36C24419R0018-0004004.docx

Lebanon VAMC Construction, Renovation and Maintenance Infection Prevention Program

PURPOSE

Minimization of the risk for patient acquisition of Healthcare Associated Infections (HAIs) as may result when fungi or bacteria are dispersed into the air via dust or water aerosolization during any construction, renovation, or maintenance activities in or near the Lebanon Veterans Affairs Medical Center (LVAMC).

GUIDELINES

Construction, renovation, and maintenance activities have become ever present at health care facilities in support of continuous change as advances are incorporated into the delivery of medical care. LVAMC must remain occupied to provide uninterrupted care during these activities.

This guide outlines LVAMC’s program to establish preventive practices in effort to reduce HAIs associated with these activities.

The Infection Control (IC) and Engineering Departments, Project Managers, Contracting Officer’s Representative (COR) and Contractors are responsible to integrate infection prevention and environmental control principles, outlined in this guide, throughout the planning, managing, active phase, through to the completion of each project. This process is identified as the Infection Control Risk Assessment (ICRA).

ICRA development will be accomplished through a multidisciplinary collaborative process. Engineering and IC will have continuous involvement in ICRA assessment and reassessment, with subsequent revisions, as the fluidity of the construction project dictates. The Engineering Department, COR and Construction Safety Committee (CSC) will participate in monitoring and validating ICRA compliance. This policy applies to all LVAMC owned buildings and will be referred to for guidance by LVAMC leased Community Based Outpatient Clinics.

I. GENERAL DEFINITIONS

A. Contractor: For the purposes of this guide, “Contractor” is defined as the General Contractor, Prime Contractor, Sub Contractor, Tradesmen, Mechanics, Apprentices, Laborers, Original Equipment Manufacturer Technicians, and includes LVAMC employees performing these tasks, et. al

B. Cleaning Company (CC): A company or division that can demonstrate competence and displays experience cleaning in an institutional environment, preferably the health care setting. The CC’s services may be arranged by the Contractor or LVAMC and will be specified in contract.

C. Engineering Department: LVAMC Engineering Department. This includes the appropriate Maintenance division, Operations, Planning, Construction, and Safety.

D. Infection Control (IC): LVAMC’s Infection Control Department consisting of the Infection Preventionist (IP), Multi-drug Resistant Organism Prevention Coordinator (MPC) or their designee.

E. Infection Control Risk Assessment (ICRA): The process of determining the potential risk of transmission of various air and waterborne biological contaminants in the facility during construction, renovation, and maintenance activities.

F. Infection Control Risk Assessment Tool (ICRA): The ICRA Tool is used to provide guidance for the minimum required environment infection control precautions through the identification of Construction Activity Types (Table 1) and Risk Groups (Table 2). The ICRA matrix combines this data to accurately identify a Classification Level “Class” (I –IV)(Table 3) while noting additional possible infection control issues and requirements. The identified ICRA Classification Level (Table 4) then designates what environmental infection control precautions need to be instituted prior to the commencement of operations. The ICRA Tool (Appendix A) is to be completed for all new construction and major renovations to patient care areas.

G. Contracting Officer’s Representative (COR): For the purposes of this guide, “COR” is defined as the individual responsible for oversight of the project construction, renovation, or maintenance activity. This may include the Engineer, Contracted Project Manager, Consulting Project Manager, Facilities Associate Director, Facilities Project Coordinator, Facilities Maintenance Supervisor, Facilities Operations Supervisor, LVAMC Information Technology (IT) Cabling Manager/Supervisor, et. al.

H. ICRA Teams: The Primary ICRA Team includes the COR, IC and if identified, the Contractor and User group. The Ad hoc ICRA Team members may include the Design Professionals, Safety Department representatives, LVAMC Environmental Management Services (EMS), Engineering, Operations, Risk Management, Patient Safety, extended user group members, and others.

II. DEFINITIONS OF CONSTRUCTION ACTIVITY TYPE

A. Table 1 determines the construction activity type. Activity types are defined by the amount of dust that is generated, the potential for dust and water aerosolization, duration of activity, and the amount of shared HVAC systems.

Table 1: Construction Activity Type Definitions

Includes, but is not limited to:

· Opening of a single ceiling tile for visual inspection or tile replacement.

