PCRA Memorandum 7-11.doc

Department of Veterans Affairs

Memorandum 626-11-138-74

VA Tennessee Valley Healthcare System July 29, 2011 Department of Veterans Affairs

Memorandum 626-11-138-74

VA Tennessee Valley Healthcare System July 29, 2011

Construction and Renovation Infection Prevention & Control Precautions

1. PURPOSE: To identify and reduce the risk of acquiring and transmitting infections among patients, employees, physicians and other independent practitioners, contractors, vendors, contract service workers, volunteers, students, visitors, and any other building occupants during hospital renovation or construction activities. Fungal organisms released into the air during these activities can cause illness and even death in people with poor immunity. This memorandum is to be included in the (Green) Safety Manual.

2. POLICY: Precautions will be taken to make conditions as safe as possible before and during all construction and renovation to protect the environment from hidden infectious disease hazards which may be released into the air, carried on dust particles or on clothing during construction activities. (For example: Aspergillus species may be found in decaying plaster, drywall, and settled dust found on ceiling tiles and in areas that have been undisturbed for long periods of time.) This applies to all construction and/or renovation managed by Engineering Service, Department of Veterans Affairs Tennessee Valley Healthcare System (VA TVHS) at VA TVHS campuses and facilities, including Community Based Outpatient Clinic’s (CBOC) and cemeteries.

3. RESPONSIBILITIES:

a. Engineering Service and Infection Prevention & Control Team, will screen future construction/ renovation projects during the project design phase and at the project start for construction activity types. Construction activity types will be defined by the amount of dust that is generated, the duration and extent of the activity, the amount of shared heating and air conditioning systems, and the location of the activity. Personnel will conduct a Pre-Construction Risk Assessment (PCRA) for all construction projects.

b. Infection Preventionists (IP) will assist in making recommendations for implementation of safety/infection prevention and control practices for the duration of the job. Precautions taken in specific settings will be agreed upon after corroboration between Infection Prevention, Engineering Service and the service chief of the specific area.

c. The Immediate Job Supervisor, Superintendent, Foreman (VA or Contractor): of the construction/renovation will be responsible for insuring that coordinated precautionary measures are properly enacted and maintained throughout the work.

d. Infection Prevention, Engineering Service and the project Contracting Officer Technical Representative (COTR) will monitor these temporary measures by conducting documented periodic inspections at predetermined intervals during construction/renovation.

e. Environmental Management Service (EMS) will have an integral part in cleaning of the areas immediately adjacent to the site and in certain cases within the work site itself.

f. Engineering/Safety, Infection Prevention, EMS and/or the construction team should be contacted if any regulation is questionable under these guidelines.

4. DEFINITIONS & PRE-CONSTRUCTION ACTIVITIES:

a. Preparation for Construction and Renovation should include the following:

(1) Patient placement and relocation;

(2) Standards for barriers and other protective measures required to protect adjacent areas and susceptible patient from airborne contaminants;

(3) Temporary provisions or phasing for construction or modification of heating, ventilating, air conditioning, and water supply systems;

(4) Protection of occupied patient areas from demolition;

(5) Measures to be taken to train healthcare facility staff, visitors, and construction personnel on maintenance of interim life safety and infection control risk mitigation recommendations.

b. Attachment A will be used to identify the Type of Construction Project Activity, Patient Risk Group (Low, Medium, High, Highest) and the Class of Precautions (I, II ,III, IV ) or level of infection control activities required.

c. Attachment B will be used to monitor Construction Project Activity during the Project. Findings will be reported to the Environment of Care Board through the Safety Manager or Chief Engineer.

