Infection Prevention in Design and

Construction of the Healthcare Environment

Janet Haas PhD, RN, CIC
Rich Vogel MS, CIC
Disclosures: Haas - Hand Hygiene Study funded by 3M
Vogel - None
VogVela

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 Healthcare Facility Design
Goals
• First, do no harm

• Meet needs of functional

program

• Support delivery of care model

• Enhance the patient

environment, staff
effectiveness and stewardship
of the environment
 Regulations
• States may have individual requirements
• Facilities Guidelines Institute
– Publish "Guidelines for Design and
Construction of Health Care Facilities" (2010)
– New edition due in 2014
Joint Commission

–“When planning for demolition,

construction or renovation, the
hospital conducts a preconstruction
risk assessment for air quality
requirements, infection control, utility
requirements, noise, vibration and
other hazards that affect care,
treatment and services.” EC.02.06.05
EP2
 Infection Control Risk Assessment
(ICRA)

• Multi-disciplinary team
• Design
• Construction
• Compliance
• Risk mitigation
Design
• Number, location and type of:
–Airborne infection isolation and Protective environment rooms
•These cannot be switchable
–Hand washing sinks, sanitizer dispensers
–Eyewash stations and deluge showers
• HVAC systems to meet functional needs -e.g. Procedure
rooms, laboratories etc.
• Water systems to limit legionella
Air Requirements

• General Principles - Clean to Dirty

–Dirty areas (janitors closets, decontamination
rooms, areas for bronchoscopy, laboratory with
specimens) are negative pressure
–Procedure areas, pharmacy compounding, sterile
supply areas are positive pressure
• Best Reference is ANSI/ASHRAE/ASHE
Standard 170-2008 Table 7-1
Airborne Isolation (AIIR)

• Negative Pressure = Air flows from corridor

to (anteroom if present) to patient room
– 12 air changes/hour with 2 outside air changes/
hour
• Exhaust air grills in ceiling over patient
head or on wall at head of bed
 AIIR (Cont’d)

•Toilet and tub/shower and pt sink in the inpatient room as

well as hand washing station for staff
•Air must be exhausted directly outside without mixing with
non-AIIR exhaust
•Continuous visual pressure monitor
•Area for gowning/storage directly inside or outside of entry
•In retrofitted settings, can HEPA filter exhaust air
•Can use for non-isolation patients, but pressure settings do
not change
http://www.cedengineering.com/upload/HVAC%20Design%20for%20Healthcare%20Facilities.pdf
 Protective Environment (PE)
Positive Pressure

• Positive Pressure = Cleanest (patient area) to less clean

• Supply air to PE room is HEPA filtered just before entering
the room or suite of rooms
– 12 Air changes/ hour including 2 outside air changes/ hour

• Permanently installed visual mechanism to constantly

monitor pressure status of the room
• Anteroom not required per Facilities Guidelines, but
does mitigate against pressure changes

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 Combination AIIR/PE Room

• Reversible air flow NOT allowed.

• Air supply = PE room
• Exhaust air = AIIR requirements
• Airflow patterns may be from anteroom
to both the pt room & corridor OR
• Airflow may be from pt room & corridor to anteroom
• Must have 2 visual monitors 1 between pt room and
anteroom; 1 between anteroom and corridor
Visual Pressure Monitoring Devices
 Legionella Prevention

• Design water systems to reduce risk

–Scale system for actual needs (don’t over build), leads
to decreased circulation around water circuits
–Limit dead legs and areas of stagnation
• Assess need for filtration in high risk areas
–Legionella in the incoming water, high risk patients,
amount of water use in the area
–COMMISSIONING PROCEDURES
 Sinks
•Hands free
Wrist blades, knee control, electronic eye
Avoid aerators as these promote water dispersal
•Electronic eye:
Save water, are popular with patients
May be more prone to legionella contamination
Must consider wiring to emergency power
Sydnor ER et al. Electronic-eye faucets: Legionella species contamination in healthcare settings.ICHE. 2012 Mar;33(3):235-40.
HargreavesJ et al. Bacterial contamination associated with electronic faucets: a new risk for healthcare facilities. ICHE 2001Apr 22(4);202-5
 Some Plumbing Basics
•Mixing Valves - control water
temperature at the outlet by use
of a thermostat
• (anti-scald valve)
•Temperature actuated
flow reduction valve -
Immediately closes in the
event of a loss of cold
water protecting patients
from being scalded.
Used primarily to control
the high limit water
temperature of showers.