· Painting (but not sanding)

· Wall covering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection

TYPE B

Small Scale, Short Duration Activities Which Create Minimal Dust Includes, but is not limited to:

· Opening of no more than one ceiling tile per 10 tiles

· Installation of telephone and computer cabling

· Access to mechanical chase or shaft spaces

· Cutting of walls or ceiling where dust migration can be controlled

· Minor renovation of existing space

· Wet sanding of walls

· Floor covering removal (without sanding or grinding)

TYPE C

Work That Generates A Moderate To High Level Of Dust Includes, but is not limited to:

· Dry sanding of walls

· Cutting of walls, removal of drywall or building finish components where work is limited to one room or suite (including removal of floor coverings, ceiling tiles, and casework)

· Wall demolition or new wall construction

· Minor duct work, plumbing work, or electrical work above ceilings (not including system demolition or installation)

· Moderate renovation of existing space

· Major cabling pulling activities, multiple rooms/lines where multiple access points are needed

· Any activity which requires construction of a barrier that does not qualify as Type D

· Floor covering removal (with sanding or grinding)

TYPE D

Major Demolition And Major Construction Projects Includes, but is not limited to:

· Activities which require the closure of a unit/wing or relocation of an entire patient area

· Demolition, removal, or installation of a complete cabling, HVAC, plumbing, medical gas, or electrical system

· Demolition of major fixed building components, assemblies, fit-out elements, or structural elements

· New construction located in close proximity (as determined by the ICRA team) of the hospital building

· Outdoor construction of new structures located in close proximity (as determined by the ICRA team) to existing patient care facility

· Excavation activities within close proximity (as determined by the ICRA team) of hospital building.

III. DEFINITIONS OF INFECTION CONTROL RISK GROUPS

Identify Risk Group (Table 2) Risk Groups have been classified by IP. Contact IP (Ext. 5452) for further specialized identification or clarification.

Table 2: Risk Group Identification

Mechanical Spaces:

Areas not directly adjacent to patient care.

Engineering Environmental Management Services (EMS) Office Areas:

Areas not attached to or adjoining patient care areas, used for patient interviews, evaluations or examinations.

Public corridors:

Spaces not on or directly attached to patient units or treatment locations.

Out Patient Units:

· Primary Care Spaces

· Specialty Clinic Spaces

· Community Based Out Patient Clinics (CBOC’s) In Patient Units:

· 1-2A

· 1-3A

· 1-3B

· 1-4A

· 1-4B

· 1-5

· Emergency Dept.

· Radiology/MRI/CT

· Nuclear Medicine

· Cafeteria/Kitchen

· Laboratories

· Oncology

· Central Sterile Supply

Surgical/Medicinal:

· ICU/SICU

· OR/ASU/Endoscopy

· PACU

· Sterile Processing Services (SPS)

· Pharmacy

IV. INFECTION CONTROL RISK ASSESSMENT MATRIX

Data obtained from Construction Type (Table 1) and Risk Group (Table 2) are inputted into ICRA matrix (Table 3) to identify the ICRA Classification Level (Class).

Table 3: ICRA Matrix

Construction Activity

“TYPE”

ICRA CLASS

V. DEFINITIONS OF ICRA CLASSIFICATIONS “CLASS”

The identified ICRA Classification “CLASS” Level designates minimum environmental infection control precautions to be instituted prior to the commencement of construction operations and adjusted as when project circumstances dictate.

Table 4: ICRA Class Infection Control precaution requirements

CLASS

I

2. Immediately replace any ceiling tile displaced for inspection.

CLASS

II

1. Provides active means to prevent air-borne dust from dispersing into atmosphere (surrounding environment.)

2. Water mist work surface to control dust while cutting

3. Seal unused doors with duct tape.

4. Block off and seal duct vents.

5. Wipe surfaces with disinfectant.

6. Contain construction waste before transport in tightly covered containers.

7. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

8. Place dust mat at entrance and exit of work area.

9. Remove or isolate HVAC system in area where work is being performed.

CLASS

III

1. Obtain infection control permit before construction begins.

2. Isolate HVAC system in area where work is being done to prevent contamination of the duct system.

3. Complete all critical barriers or implement control cube method before construction begins.

4. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

5. Remove or isolate HVAC systems in area where work is being performed.

6. Do not remove barriers from work site until complete and project is thoroughly cleaned by EMS.

7. Vacuum work with HEPA filtered vacuum.

8. Wet mop with disinfectant.

9. Remove barrier material carefully to minimize spreading of dust and debris associated with construction.

10. Contain construction waste before transport in tightly covered containers.

11. Cover transport receptacles or cart and tape covering in place.

CLASS

IV

[ same as Class III plus three more items. ]

13. Seal holes, pipes, conduits and penetrations appropriately.

14. Construct anteroom & require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving worksite or they can wear cloth or paper coveralls that are removed each time they leave the work site.

15. Wear shoe covers when within entering work site.

Additional Requirements:

VI. PERFORMANCE REQUIREMENTS

A. Infection control is critical in all areas of the health care facility. Construction, renovation, and maintenance activities causing disturbance of existing dust, or creating new dust, must be conducted in tight enclosures to prevent any flow of particles into patient areas.