5. REFERENCES:

a. Association for Professionals in Infection Control and Epidemiology. Text of Infection Control and Epidemiology: Construction Renovation, 3rd Edition: Chapter 106;1-18. Washington, DC: APIC, 2009

b. American Lung Association, Environmental Protection Agency, Consumer Product Safety Commissions, American Medical Association. Indoor Air Pollution: An Introduction for Health Professionals. Washington, DC: US Government Printing Office, 1994. Publication 523-217/ 81322

c. American Institute of Architects. Guidelines for Design and Construction of Hospital and Healthcare Facilities. Washington, DC: A1A Press: 1996

d. Occupational Safety and Health Administration, Legionnaires’ disease. In OSHA Technical Manual Section II, 1997;7:1-46, U.S. Department of Labor

e. VHA Center for Engineering & Occupational Health and Safety. Construction Safety Guidebook. St. Louis, MO. April 2009

6. RESCISSION: VA TVHS Memorandum 626-08-138-74

7. RESPONSIBILITY AND REVIEW DATE: This memorandum will be reviewed annually by the Chief, Engineering with the assistance of Infection Prevention and Environmental Management Service and will be reissued no later than June 30, 2014.

/s/ Juan A. Morales, RN, MSN 8/15/2011 Juan A. Morales, RN, MSN

Health System Director

Attachments:

A – Pre-Construction Control Risk Assessment (PCRA)

B - Infection Prevention/ Safety Program, Periodic Construction Rounds Compliance Monitor

DISTRIBUTION: Green Safety Manual

ATTACHMENT A

(Note: To be filled out by Infection Control and Engineering Service during project design and revalidated at the start of construction.)

Pre-Construction Risk Assessment

Infection Prevention/ Safety Construction Permit

Description of project:

Construction Activities

The following jobs do not require completion of the Pre-construction risk assessment form on low and medium risk project areas:

1. Paint and wallpaper in business offices and non-patient areas.

2. Paint in empty patient room if closed for painting and less than 3 sq.ft. of wall needs patched. Filter for room unit changed after painting.

3. Installation of soap dispenser/needle box/paper towel holder in patient room.

4. Repair of window blind.

5. Ceiling tile replacement for area less than 5 2 X 2 tiles in a patient area if patient is out of the immediate area and clean up can be accomplished before patient returns.

5. Minimum repair of nurse call system/TV/Bed/Telephone.

6. Check or replace electric outlet.

7. Replace light bulb.

8. Unstop sink/commode with no water on floor.

9. Unstop commode when water on floor requires maintenance to have Housekeeping clean area immediately.

10. Repair medical gas outlet. (Front Body)

11. Air balance readings.

12. Check air-conditioning.

13. Intermediate jobs that create a moderate amount of dust inside room and is made negative by use of hepa-equipped unit with minimum 10 ACH, and all air discharged outside, hepa unit must run 2 hours after completion of job and Housekeeping must clean room before unit is removed from room. All work and use of hepa unit must be documented and copy forward to Infection Control and Safety. NOTE: all duct vents to be sealed off during work!

· The above does not apply to any Protective Environment patient areas or occupied high and highest risk areas.

Will there be noise generated that will impact a department adjacent to, above, or below the construction area?

a. If so, these departments must be notified.

b. How are you going to reduce the noise to an acceptable level?

Will there be vibration generated that will impact a department adjacent to, above, or below the construction area?

a. If so, these departments must be notified each time this type of work will be performed.

b. How are you going to reduce the vibration to an acceptable level?

Are Emergency Procedures in place and posted on each job for accidental events that could greatly impact Patient Care or Life Safety to the facility? Included in these procedures are such things as:

· Emergency telephone numbers of key departments.

· A plan that describes where main valves, switches, and controls are for the area in case of an emergency.

· A plan for unexpected outages.

Environment

Will hazardous chemicals be used on this project? How will fumes and odors be controlled? MSDS Sheets are required.

Is asbestos abatement required on this job? If so, notify Safety and FES at the activation.

Will there be hot work done on this project? If there are, then a hot work permit must be posted on the job site. All hot work must have a fire watch assigned to each area while the hot work is being performed.

Will there be a Confined Space Entry required on this project? If so, the Medical Center’s confined space entry program must be followed.

Utility Failures

· Fire alarm (If out for more than 4 hours, Interim Life Safety Measures must be implemented.)

· Sprinkler (If out for more than 4 hours, Interim Life Safety Measures must be implemented.)

