercy Floor Plans 4th Floor - Demolition.pdf (98% of Scale); SMH 4th Floor Renovation; PBG-Projects; 2/28/2011 06:41 PM

Phase I 4,017 SF

Phase II 2,354 SF

Phase IIB 224 SF

Phase IIA 223 SF

Phase III 317 SF

04 Mercy Floor Plans 4th Floor - Phasing & IC.pdf (98% of Scale); SMH 4th Floor Renovation; PBG-Projects; 2/25/2011 09:27 AM

FOURTH FLOOR=Infection Control Barriers=Designated exit routes4th Floor renovation-PHASE 2

FOURTH FLOOR=Infection Control Barriers=Designated exit routes4th Floor renovation-PHASE 4

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