Healthcare environments are sensitive settings where the planning and performance of renovation and construction projects require additional preparation and consideration. Contractors and in-house facilities must be aware of evolving infection control guidelines that dictate work practices and limit the risk of patient exposure. Infection Control Risk Assessments are an essential component of the planning process. Of note, in October 2021, the American Society of Healthcare Engineers (ASHE) updated the ICRA Guidelines, ICRA 2.0, as described below.

Overview

Roughly 5% of healthcare associated infections can be directly related to construction activities which have the potential to create dust migrations and changes in airflow that carry pathogens. Understanding the challenges in these settings and the standards of practice necessary to protect immunocompromised individuals, as well as workers, allows for specifics policies and precautions to be incorporated into the planning process. Plans include risk assessments and mitigation precautions that are job-specific for each construction activity performed and developed by a multi-disciplinary team. Keeping up to date with industry changes is key to a successful project.

Pre-Construction Risk Assessment (PCRA)

Before construction projects begin, it is the responsibility of the healthcare facility to complete a PreConstruction Risk Assessment (PCRA) as defined through guidelines published by Association for Professionals in Infection Control and Epidemiology (APIC) and American Society of Healthcare Engineers (ASHE).

There are seven components of a PCRA:

          1. Life Safety Code Deficiencies (ILSM)
          2. Air Quality and Pressure Management (ICRA)
          3. Utility Interruptions and Impacts
          4. Noise
          5. Vibration
          6. Environmental Services
          7. Other Safety Hazards

These components are assessed by a multidisciplinary team, ideally consisting of project managers, engineering representatives, safety office representatives, infection preventionists, environmental services and contractor representatives. While it is the direct responsibility of the healthcare facility, PCRAs can be completed most efficiently with the assistance of the outside contractor performing the work.

The Joint Commission also includes in its standards a requirement for PCRA when planning for demolition, construction, or renovations. 82% of hospitals are accredited through the Joint Commission and are subject to periodic surveys which ensure facilities are adhering to these requirements. Therefore, proper documentation of the PCRA process is essential as well.

Life Safety Code (LSC)

A key component of the PCRA is the Life Safety Code. The National Fire Protection Association publishes Life Safety Codes (LSC) with the overall goal of fire prevention and patient safety in mind. The LSC sets requirements that must be adhered to during construction in a healthcare facility since patients in healthcare facilities may not be capable of self-preservation. During the PCRA process, specific precautions must be identified and addressed when LSC deficiencies are deemed to occur during the project. Interim Life Safety Measures (ILSM) define the life safety systems that will be compromised during construction and identifies the measures necessary to mitigate risk to patients; such as blocking of exits, loss of integrity to fire walls or smoke barriers, or when a fire alarm or fire protection system is impaired. When these life-threatening conditions exist they are combated with defend-in-place strategies utilizing facility compartmentalization, firestop, and sealed penetrations.

Infection Control Risk Assessment (ICRA)

The Centers for Disease Control (CDC) and The Joint Commission also require healthcare facilities to perform Infection Control Risk Assessments (ICRA) developed by ASHE in 1996. ICRA focuses on containment of the work area, indoor air quality and implementation of mitigation recommendations. The ICRA developed for a project operates as a blueprint to ensure all those involved are working towards to same goal and in the same manner. ICRA components address building features that promote patient safety such as air handling, ventilation, water delivery systems, and hand sanitization systems. For interior projects the ICRA evaluates the location of the project, the type of work to be performed, extent of activity, and the potential impact on surrounding areas to determine class of precautions to be put in place. Containments for each project are specified based on the type of work to be performed, the amount of dust expected to be generated, and the patient care area. Critical barriers must be monitored for effectiveness throughout the duration of the project. For exterior projects the staging areas, proximity to air intakes, and impact on water systems are evaluated.

In 2020, ASHE assigned a committee of experts to update ICRA guidelines and in 2021 published an updated ICRA 2.0. Since its original implementation, industry resources have evolved and work practices have changed to further limit infections resulting from construction activities. One of the key changes in the ICRA was to add more description to tables. This information clarified project activity types and risk groups which determine the class of precautions in place during a project. A fifth class of precautions was also developed to address large-scale projects which were not completely covered by Classes I through IV. The updated ICRA 2.0 also includes a process guide to more clearly facilitate how the ICRA should be implemented to avoid misapplications of the process that can be construed by inexperience or lack of training. The “Matrix of Precautions for Construction, Renovation and Operations” is a
fundamental tool which can accessed free of charge to provide greater clarity in the application of the ICRA.

Conclusion

Knowledge of life safety measures and experience in performing risk assessments is essential for contractors and in-house facilities to successfully perform work in healthcare facilities. A 2020 ASHE survey found 62% of projects underway required contractors to complete infection control risk assessments (ICRAs) and 26% of projects also required contractors to have certified credentials. Trade organizations are a great resource for standardized trainings for renovation and maintenance in healthcare facilities, as well as private consultants who can tailor certified trainings to the contractor’s needs and experiences.

Contractors working in healthcare facilities may not be fully aware of the hazards they can introduce to patients and staff during construction activities until they complete proper renovation and maintenance training specific to healthcare. The importance of certified training is evident when working in healthcare environments to prevent infections and gain a thorough understanding of healthcare life safety codes, worker protection and the risk assessment process. When working in a healthcare facilities, it is well established that both outside contractors and in-house facilities are crucial members of the healthcare team.

If you have any questions, you can click here to schedule a customized consultation with Shari Solomon, President of CleanHealth Environmental.

In addition, we invite you to learn more about our Healthcare Renovation & Maintenance Best Practices Training program.