· Electrical

· Domestic water

· Oxygen

· Sewage

· HVAC

Attachment B (Note: Fill out for Class II, III, and IV at interval specified by Infection Prevention on A-1)

Infection Prevention / Safety Program

Periodic Construction Rounds Compliance Monitor

a. Construction signs posted for the area

b. Doors properly closed and sealed

c. Floor area clean, no dust tracked

2. Air Handling

a. All windows closed behind barrier

b. Negative air at barrier entrance (Types III & IV)

c. HVAC system adjusted/modified (Per Attachment. A-1)

3. Project Area

a. Debris removed in appropriate container

b. Dust Control mats: Walk off mats clean & adequate to contain construction dust

c. Routine cleaning of trash/waste/debris

4. Traffic Control

a. Restricted to necessary staff only with proper escort and construction workers

b. All doors and exits free of debris

5. Dress Code

a. Appropriate for the area

b. Required to enter

c. Required to leave

Comments

Yes� No� Will there be any work that will require activation of the Interim Life Safety Measures during this project? Some things that trigger ILSM's to be implemented are but not limited to:

Any construction that impacts an EXIT or stairs, Any construction that impacts major breaches in a fire or smoke wall, (penetration permit required)

Taking the main fire protection system out of service (sprinkler), Taking the main fire alarm system out of service, Taking the "area" fire or fire alarm systems out of service for more than 4 hours within a 24-hour period.� Implementation of the ILSM requires a fire watch and the ILSM forms to be completed (forms are to be obtained from the � Medical Center Fire Department� Additional Safety Concerns� Yes� No� Will construction affect exit routes from occupied areas adjacent to construction site?� Will project affect traffic patterns in area? If yes, explain plan.� The following must be completed prior to any construction activities.� Separation wall must be constructed prior to project beginning.

Fire protection systems must remain intact.

Provide extra fire extinguishers in work areas.

Maintain exit lights in work area.

Maintain negative air in construction area (24/7) through duration of project.

There cannot be any return air from within the construction area to the rest of the building.

Redirect exiting not to go through construction area.

Put signs on doors into construction area "Construction Area – Do Not Enter".

Maintain daily logs and keep a current Hot Work Permit.

Place tacky mats at doors exiting construction area.

All debris removal must be by covered cart.

Maintain clean and orderly work area.

How will this project affect the departments above, below and adjacent to this project?� Air Quality and Infection Control� The construction activity types are defined by the amount of dust that is generated, the duration of the activity, and the amount of shared HVAC systems. Contact CVAMC's Safety Office and Infection Preventionist if any activity is questionable under these guidelines.� Yes� No� Will dust be generated during this project?

If yes, explain location of and plan for interim dust barriers or attach floor plan with barriers clearly marked.� Will debris removal be necessary? If yes, explain plan for debris removal and control.� Negative airflow ventilation and filtration in place and assessed for effectiveness.� Exhaust fans in place and functioning.� Is supply duct to area closed and HEPA filtration unit in place and functioning in adjacent patient care area?� Will work be done in a sterile area? If so, how are you going to maintain sterile atmosphere in work area and access to and from work area?� Type A� Inspections and Non-Invasive Activities or Small scale, Short duration Activities� Yes� No� Removal of ceiling tiles for visual inspection (limited to <25% of total area)� Painting (limited sanding to <10% of area)� Wall covering—Describe work to be done:� Electrical trim work. Describe:� Minor plumbing. Describe:� Type B� Small scale, short duration activities that create minimal dust.� Yes� No� Installation of telephone and computer cabling� Access to chase spaces� Sanding of walls for painting or wall covering (minor repairs—not sanding for drywall finishing)�

Type C� Any work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies.� Yes� No� Sanding of walls-(>50% of surface area)-drywall finishing� Removal of (floor coverings (ceiling tile (casework (>50% of surface area) Describe:�% Describe:� Cutting of walls or ceiling. Describe:� New wall construction� Minor ductwork or electrical work above ceilings� Major cabling activities� Activity cannot be completed within a single work shift� Type D� Major demolition and construction projects. � Yes� No� Will require heavy demolition or removal of a complete ceiling system� New construction�

