When it comes to infection control, an ounce of prevention is, indeed, worth a pound of cure. This is especially true during construction projects. While the logistics and planning details required for an effective construction-generated infection control program may be daunting, they are nothing compared to the problems that could arise later if a program is not carried out.

A team effort

The best way to deal with construction-generated contaminants is prevention, and the first step in developing a prevention program is to have a team in place to deal with the multiple facets of the project.

The core group of the IAQ team consists of the director of facilities engineering, the infection control coordinator and the employee health and safety manager. Depending on the nature of the project, the team may add the charge nurse from the floor or floors where the project will be taking place, the construction and design department, information services, ES, etc.

Once the basics are established in terms of education and reporting, an infectious material containment (IMC) program needs to be put into place. This is best handled by retaining an outside contractor experienced in containment programs, as most health care organizations do not have the necessary manpower available to do this. A second and oftentimes more compelling reason for third party involvement is to offset liability. The level of protection needed for each construction, repair, replacement or maintenance activity needs to be assessed by the IAQ team.

Defining the risk

Before any construction activity takes place, the construction and infection control risk needs to be defined. The term "construction" is divided into four basic types:

Type A. Non-invasive inspection or minor repair work taking less than half an hour.

Type B. Small scale, short duration maintenance, repair and component installation activity taking less than two hours.

Type C. Major system upgrades, in particular those involving cable pulling, and remodel or construction projects generating moderate to high levels of dust. Landscaping projects could be included in this category.

Type D. Major demolition, reconstruction and new construction projects.

Minor maintenance, repair and construction activities account for many of the potential sources of risk. Something as simple as opening up a ceiling cavity for service access can trigger an infection event. Indeed, it is the most minor tasks that often catch us off guard. Water intrusion from any source--rain leaks, pipe leaks, etc.--are not to be treated lightly. Intrusions into such areas as the ceiling cavity, wall cavities or below base cabinets must be corrected quickly.

In new construction, the assumption is since all materials are new, that they are free of fungal contamination, which is untrue. Unless the wall cavities are cleaned prior to wallboard installation, and ceiling cavities are cleaned prior to installing the ceiling grids, the spores that are present in these cavities can grow to become problems after the project is completed.

Along with identifying the construction types, the level of infection control risk must be considered. IC risk levels have been well defined by the Association of Practitioners in Infection Control (APIC) as shown below:

Group I. Office, administration, medical records and non-patient care areas.

Group II. Low risk patient care areas, such as cafeterias and kitchens.

Group III. Medium-high risk areas, such as admissions, triage and emergency department.

Group IV. High-risk areas, such as oncology, neonatal, surgical suites and transplant units.

The next step is to marry the construction type with the IC group in order to determine the level of protection required. Some examples include:

Construction type A in IC group I does not require control cubes, barriers or negative air considerations. This is a case of just get in and get it done.

Construction type A in IC Group II requires cubes or barriers for work lasting more than 30 minutes, but does not require negative air considerations unless work effort will exceed one hour.

Construction types A­D in IC Group III and IV require HEPA-filtered vacuums with cubes and negative air machines with barriers.

Following the protocol

This program must be applied universally to everyone performing work in the facility, from hospital maintenance staff to outside contractors. This includes coordinating with the IAQ team and following the protocol:

• The staff maintenance engineer or outside contractor is responsible for obtaining the infection control permit from the infection control department prior to commencing construction.
• Infection control or IAQ team members reserve the right to add requirements to a project on an individual basis to preserve proper infectious material containment.
• Infection control or IAQ team members will make routine visits to the work site to ensure compliance of policy.