B. Prior to initiation of any construction, renovation, or maintenance activities, the contractor’s on-site management team shall view IC precautions and rationale. Contractors who perform their work exclusively outside (e.g. landscape, snow removal, etc.) are exempt from this requirement.

C. Engineering or IC may enhance performance requirements designated on ICRA forms as conditions warrant. These modifications do not negate the intent of this guide.

VII. SUBMITTALS

A. The Contractor will provide LVAMC Engineering Division a listing of product data for products that will be used during construction to ensure evaluation during the ICRA. Submittals will be identified in the LVAMC bid documents, under Special Requirements, to ensure all bidders are aware of the requirements of this guide.

VIII. PRODUCTS AND MATERIALS

A. Barrier types must be constructed with the following materials/specifications and comply with National Fire Protection Association (NFPA) standards.

1. Fire retardant polyethylene barrier (minimum 6-mil thickness.) Used solely as an IC barrier.

2. Gypsum wall board.

3. Fire rated reinforced plastic fiberglass (similar to Fire-X Glass board).

4. Masonite (must be painted with fire resistant paint [Flame Control Coatings, #320A or equivalent] prior to entering the building).

5. Other fire resistive materials to be specified prior to completion of ICRA Work Permit.

B. Bleach: Contains the active ingredient sodium hypochlorite and is designated as effective water based disinfectant. To obtain solution strength for effective disinfection mixture, 1 part bleach is mixed in 10 parts water (equivalent to 1¾ cups of bleach in one gallon of water.) Mixture must be made fresh every 24 hours in a clean container. Commercially available products (e.g. Clorox Clean-Up) have an extended shelf life and may be used if within the labeled expiration date.

C. Carpet Vacuum: Nobles Ultra-glide 18" w/ dual motors and HEPA filters, or an equivalent commercial grade carpet vacuum cleaner. An equivalent vacuum must have HEPA filters.

Nobles Ultra-glide 18" w/dual motors (HEPA Filters ordered as option)

D. HEPA Vacuum: A Dayton “shop style” vacuum, or equivalent, with a HEPA filter cartridge filter capable of 99.97% filtration @ 0.5 microns, similar to Dayton part # 4TB93. This filter shall be used in conjunction with a dust collection pre-filter bag for fine particles and dust, similar to Dayton part # 1UG85.

Dayton Shop Vacuum

Dayton part# 4TB93

Dayton part#

1UG85

E. Control Cube: Portable Ceiling Access Module, such as “Kontrol Kube Mobile Containment Solution” with heavy duty vinyl enclosure as manufactured by Fiberlock Technologies, Inc. or equivalent.

Kontrol Kube Containment System w/example of operation

F. Door types (as specified in the ICRA work permit):

1. Solid core wood door in wood or metal frame.

2. Metal door in metal frame.

3. Zipper door in polyethylene, or an overlapped polyethylene entrance.

4. Masonite doors may be used if painted with fire resistant paint (Flame Control Coatings, #320A or equivalent) prior to entering he building.

G. Exhaust Hoses: Heavy duty, flexible steel reinforced, ventilation blower hose manufactured by Federal Hose Mtg. Co. or equivalent.

Flexible Steel Reinforced ventilation blower hose w/attachments

H. Negative Air Machine: HEPA filter equipped negative air machines that provide roughing filters, primary filters, and HEPA final filters, with a rating of 200 to 2000 cubic feet per minute (CFM). HEPA filters to be a minimum of 99.97 % efficient. The HEPA filter will be factory scan tested and factory accepted after manufacture. Scan testing should be in accordance with Section 6.2 of IEST -RP-CC034.1 Type C. No leaks greater than 0.01 of the upstream concentration at rated capacity of 2,000 CFM . Initial clean resistance shall be no more than 1.35” W. C. @ 2,000 CFM (for 2000 CFM machines). Common supplier is Airborne Contamination Identification Associates, Abatement Technologies.

Abatement Technologies Negative Air Machine

I. Negative Air Fan: A high air flow, high static pressure, unfiltered, smoke ejector style fans equivalent to Super Vac P164S, 16” Smoke Ejector Fan.

Super Vac P164S, 16” Smoke Ejector Fan J. Walk-Off Mats (adhesive): Provide minimum size mats of 18 inches x 24 inches such as those manufactured by 3M or equivalent.

Adhesive Walk-Off Mat by 3-M

K. Walk-Off Mats (other): Carpet, carpet squares, etc. can be moistened with bleach solution and used to prevent premature loading of the adhesive walk off mats and the tracking of dust from the work zone.

IX. BARRIERS AND DOORS

A. An existing door may be acceptable as the ICRA barrier for work projects which can be contained in the room. This will be based on the existing room construction, construction activity type, and risk group.

