Unlike typical building projects, hospitals rarely can shut down when additions are built or spaces are renovated.
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Health care facilities managers have many responsibilities when a hospital is building a new facility or renovating existing space, but a top priority is keeping patients safe during construction.

Interim life safety measures often are needed when construction interrupts the flow of a hospital or other health care facility. Brian Cotten has seen the precautions construction contractors take when renovations on a patient tower required a shutdown of the sprinkler system, including an around-the-clock fire watch.

"They constantly made tours through the entire area to look for smoke or anything else related to fire," says Cotten, PE, CHFM, FASHE, executive director of design and construction at the University of Arkansas for Medical Sciences in Little Rock.

Unlike typical building projects, hospitals rarely can shut down when additions are built or spaces are renovated. And patient needs — including their safety, comfort and protection from infection — trump construction needs every time.

"Figuring out how to work through the issues, how to get the project done and, at the same time, not have a detrimental impact on the patients — that is the challenge," says Tim Adams, FASHE, CHFM, CHC, director of leadership development for the American Society for Healthcare Engineering (ASHE). "It would be great if there were a cookie-cutter solution, but there is not. We have to come up with a solution for every project."

Infection control

One of the largest concerns when a hospital is being torn up for renovations is the risk of infection caused by dust and other contaminants that may flow from the construction site to patient areas. Construction zones are inherently dusty, while many parts of hospitals must be kept pristine.

"Infection control is certainly one of the largest issues," Cotten says. "Trying to keep the environment clean is always a challenge, especially during construction."

The contaminants from construction can enter patient areas multiple ways — through the ventilation system, through open doors and windows, or tracked in on the boots of workers walking through patient areas. The effects vary depending on multiple factors — a little dust in the lobby may be harmless, but fungal spores in an operating suite may pose serious consequences.

A key resource in the fight against construction-related infection is the "Infection Control Risk Assessment Matrix of Precautions for Construction & Renovation," which is available on the ASHE website at www.ashe.org/resources/tools. The matrix provides a quick way for facilities professionals to determine the level of precautions required based on the type of construction and the risk-level of nearby patients.

One side of the matrix identifies the level of construction, from Type A (e.g., noninvasive work, such as painting or minor plumbing) to Type D (e.g., major demolition or new construction). The other side of the matrix identifies the risk to patients normally found in the area affected by the construction, from lowest risk (i.e., office areas) to highest risk (i.e., burn units and operating rooms). Matching the construction level to the risk group results in prevention-control recommendations ranging from Class I to Class IV.

For example, Type C work in a medium-risk area requires Class III infection prevention measures, such as isolating the HVAC system in that area and other precautions. For highest-risk areas, even Type A work requires Class II infection prevention measures such as sealing doors with duct tape, blocking and sealing air vents, and placing dust mats at the entrances and exits of work areas.

"The matrix helps us to determine what we have to do based on the area and the job," says Cotten, who has overseen more than $500 million in construction on his campus over the past eight years, including a new cancer institute and a new patient tower.

While the problems of infection control are obvious in an occupied health care facility, they also need to be considered in new construction.

"There are things we can do during construction that will prevent the spread of infection down the road," Adams says. For example, keeping a work site clean, including areas that will not be seen by occupants, such as behind walls and above ceilings, may prevent infection problems once the space is occupied.

Adams remembers an ASHE training program he participated in at a new hospital being built far from any existing structures. Infection control issues seemed less urgent, because no patients were nearby. But the training emphasized that dirt left behind in hidden spaces could become problematic once the building was occupied.

"The next day they asked me to inspect the work site, and every worker had a broom or a mop and was cleaning up the area," he remembers. "They stopped all work and took a day or two to clean all the spaces before they went ahead."

Noise and vibration

Noise and vibrations also can be a problem when construction workers and patients occupy the same building. Hospitals can be noisy to begin with, but the pounding of jackhammers or table saws can be unbearable for recovering patients. Unfortunately, there are not many ways to limit construction noise and vibration.

"The reality is that nobody has invented noiseless construction," Adams points out. "Our task is to figure out how to reduce that noise so that people are not put at risk or are in discomfort because of lack of sleep."

An especially important concern in noise reduction is in the neonatal intensive care unit (NICU). Babies need their sleep, and they don't get it in a noisy environment.

"Sometimes we have to get really creative," Cotten says. "Maybe if the [NICU's] not completely full, we can get the babies farther away from the area in which we're working. We really have to work with the staff to see what our options are."

Noise and vibrations also can affect surgery. In the case of the operating room, one solution is to schedule work during downtimes, says Gordon Burrill, P.Eng., FASHE, CHFM, CHC, president of Teegor Consulting Inc., a health care engineering consulting firm based in Fredericton, New Brunswick, Canada. Another solution is to use less powerful — and less noisy — tools. This may make the work go more slowly, but it can reduce the effects of noises and vibrations on patients and staff.

Even construction workers walking through patient areas can cause noise. Jangling tool belts, clunky boots and overloaded dollies rumbling down the hall can be startling to resting patients.

Facilities professionals can lessen this noise by carefully considering how workers access construction areas. Rather than have them walk through the front door, Burrill suggests designating alternate entrances just for the workers. The same goes for construction vehicles. Temporary roads and lots built just for them could alleviate traffic pressure on regular hospital roads and parking lots and perhaps reduce noise and vibration in the buildings.