Prior to construction

Once the type of activity and infection control group for the project has been established and the infection control permit issued, there are a few steps that need to be performed prior to commencing actual construction. They include the following:

• Define construction crew path of entry and exit from the construction zone to the staging area outside of the facility and place proper signage to keep patients, health care workers (HCWs) and visitors away from the construction area and path.
• If an elevator must be used to access the construction zone, then one car must be keyed off from public or staff use, limiting it for construction only. An anteroom must be set up on the construction floor around the designated elevator to prevent construction dust and debris from contaminating the shaft.
• Tacky walk-off mats must be provided at the entrance to the construction anteroom and construction zone.
• Identify the HVAC system serving the construction area, and what other areas of the facility are also served by this system, and develop a means of isolating the system from the construction zone. Isolation means cutting both the supply and return air grills out.
• Establish a means of providing a negative pressure in the construction zone relative to adjacent areas. In some cases, a window panel must be removed to allow the installation of a temporary panel with a duct opening in it. Care must be taken when doing this to ensure that the point of discharge is not in a public pathway.
• Perform airborne testing for fungi and respirable dust in areas adjacent to the construction zone to serve as a background test. The initial testing should include the use of respirable dust analyzer, an Anderson Impact Sampler using both malt extract agar and DG-18 agar, a spore trap and a quick test non-species identification unit similar to the BioTest sampler using malt extract agar.

Precautions during construction

During construction, the following precautions should be taken:

• Ensure that tacky mats are maintained at the entry to the construction zone and anteroom.
• Ensure that all materials leaving the facility and the construction zone are securely bagged and placed in covered rollout bins. All materials entering the facility must also be covered or placed in covered rollout bins.
• Ensure that construction crews are using only the designated path to the construction zone.
• Ensure that construction crews are not using staging areas within the facility but outside of the construction zone. Staging must take place outside of the facility.
• If construction crews are to be allowed access to non-construction areas such as the cafeteria or restrooms, then disposable coveralls ("bunny suits") must be worn in the construction zone, and discarded in the construction zone anteroom as they leave.
• Ensure that the supply air and return air outlets are sealed in the construction zone to prevent contamination of the HVAC system and surrounding areas.
• Routinely verify that the construction zone is under negative pressure with respect to surrounding areas.
• On a random double-blind basis, perform airborne testing in areas that are adjacent to the construction zone for fungi using the BioTest unit and respirable dust analyzer.

Clean-up time

After project completion, but prior to occupancy by the hospital, the following steps should be taken:

• Remove all debris and construction dust from the ceiling cavity using a HEPA-filtered vacuum. This includes any wall cavities or vertical shafts and utility chases that have been part of the construction project.
• Perform HEPA vacuum cleaning of all surfaces in the construction zone: ceiling, walls, cabinets and other built-in furniture and partitions, and flooring.
• Where extensive work has been performed in the ceiling cavity, fog the area with a dilute aqueous anti-fungal solution using an atomizing fogger.
• Perform a final airborne test for fungi and respirable dust in the areas adjacent to the construction zone and in the construction zone prior to occupancy. As in the initial tests, this final test will use the respirable dust analyzer, the Anderson Impact Sampler with both agar media, the spore trap and the BioTest sampler using malt extract agar.

Need for education

Additionally, the IAQ team needs to educate the hospital medical, administration and maintenance staff of additional areas where they can help. Some examples include the following:

• *Closing any unattended exterior door that is blocked open, and reporting it to the facilities department.
• If the facility has operable windows, they must be kept shut.
• Reporting any and all moisture or leaks from items such as refrigerated drinking fountains, cold drink vending machines and ice machines. Water leaks in base cabinets under hand lavatories is another common source of potential problems. Any signs of water stains on ceiling tile are a good indication that there could be fungal growth on top of the tile.
• When visible signs of water intrusion are not readily apparent, but there are moldy or musty odors, it should also be reported to the facilities department.

Well worth the effort

This program may seem daunting at first, but hospitals that have implemented programs of this type have been pleased with the results and the speed of the learning curve.

Like anything new, it will take some time for the process to settle in and establish itself as a valuable tool, but the time spent will be well worth it.

Wayne Hansen, P.E., CEM, REM, is director of engineering for Mintie Corp., a national, indoor environmental solutions provider. Hansen was contributing editor of the recently published book, Infection Control During Construction: A Guide to Prevention and JCAHO Compliance, on which this article was based. The book outlines complete steps for compliance, as well as detailing a methodology for conducting an IAQ risk assessment and establishing an IAQ team that includes a smaller, more manageable range of participants than those set out in the recent CDC Guidelines. Hansen was also contributing editor for the JCAHO's IAQ Guide for Healthcare Organizations. He can be reached at (800) 9-MINTIE.