B. Barriers that may be specified:

1. A polyethylene barrier, with an overlapping entrance flap or zipper, may be placed between the door and the construction site.

2. An anteroom immediately outside the work zone entrance.

3. Barriers may be required to contain the ceiling envelope, chases, interstitial spaces, etc.

4. Other barrier methods as determined during the ICRA process.

C. Plastic barriers may be adhered to metal studs using spray adhesive, double face tape, sheet metal screws etc.

D. Drywall barriers will have the joints and screws covered or sealed.

E. Overlapping polyethylene flaps that are used as the entrance to the work site must overlap a minimum of 2 feet.

F. If a hinged door is used for the barrier entrance, a large (2000 CFM) negative air machine shall be used to ensure 100 feet per minute of air flow into the work zone with the door open. This requirement may be modified for very small rooms or if overlapped polyethylene is used in conjunction with the hinged door.

G. Anterooms (double entrance openings) may be required. Anterooms serve as an airlock and PPE donning area. The air lock function requires that only one door be allowed open at a time. Exceptions are made for the delivery of large materials. Both doors open at one time should be minimized. The anteroom is to be kept clean and tidy. Cleaning products and materials (bleach, wipes, shop vac, mops, etc.) will be kept in the anteroom.

X. INFECTION CONTROL PROCEDURES - GENERAL

A. Facilities and IC will be notified at the beginning of the planning or design phase of all projects to issue initial ICRA concerns.

B. Post awarding of contract, ICRA will be conducted by and ordered in the following steps.

1. COR, IC in collaboration with the ICRA team will evaluate the project to determine its ICRA classification rating by delineating construction activity type, risk group, and classification level. Accurate determination of ICRA requirements will be achieved through the solicitation of the Ad Hoc ICRA Team, as necessary, with complete review of project’s design, scope of work, along with subsequent impact to surrounding locations and utility systems.

2. ICRA team will develop ICRA permit (Attachment A).

3. COR and IC will retain copy of ICRA.

4. COR is responsible for obtaining the ICRA work permit prior to commencing work, ensure its posting post at all work zone entrances, and for communicating the ICRA requirements to all affected persons.

5. ICRA may be revised throughout all stages of the project, as conditions warrant.

C. LVAMC facilities employees will follow ICRA precautions for Level I and II projects without a formal ICRA assessment or work permit.

1. Projects indicating classification level III - IV will require obtaining an ICRA work permit from IC and facilities manager.

D. HVAC Design General Requirements

1. The purpose is to have easy to follow summaries to assist all involved to better understand the design intent, during all phases of the project, and to establish a record for future operations and initial reference for maintenance. Showing transfer air on a complicated duct drawing does not work well. The concept is similar to having simple Life Safety Plans for accurate and quick understanding. All drawing sets shall include:

a. Coordinated single line diagrams with both existing and new work as applicable.

b. Clear delineation between demolition, existing to remain, and new work on plans and riser diagrams.

c. Plans shall be the basic floor plan (clearly identifying all room names/use, not just numbers) with easily recognizable tags for any room that is not neutral pressurization. The tag would indicate airflow direction (e.g. + and – or POS and NEG) and airflow (cfm).

d. Overall building airflow showing interrelationships of air handling units, exhaust fans, duct risers and mains, primary dampers with air balance/pressure relationships.

e. Overall building hydronic and steam systems showing interrelationship of main heating/cooling plant equipment or central utility source, heat exchangers, pumps, pipe risers and mains, primary isolation and control valves.

f. Connected and cumulative design capacities and flow rates which can be toggled on during design phase for review purposes and off if desired for final construction documents.

g. Areas with special pressure relationship requirements that must be properly controlled, the design professionals shall include plans in the construction set of drawings showing simplified pressure relationships and tabular summaries of overall air balance for each pressure controlled space with summaries of system airflows.

h. Table indicating system level summaries of airflows per floor (e.g. system SA [max/min], system RA [max/min].), General Lab Exhaust (max/min), Fume Hood Exhaust (max/min), General Exhaust, Transfer Air (including intended source – adjacent system), and any other special exhaust systems.

2. HVAC registers and vents within the construction area shall be capped unless specifically approved by the COR or IC. The method for capping shall be dust tight and shall withstand the static air pressure.

E. Contractors are responsible for providing the manpower and equipment (including negative air machines, ICRA barrier materials, etc) for meeting the design and intent of the ICRA requirements.

1. Depending on the scope of work, the phase of the work, and the location of the exhaust, unfiltered negative air fans may be permitted.

2. Negative air machines may be connected to normal or emergency power and shall run continuously. Critical areas may require the negative air machine be connected to emergency power only.