These devices may impact ability to superheat water for legionella eradication
 Ice and Water

•Cold water less likely to harbor legionella

•Need water and ice for patient care/comfort
•Assure cleaning and maintenance plan is in place
•Assure people are trained to change filters and
clean/disinfect various components of machines
•Trouble spots are anywhere water sits for prolonged
periods
•Prevent contamination of ice by providing place
outside of ice for the scoop
 Flood Damage Prevention
• Raise Sheetrock off floor during
construction.
 Excretions/Secretions/Waste

• Everyday concern
• May contaminate
environment
• Staff safety
concern
• Red bag waste is
costly to manage
 Your Choice?

Q: Are toilets required everywhere?

 Technology Infrastructure

•Nurse call, documentation, patient

education and diversion/recreation
•Computer cabling and device
location
•Other controls - access hatches
•Water filtration
•Environmental disinfection technology
 Patient Handling and Movement
Assessment (PHAMA)
• Needs assessment to identify appropriate
equipment for the service area.
• Definition of space and structural and other
design requirements to accommodate this
equipment

– Prevent hallway clutter

– Adequate outlets

– Assure safe patient handling

 Supply Storage

• Provide supplies within work flow while

minimizing risk of cross contamination
• Just outside the patient room
• Outside to inside access
Staff Support Areas
 QuickTime™ and a
decompressor
are needed to see this picture.
Patient/Family Space

• For patients and families

• Match needs of functional program
and care delivery model
• Assess length of stay/needs
–Example: If you offer washer/dryer, then
consider clothes storage space
–CLUTTER PREVENTION
 Carpeting
Pleasant, inviting appearance
(at least when new)

• Comfort and warmth underfoot

• Sound deadening properties
• No solid evidence that carpeting is
linked to increased risk of HAI under
normal circumstances
• Wet carpet is a risk for Aspergillus
Gerson, SL et al. Aspergillosis Due to Carpet Contamination, ICHE 1994: 15(4) 221-3
 Finishes

• Easily cleanable with hospital

disinfectants
• Not prone to soiling with
extensive use (e.g. vinyl
upholstery vs. cloth)
• Skid-resistant
• No crevices for dust
 Furnishings

•Cleanable/rust resistant
•Designed to reduce clutter
•Support patient
mobility/independence
•Bed bug ‘resistant’
(limit crevices, assure no tears in upholstery)
Fixtures
Fixtures (Cont’d)
 Antimicrobial Surfaces
• Copper Surfaces
– Passive continuous activity; need info on exact
alloys and application method; long term efficacy
• Curtains
– become contaminated again shortly after
cleaning (within 1 week)
– Antimicrobial curtains may delay contamination (to 2
weeks in recent study)
– May be more effective vs certain pathogens
– Consider alternatives (e.g. smartglass)

Schweizer M et al. ICHE2012 Nov;33(11):1081-5, Trillis F et al. ICHE 2008 Nov;29(11):1074-6, Ohl M et al. AJIC 2012 Dec;40(10):904-6
Otter JA et al JHI 2007 Oct;67(2):182-8 Bearman G et al ICHE 2012 Mar;33(3):268-75 Salgado CD et al. ICHE 2013:34(5)479-86.
Schmidt, MG et al. ICHE 2013:34(5)530-33.
O’Gorman J & Humphreys H. 2012 JHI in Press
 Summary
• Attention to detail at all levels
• ICRA is not just a permit for dust control
during construction
• Design is something you will live with for
years
• Don’t forget the fixtures and finishes
– Thank You!
 2010 FGI Guidelines

1.2-3.1.4 ICRA Recommendations

Based on the results of the initial stage of the ICRA, the owner shall
provide the following recommendations for incorporation in the
functional program:
(1) Design recommendations generated by the ICRA
(2) Infection Control Risk Mitigation Recommendations
(ICRMRs)
 Determining Dust Control Measures
 How big is the construction project?
 How ill/frail are the patients?

STEP 3: Project Class  Non-patient area?

 Ambulatory Patient / Patient access
area?
 In-patient area/ High risk ambulatory?

