Infection Control Primer, Part II

Posted on May 8, 2014


Infection Control Primer, Part I

Hospital acquired infections (HAIs) continue to be an important focus in hospitals from a risk management standpoint, and like biology, they are always evolving.  The infection problems du jour may not be the same ones five years from now.  Regardless, I present the second part to my infection control design and construction primer, which is a general approach to understanding infection control from the construction standpoint [see above link for design].

From an awareness approach, it is important to realize the enemy is an invisible collection of pesky “germs” (bacteria, viruses) that are not the same.  They live, transfer and reproduce differently.  Multi-drug resistant organisms (MRDOs) can be controlled and are far more difficult to control in the air than food-borne (salmonella) or water-borne (legionella) germs that occasionally break out in hospitals.  Something like Aspergillus can live on surfaces like plumbing fixtures or in air ducts.

Regulatory standards exist for infection control, and JCAHO wrote the book on how to proceed when a project is under construction in a hospital.  An infection control risk assessment (ICRA) is essential and is based on another set of guidelines, the AIA Guidelines for Design and Construction of Healthcare Facilities (updated every four years).  The ICRA is tailored to the type of project, patient population(s) involved and size of project.

Where Germs Are: Things to Pay Attention To – Hospitals & Builders

  1. Germs live everywhere in a hospital:  in the air, on hard and soft surfaces, above the ceiling tiles, in the trash, on shoes and clothes.  Primarily, germs come in from outside—from materials and people outside a hospital—but they can stay and originate from the inside, too.
  2. Understand the typical chain of infection is a never-ending cycle that includes:  an infectious agent, reservoirs where it lives, a portal of exit to somewhere, a means of transmission to move, a portal of entry to somewhere, and a susceptible host.  Much like any other chain reaction, you win control by eliminating one of the steps in an absolute way…easier said than done.
  3. Anyone can catch an HAI, but certain populations are more important.  Group 1 areas are low-risk populations of people:  public areas and office areas with visitors and workers.  Group 2 is patient care areas.  Group 3 would be more at-risk populations:  newborns, radiology, rehab, intensive care.  Group 4 populations are the most sensitive and vulnerable because they have the most compromised immune systems of anyone in the hospital.  This includes chemotherapy, dialysis, oncology and transplant patients.  Groups 3 & 4 receive extra protection, and especially Group 4.
  4. According to the ICRA, match the type of construction activity to the patient population involved to understand the Class of protection needed.  Type A construction is non-invasive work like popping a ceiling tile for an inspection of installing wall covering.  The significance of infection increases until Type D is met, where there is heavy demolition and major construction that may involve 24/7 work.  If Type D work is done around a vulnerable patient population, plan on executing at the highest level of diligence and protection:  every activity from Classes I-III, including sealing holes, pipes, covering shoes, negative pressure set-ups and isolated HVAC, temporary clothing, temporary barriers and anterooms.
  5. ICRA is a team effort, like a sustainability team.  Everyone has a role with defined tasks.  The team should meet and discuss infection control regularly throughout the job.  Multi-disciplinary in nature, the team should have architects, consultants, builders, owner’s rep’s, clinicians and perhaps C-suite involvement.

Now that the big ideas are identified, let us examine the best ways to avoid infections during an active construction project.

Infection Control Prevention Strategies

  1. Keep the construction team out of the hospital.  OK, so this is a little bit idealistic, but it can be followed surprisingly closely.  With patient safety as the filter through which all decisions should be made, ask if each action is in the best interest of the patient, or at the convenience of the worker?  Eliminate access through; go around.  Create tents; contain dust.  All eating should happen outside.  Maintain dedicated circulation routes, including vertical ones.  Build temporary / duplicate items when needed.
  2. Remember the ICRA.  Five steps will guide the best decisions:  control, train, plan, monitor, isolate.  The ICRA is a malleable, working contract supported by a diverse, active team.
  3. When in doubt, do more where possible and plan ahead.  No one, including the architect, is an infection control expert, so price in these efforts whether spelled out in detail or not.  If anything is in question expect:  to take walls to deck, to wrap things in polypropylene, to duplicate egress.  Seal things off.  Exhaust directly to the exterior when at all possible, and utilize negative air pressure as much as possible.
  4. Communicate with your team.  Work with everyone to get the work done right.  Set high expectations and use all of the standard quality control techniques to enforce compliance:  inspections, citations, fines, checklists, regular meetings, certify / train every single person on the job in a similar standard like APIC.  Self-police.

Much like the design effort, flawless construction won’t make a difference if only one or two strategies are followed.  No single team member can beat infection control by itself, but he or she can be the weak link that brings the whole team down.  The builder cannot control the MRSAs and staphs in the hospital, but they should be able to control the HAIs that originate from construction activity.