3. Should a negative air machine be incorporated to exhaust air into a HVAC return air or exhaust air duct, the COR, IP, and the HVAC Department will review the installation prior to connection.

4. The negative air machine testing will be performed by the LVAMC HVAC Department or Biomedical Engineering.

5. When negative air pressure is required, Contractors will verify the presence of negative air pressure IAW Negative Pressure Monitoring Guide (Appendix C), and post the Negative Air Pressure Verification Log (Appendix B.) Appropriate log entries shall be completed prior to the beginning of every work shift.

F. Contractors are responsible for maintaining their equipment including the replacement of the HEPA and other filters as per manufacturer’s recommendations and the LVAMC HVAC Department HEPA filter maintenance program.

1. HEPA Filter Maintenance includes:

a. The HEPA filter in the negative air machine will be tested upon new installation into the machine and at least semi-annually thereafter. More frequent testing may be required as determined necessary during the ICRA process

b. Certification stickers with the date of the testing shall be visible on the machine.

c. The filter efficiency testing requirement may be relaxed if the machine is exhausted directly to the outside and is not within close proximity to an air intake or a public walkway.

d. A particle counter meter will certify a 99.0% reduction at the .5 micron setting on the particle counter.

G. Contractors are responsible to ensure the ICRA barriers are maintained for the duration of the project; the doors are working and latching properly, doors are kept closed, all seams and joints resealed, negative air is maintained, etc.

1. The Contractor will inspect the barrier at the beginning of each work shift.

2. Barriers shall be required at elevator shafts or stairways that are within the work zone.

3. Barrier effectiveness shall be monitored and barriers repaired or improved as necessary to prevent dust and debris from escaping the work zone.

4. Penetrations (pipe, conduit, cable, etc.) in the ICRA barrier or existing walls used as barriers are to be sealed.

5. Control Cube usage is delineates following criteria:

a. Will be vacuumed from the inside of the cube prior to opening the door zipper.

b. If negative air is required, a certified negative air machine will be used.

6. Work performed outside the regular ICRA barrier may be performed in a temporary barrier; a Control Cube, a polyethylene enclosure erected around the opening, or other methods approved during the ICRA determination. Upon completion of the work the area inside the barrier must be cleaned prior to removal.

7. Investigations may require the opening of ceiling tiles or access panels outside the ICRA barrier. The ceiling tile or access panels shall be replaced immediately upon completion of the investigation and when unattended. Control cubes or other interventions may be required for accessing these spaces.

H. The Contractor will arrange for or provide the manpower and equipment (cleaning supplies, dust mops, wet mops, brooms, buckets, bleach, etc.) or ongoing and timely (normally daily) cleaning in the work zone, anteroom, and as necessary adjacent areas to prevent the accumulation of dust and debris. The following cleaning requirements are to be followed by contractors:

1. Contractors and materials are not to be transported using patient transport designated elevators.

2. Workers are to be free of dust prior to exiting the work zone. If used, coveralls are to be removed in the work zone just before entering the anteroom. Vacuuming of clothing may be done in the work zone or the anteroom. Booties are to be removed in the anteroom.

3. Vacuuming is to be done using a HEPA filtered vacuum.

4. Workers shall clean shoes, equipment, transport carts, transport cart wheels etc. with bleach solution to prevent dust from being tracked outside the work zone. Any dust tracked outside of the work zone shall be immediately removed.

5. Transport receptacles, carts, toolboxes, equipment, etc. are to be free of dust.

6. Debris removed from the work zone shall be in tightly covered containers and transported following the designated route as identified during the ICRA determination.

7. Adhesive walk off mats shall be kept clean and changed daily or more often to remain effective. Bleach solution moistened carpets, carpet squares, etc. may be used to prevent premature loading of the adhesive mats.

XI. INFECTION CONTROL RISK ASSESSMENT (ICRA) PERMIT

A. LVAMC can perform and post “self-evaluation” ICRA Permit (Appendix A) for Class I & II level work.

B. An IC approved ICRA Permit (Appendix A) is required for Level III and Level IV work and may be required for Level II work at the discretion of COR and/or IC.

C. The COR or IC may add additional details (scope descriptions, interventions, egress designations, unique interventions necessary for a specific job, etc.) in the ‘Additional Requirements’ section.

D. The ICRA Permit form and the listed interventions may be modified as deemed necessary.

E. The IC will prepare the permit and then release it to the COR.

F. The COR will review the permit with the contractor and obtain his signature. The signed ICRA permit will be placed in the engineering project file and posted at all accesses to the construction site for the duration of the project.

G. Contractors shall adhere to all precautions listed for class levels indicated an notations listed in the ‘Additional Requirements’ section, and if applicable.

