infection control risk assessment (icra) developed and ... · 10/16/2019 · infection control...
TRANSCRIPT
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?