"I think the biggest technique is simply separating the construction teams from the hospital teams as much as you can," Burrill says. "You always look to isolate the two."

Interim life safety

Facilities professionals and contractors also must be concerned with life safety during construction. Maintaining a safe environment in a facility housing a large number of potentially immobile individuals is a challenge under any circumstance, but it becomes especially difficult when doors and hallways are being renovated, electricity is turned off or gas lines are rerouted.

"Unexpected shutdowns, such as a severed gas line, a cut cable or an electrical system shutdown are serious problems," says Burrill. "In an office building or a school, something like that could be an inconvenience. But in a hospital, it can put people's lives at risk."

Burrill recalls an incident when a worker in a hospital's mechanical room caught his tool belt on the main oxygen valve and shut it half off. He wasn't sure what to do, so he reopened the valve, but quickly shut it completely when he heard the rush of gas flowing. "That shut off oxygen in an entire patient tower," Burrill remembers. "It wasn't down for long, but it was long enough that the oxygen was on low pressure in some of the patient units."

Fortunately, the worker was savvy enough to realize that he could not ignore the problem and quickly found knowledgeable help. The flow was properly restored. "There was no negative impact, but the potential for negative impact was very large," Burrill says.

An essential ingredient in successful interim life safety measures is planning, Cotten notes. When hospital personnel have the time to prepare, instituting effective measures is much easier.

Planning and communication

Smart planning and extensive communication play critical roles in all aspects of construction, including managing contractors during the process.

"In a health care setting, we can't just tell folks, ‘Hey, we're doing this, so stop all your activity until we're done,' " Adams says. "In a clinical setting, taking care of people takes precedence."

Cotten says effective planning and communication played key roles during a recent electrical shutdown in an operating room on his campus. He said the contractor, the internal project manager and the staff went through the project step-by-step and discussed a detailed timeline.

During a planned outage, electricity was provided through extension cords and alternate circuits as needed, and the operating room's workflow was only minimally affected. "We took an outage that could have been critical and it went very smoothly," Cotten says.

Even smaller issues need to be well-communicated, Cotten notes. He said a two-week notification for a minor shutdown or noise situation is typical. This allows the hospital staff to prepare for
any contingencies.

On major construction projects, communication involves more parties. Burrill was involved in a major project in which the contractor devoted one employee to facilitating communications among the various parties.

"He liaised with the hospital, all the contractors and the architects, and he was the primary contact with external agencies," Burrill says. "There's a cost factor to that, but they knew that somebody was responsible for channeling all the communication."

Well-trained personnel

Training plays a key role in limiting the problems with health care construction projects. ASHE offers a variety of programs for contractors and others involved in health care construction projects.

"From the standpoint of the construction professional, the training has really improved over the past 10 years," Adams says. "I think part of it is changing the culture, and how we approach a project in a health care setting. I see many companies that have really embraced that."

Many hospitals and care systems require contractors to undergo training before working on the hospital site. By completing ASHE training, facilities managers know contractors understand the special precautions needed to keep patients safe.

Ed Avis is an Oak Park, Ill.-based freelance writer who was contracted by the American Society for Healthcare Engineering to write this article.

Health care construction training opportunities

The American Society for Healthcare Engineering (ASHE) offers several training opportunities for health care facility managers and construction personnel to help with the planning, design and construction process.

• Managing the PDC process course. This educational course helps facility managers to deal with the challenges faced during the planning, design and construction process — including how to prepare to be the leader of the cross-functional team of professionals working on a project.

The course is taught by experienced facility managers and covers topics including functional planning, programming, budgeting and scheduling.

• Healthcare Construction Certificate workshop. The Healthcare Construction Certificate (HCC) workshop explains what owners, staff and patients expect of constructors working in the health care environment.

"There is a need for training and understanding for all people on the job site," says Tim Adams, FASHE, CHFM, CHC, director of leadership development for ASHE. "The HCC is appropriate for the senior folks on the job site, such as the foreman and supervisors. And it's anticipated they will facilitate training of all the folks on the site."

Those who complete the HCC program have their names listed in a searchable database, so health care leaders and facility managers can see who has gone through this important training.

Brian Cotten, PE, CHFM, FASHE, executive director of design and construction for the University of Arkansas for Medical Sciences, says his organization requires that the supervisor or project manager on a job attend the HCC workshop.

"That gives us the knowledge that they have an understanding of what it takes to work on a health care campus," Cotten says.

• CHC preparation course. ASHE also offers a Certified Healthcare Constructor (CHC) preparation course to help people striving to earn the valuable CHC credential, which is offered by the American Hospital Association Certification Center. Candidates must meet eligibility requirements that blend education and experience and then pass the CHC exam.

The CHC credential recognizes the elite in the critical field of health care construction. It can help to provide distinction for construction firms in an increasingly competitive marketplace.

• Videos. ASHE also has two video resources for hospital facility managers. The "Today You Are Health Care" DVD provides an overview of important issues in health care construction for workers who have not previously been involved in building health care environments. And "This New Hospital" provides an insider's view of all phases of a health care construction project.

For a detailed list of ASHE educational programs, see the ASHE education calendar at www.ashe.org/learn. For DVDs, visit the ASHE store at www.ashestore.com.