XII. INFECTION CONTROL PROCEDURES –IMPLEMENTATION

A. Following is the typical sequence for the implementation of the Infection Control Procedures:

1. The COR and ‘User Department’ will arrange for the relocation of supplies, equipment, furniture, etc. from the work zone before the temporary barriers are installed.

2. Exterior window seals and building penetrations must be assured to minimize infiltration of outside contaminates when the work zone is under negative pressure.

3. The contractor will install and run the negative air machine in the work zone location prior to any barrier construction.

4. The ICRA Permit will indicate if a temporary polyethylene barrier is to be erected prior to the construction of the ICRA barrier and if it shall be dust tight.

5. The contractor will install the ICRA barrier using approved materials and following the requirements of the ICRA Permit.

6. The anteroom will be constructed to maintain airflow from the clean side through the anteroom and into the work zone.

7. The contractor will arrange for the installation of negative pressure monitoring device, if required by ICRA Permit.

8. Upon completion of the barrier, the Contactor will verify acceptable negative pressure.

XIII. INFECTION CONTROL PROCEDURES –COMPLETION

A. Following is the typical sequence for the completion of the Infection Control Procedures.

1. The COR will verify that utility and mechanical systems are commissioned and/or functioning per designated specifications.

2. Following the removal of all contractor equipment and supplies, contractor provided cleaning can be performed. After all cleaning is completed; the contractor will flush all plumbing systems by opening all water fixtures (hot and cold) to run continuously for fifteen minutes and flushing every toilet/urinal at least three times. Plumbing systems distal to plumbing construction will have Heterotrophic Plate Count (HPC) and Legionella testing samples obtained.

3. Following plumbing flush, barrier pre-removal cleaning will be performed. This includes the cleaning of the entire work zone, ICRA barrier, HVAC covers, and the outside of the negative air machine(s) with its associated ducting.

4. After all cleaning is completed, the COR or designee will inspect the entire work zone to ensure cleaning was in compliance to designated standards.

5. Covers on HVAC supply ducting will then be removed with the HVAC system initiated to observe performance. If this action produces any dust or dirt, pre-removal barrier cleaning and inspection will be repeated.

6. HVAC return air covers can then be removed for full HVAC system operation.

7. ICRA barriers can now be carefully removed as to prevent contamination of adjacent areas.

8. Minimization of dust aerosolization during barrier removal can be achieved by lightly spraying the polyethylene barrier with appropriate strength bleach solution.

9. Polyethylene barriers will be rolled of folded ‘on itself’ to inhibit the creation of as little dust as possible.

10. Barrier debris shall be placed in a sealed or covered container for transport.

11. Barrier post-removal cleaning will be performed immediately following the ICRA barrier removal. This cleaning is to remove all dust and debris generated during the barrier removal.

12. Barrier post-removal cleaning will be inspected and approved by the COR or designee.

13. Negative air machine(s) can now be removed. Dust or dirt generated by its removal shall be removed by contractor using a HEPA filtered vacuum system.

14. HVAC system airflow will be balanced as per designated specifications.

15. If air sampling is not required:

a. The COR will notify the user group when the barrier post-removal cleaning has been approved so they may take possession of the space.

b. If the space is used for patient occupancy or exam/treatment, following the installation of all furniture, durable medical equipment and supplies, the COR or Service/Care Line Manager will arrange for LVAMC to do the occupancy cleaning using the standard protocol for the service line.

c. If greater than three days has elapsed since the plumbing was flushed, all fixtures (hot and cold) will be turned on for fifteen minutes and toilets flushed at least three times.

d. The Department Manager will notify admissions after inspection and approval of space cleaning.

16. If air sampling is required:

a. HVAC system must be fully operational with all air diffusers and return air portals uncovered. Negative air machine is removed with exhaust portal secured. Particle counts will be obtained by qualified personnel (e.g., consultant).

b. Particle counts verifying that HVAC system diffusers are filtering air IAW required specifications will let COR proceed to secure the space, undisturbed for an overnight period.

c. Repeated particle counts along with microbial air samples will be obtained the following business day. IC will review microbial and particle count results with recommendations to the COR pertaining to air quality acceptability standards and space occupation.

d. Spaces used for patient occupancy or exam/treatment will be cleaned following the installation of all furniture, durable medical equipment and supplies. The COR or Service/Care Line Manager will arrange for LVAMC to do the ‘occupancy cleaning’ using the standard protocol for the service line.

e. The Department Manager will notify admissions after inspection and approval of space cleaning.