STEP 2: Identify the Risk Group

 Minor repair?
 Major renovation?

STEP 1: Type of Construction

 ICRA Compliance
1.2-3.3 Compliance Elements
1.2-3.3.1 ICRA Documentation
This written record shall remain an active part of the project documents for
the duration of the construction project and through commissioning.
Infection Control Risk Mitigation Recommendations (ICRMR)
Monitoring Plan
Daily/weekly checklist to verify described methods are in place
Plans which describes specific methods by which transmission of
contaminates will be avoided
 Barriers, negative pressure, sticky mats, HEPA filters, etc
Communication
 Report checklist findings to Infection Control/Safety Committee
 Dust Control Measures
1.2-3.4 Infection Control Risk Mitigation
1.2-3.4.1 ICRMR Planning
Infection control mitigation recommendations (ICRMRs) shall be
prepared by the ICRA team and shall, at a minimum, address the
following:
•Patient placement
•Barriers and other protective measures
•Protection from demolition
•Training
•Debris and traffic flow
•Bathrooms and food for construction workers
 Barrier For Dust Control

Door Closed

Tight to ceiling and walls

 Barrier For Dust Control

Zipper closed

Sticky mat

Tight to ceiling and

walls
Barrier For Dust Control
STICKY MATS
Use Of Coveralls Debris Removal
During Demolition
Sealed Air Ducts
Mobile Dust Control Devices
 Instructions to Contractors
Guidelines for Reduction of Infection Risk During Construction &
Renovation

 Infections associated with hospital renovations are a concern due to the vulnerability of
patients who are near the construction activities. The control of infection risks
(primarily airborne) during these periods is essential.
 Dust containment is a critical component in the control of fungi in patient areas as well
as the prevention of irritation and illness in patients, visitors and staff. It is the policy of
NYP that whenever work creates an open space between construction areas and other
dust or possible fungi containing areas, EHS, the Department of Epidemiology and
Facilities will conduct a careful evaluation of these areas. The degree to which the
project will require dust abatement measures is determined by completing an Infection
Control Risk Assessment (ICRA). EHS, Epidemiology and the NYP/PM will monitor
compliance with the procedures described in this policy.
 Although each project is unique in items of required construction, and the location and
vulnerability of nearby patients, certain general precautions are prudent. The purpose
of these guidelines and the ICRA is to enhance the prevention of illness in patients who
may be immune-compromised and susceptible to fungal infections and others who
may be sensitive or otherwise allergic to materials found in or carried by dust.
 These guidelines apply to all activities in the hospital that may create dust, aerosolize
fungal spores, or generate other antigenic or irritating materials that will cause illness
or discomfort and obligates EHS, Department of Epidemiology and Facilities to
evaluate and monitor all such activities. All GC/CM staff are expected to comply with
these requirements.
Educational Material for
Construction Workers
Staff Education
Dust Control Plan
Dust Control Plan
 Air Flow in Construction Sites

A1.2-3.4.1.2 Ventilation of the construction space

Airflow into the construction zone from occupied spaces should be
maintained by means of a dedicated ventilation/exhaust system for the
construction area.

Location of exhaust discharges

Cleaning of existing building systems
Visible display of airflow in high risk areas
Pressure differential of at least 0.03 inch water gauge
 CREATING NEGATIVE PRESSURE

Construction Site Entrance Window with exhaust fan

Construction Dust

Construction Site
CREATING NEGATIVE PRESSURE

HEPA Filter Ante Room

Construction Dust

Construction Site Entrances

Construction Site
(top view)
Creating Negative Pressure
 Creating Negative Pressure

Exhausting HEPA filtered air

 Creating Negative Pressure

Exhausting HEPA
filtered air
Checking HEPA Air Scrubbers
Air Flow Indicator
Continuous Monitoring of Negative
Pressure
Vivian and Seymour Milstein Family
Heart Center Construction
Exterior Demolition
Creating Negative Pressure
Creating Negative Pressure
Creating Negative Pressure
Creating Negative Pressure
Radiation Oncology Plan
Radiation Oncology Site
Watering Down Excavation
Quick Set Up Dust Barrier
Mobile Dust Control Devices

VS
Reusable Dust Control Barriers

VS
QUESTIONS?