XIV. PRECAUTIONS BY CLASSIFICATION LEVELS (Refer to Table 4) A. Classification (Class) I - IV precaution responsibilities of COR and/or contractor:

1. Class I Infection Control Precautions:

a. An ICRA Work permit is not required; however COR may complete if desired.

b. Identify when Class I precautions apply per Tables 1, 2 and 3. If unclear, they are to consult with IC.

c. Verify that Class I precautions are maintained and adhered to for all projects for which they are responsible.

d. Refer to ICRA Permit Table 4 for specific precautions.

2. Class II Infection Control Precautions:

a. An ICRA Work Permit is not required, however the COR may complete one if desired.

b. Identify when Class II precautions apply per Tables 1, 2 and 3. If unclear, they are to consult with IC.

c. Verify that Class I and II precautions are maintained and adhered to for all projects for which they are responsible.

d. Refer to ICRA Permit, Table 4 for specific precautions.

3. Class III Infection Control Precautions:

a. Required to complete an ICRA.

b. Identify when Class III precautions apply per Tables 1, 2 and 3. If unclear, they are to consult with IC.

c. Verify that Class I, II and II precautions are maintained and adhered to for all projects for which they are responsible.

d. Refer to ICRA Permit, Table 4 for specific precautions.

4. Class IV Infection Control Precautions:

a. Required to complete an ICRA.

b. Identify when Class IV precautions apply per Tables 1, 2 and 3. If unclear, they are to consult with IC.

c. Verify that Class I, II, III and IV precautions are maintained and adhered to for all projects for which they are responsible.

d. Upon completion of the major dust generating demolition/construction activities, the coveralls and shoe cover requirements may be removed.

e. Refer to ICRA permit, Table 4 for specific precautions.

B. Additional precautions for specific highest risk locations (ORs, Sterile Processing etc.):

1. All tools (equipment, ladders, carts, etc.) brought into these areas must be pre-cleaned by wiping with a disinfectant cloth (hospital approved Cavi-Wipe or proper strength bleach solution) until they are dust and dirt free.

2. Contractors will change into scrub suits if working in the OR Suite or Sterile Processing.

3. Work must be scheduled through the department Nurse Manager or their designee by the COR.

4. Work done above ceilings or work that creates any dust or water aerosolization must be contained utilizing a fabricated containment structure or ‘Kontrol Cube’ utilizing a certified HEPA negative air machine.

XV. ENVIRONMENTAL MONITORING

A. Requirements for air sampling will be noted on ICRA, as determined by the COR, Safety Department, and/or IC.

B. The ICRA permit will indicate if a negative air pressure continuous recording device (chart recorder) or other visual indicator is required. The COR will document the presence of negative pressure on the Negative Air Pressure Verification Log (Appendix B) only after visual confirmation of negative pressure in the designated space.

C. LVAMC may choose to independently monitor air quality throughout the project.

XVI. COMMISSIONING

A. Commissioning is a quality process used to validate, and document that facilities and component infrastructure systems are planned, constructed, installed, tested, and can meet operational standards as per intended design or performance expectations.

1. Acceptance criteria for mechanical systems shall be specified in the design specifications.

2. Crucial ventilation specifications for air balance and filtration shall be verified before owner acceptance. Ventilation deficiencies shall not be accepted.

3. Acceptance criteria for local exhaust systems dealing with hazardous agents shall be specified and verified. Ventilation deficiencies shall not be accepted.

4. Areas requiring special ventilation (e.g. surgical services, protective environments, airborne infection isolation rooms, laboratories, and local exhaust systems for hazardous agents) shall be recognized as required mechanical systems that ensure infection control.

5. Refer to Facilities Guidelines Institute (FGI) 2010. Guidelines for Design and Construction of Health Care Facilities, Chicago, IL: ASHE (American Society for Healthcare Engineering) of the American Hospital Association; Section - Planning, Design, and Construction/Commissioning.

XVII. FACILITIES DEPARTMENT AND CONTRACTOR INFECTION CONTROL

EDUCATION

A. ICRA education shall be performed prior to the individual beginning work.

B. All Contractors and CORs shall attend ICRA training. Contractors who perform their work exclusively outside (e.g. landscaping, snow removal etc.) are exempt from his requirement. The COR for these exempt contractors must make them aware that they are not to enter the building with soiled clothing or shoes.

C. Contractors performing very short term or emergency work may be excused from the training requirement. These untrained contractors shall be escorted by an ICRA trained individual. The escort must assume the responsibility that the untrained contractor will follow all provisions of the policy. Approval for using non-ICRA trained contractors must be approved by the COR.

D. The education session will be offered in video format or by an IC approved recorded presentation. A written test will be administered to ensure the pertinent Terminal Course Objectives (TCO’s) have been learned. These TCO’s include:

1. Why dust control is important.

2. Types of work that will most likely generate dust.

3. Preventions used to reduce the spread of dust and the aerosolization of water.

4. Define "ICRA".

5. Identify where the ICRA Permit should be posted.

6. List the four‘Class’ levels of infection control preventions.

7. Identify on a sample ICRA permit the ‘Class Level’ of the project and where to find the specific preventions designated in each class they are required to follow.

E. Contractors who complete the training will receive a certification sticker or card. Training indicated by issued sticker/card will be valid for one year. Training certification must be carried by the contractor while on site.

F. ICRA recertification training will be completed annually.

XVIII. ENFORCEMENT

A. The COR, IC, and Engineering Department will ensure compliance with this guide. They have the authority to stop all work if there is immediate risk to patients, staff, or the public.

B. The COR will perform daily inspection of ICRA barriers within the work zone.

C. The COR will immediately address ICRA non-compliance issues to contractor verbally with follow-up written documentation. The details of the deficiencies will be sent to IC and the Facilities/Engineering Departments with placement in the project file.

D. ICRA non-compliance issues will be reviewed and discussed at project and construction meetings to identify possible causes and process improvement measure to delineate repeated infractions.

XIX. CLEANING SPECIFICATIONS FOR POST CONSTRUCTION/RENOVATION CLEANING

A. The Contractor will arrange for post construction/renovation cleaning, utilizing a professional Cleaning Company (CC) that has experience and demonstrated competence in cleaning institutional environments, preferably healthcare.

B. The designated CC will furnish labor and supplies for all cleaning services required during assigned construction and renovation projects.

C. All CC workers will be required to adhere to applicable LVAMC guidelines including not working while ill. This is to be enforced by the CC’s management.

D. Two Step Cleaning Requirements:

1. Barrier Pre-Removal Cleaning:

a. Clean inside the project area with the barrier in position.

i. HEPA vacuum all horizontal and vertical surfaces, including the barrier and the inside of the metal stud tracks. If work was performed above an existing suspended ceiling, vacuum the top of the ceiling tiles.

ii. Completely clean inside of the barrier, to include the interior portion of the barrier using solutions previously designated, removing all dust, dirt, debris, and grime from all surfaces located within the project area.

b. Clean, without removal of, supply and return ventilation covers that are isolating HVAC system.

c. Clean the outside of the negative air machine and its attached exhaust ducting from machine to exhaust portal.

d. Clean all flooring and apply floor finishes as prescribed by the manufacturer of the product and/or LVAMC’s EMS department.

e. The barrier pre-removal cleaning will be inspected and approved by the COR.

f. In event HVAC ventilation supply and exhaust portal cover removal or system operational testing produces any dust or dirt, barrier pre-removal cleaning and inspection will be repeated.

g. The COR will give approval for the removal of the ICRA barrier.

2. Barrier Post-Removal Cleaning:

a. Prior to removal of the barrier, the contractor may lightly mist the barrier, with appropriate percentage bleach solution, to prevent residual dust from aerosolizing during the barrier removal.

b. The Contractor will remove the barrier.

c. The cleaning will be completed to remove any dirt generated during barrier removal. Cleaning encompasses all surfaces in the same room of barrier location and adjacent areas possibly affected areas.

d. The negative air machine and its associated hardware may be removed once initial barrier post-removal cleaning is complete.

e. The contractor is responsible to HEPA vacuum any dust or debris generated by removal of the negative air machine. Final barrier post-removal cleaning will then be performed to eliminate all dust that resettles on any horizontal surfaces in or adjacent to previous barrier location.

f. Final barrier post-removal cleaning will be inspected and approved by the COR.

E. Specific Cleaning Expectations:

1. When complete, all surfaces should have a “white glove” finish.

2. Clean all ceiling, lights, and ceiling diffusers and grills.

3. Clean all walls, from top to bottom, including vents, trim, recessed spaces and other detail in walls, including built-in cabinets and drawers.

4. Clean the blinds and windows.

5. Clean all horizontal surfaces (equipment, TV, computers, phones, furniture, desks, countertops, lodges, sills, and rails, door jambs, handles, crevices, etc.).

6. Clean all cove base, floor tile, sheet vinyl, and carpeting.

7. Clean bathroom in sequence going from toilet, to shower/tub, to sink, to floor.

8. Clean shower using friction to remove all visible stains, grime, rust, and soap scum.

F. Cleaning Products:

1. All cleaning products are to be consistent with cleaning supplies used by LVAMC.

2. Products for specific equipment must also be of approved type as specified by the original equipment manufacturer.

3. Contact the EMS Chief for a current list of approved products.

G. Carpet Cleaning Equipment:

1. Carpet shampooing equipment must be a type using steam or hot water extraction.

2. Vacuums must be equipped with brushes and HEPA filters.

H. Products currently used by the Lebanon VAMC EMS can be found in SOP 22-2011.

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