GROUP I�LOWEST�

GROUP 2 MEDIUM�

GROUP 3 HIGH�

GROUP 4�HIGHEST�

1.) Office areas� 1)� Ancillary Therapy areas

1)� Pharmacy Areas� 1)� CLCs� 2.) Hallways� 2)� Respiratory Therapy� 2)� Radiology�

SPD�

3.) EMS �

Outpatient Clinics� 3)� Triage� 3)� Acute Care Units

4)� CBOC’s� 4)� Laboratories� Mar� Bone Marrow Transplant Unit

5)� Mental Health Units� Oper� Operating Rooms� Chemotherapy areas (outpatient clincs/inpatient units)� Areas/Units adjacent to BMTU�

8) Palliative Care� Palliative Care�

9) � ICU’s�

Contact the Infection Preventionist or Safety Office for risk assessment of any area not listed above.

CONSTRUCTION ACTIVITY (from previous page) Check type of activity� INFECTION CONTROL RISK GROUP (see above) Check risk group� TYPE A: Inspection, non-invasive activity� GROUP 1: Lowest Risk� TYPE B: Small scale, short duration projects� GROUP 2: Medium Risk� TYPE C: Activity generates moderate to high levels of dust, requiring >1 work shift for completion� GROUP 3: High Risk� TYPE D: Major duration and construction activities�Requiring consecutive work shifts� GROUP 4: Highest Risk�

CLASSIFICATION OF REQUIRED PREVENTIVE MEASURES

CONSTRUCTION ACTIVITY-�

TYPE "A"�

TYPE "B"�

TYPE

"C"� TYPE “iy,�

INFECTION CONTROL

RISK GROUP 4,�

Group I� I� I�

II�

III/IV�

Group 2� I� I�

III�

IV�

Group 3�

II�

III�

III/IV�

IV�

Group 4�

III�

III/IV�

III/IV�

IV�

An Infection Control—Safety Construction Permit is required for Class III or higher projects. Refer to shaded area on Construction Activity/Risk Group Matrix (above).

CLASS I�

1.� Execute work by methods to minimize raising dust from construction operations.� 2.� Immediately replace any ceiling tile displaced for visual inspection.�

CLASS II�

1.� Provide active means to prevent air-borne dust from dispersing into atmosphere� 6.� Contain construction waste before and during transport in tightly covered containers.� 2.� Water mist work surfaces to control dust while cutting.� 7.� Wet mop and/or vacuum with HEPA filtered vacuum before� 3.� Seal unused doors with duct tape.� leaving work area.� 4.� Block off and seal air vents.� 8.� Place dust mat at entrance and exit of work area as needed.� 5.� Wipe surfaces with disinfectant.� 9.� Remove or isolate HVAC system in areas where work is being performed.�

CLASS III

Obtain infection control permit before construction begins. 7. Place dust mat at entrance and exit of work area. Replace as

Isolate HVAC system in area where work is being done to needed.

prevent contamination of the duct system. 8. Do not remove barriers from work area until completed project is

Complete all critical barriers before construction begins. inspected by Safety and Epidemiology Depts. and thoroughly

Maintain negative air pressure within work site utilizing cleaned.

HEPA equipped air filtration units.

Contain construction waste before and during transport in After work is completed:

tightly covered containers. 9. Remove barrier materials carefully to minimize spreading of dirt

Seal holes, pipes, conduits, etc. appropriately. and debris associated with construction.

10. Remove isolation of HVAC system.� Class IV� 7.

1. Obtain infection control permit before construction begins. All personnel entering work site are required to wear shoe

2. Isolate HVAC system in area where work is being done to covers prevent contamination of duct system. 8. Contain construction waste before and during transport in tightly

3. Complete all critical barriers or implement control cube covered containers. Cover transport receptacles or carts. Tape method before construction begins. covering.

4. Maintain negative air pressure within work site utilizing 9. Do not remove barriers from work area until completed project is

HEPA equipped air filtration units. inspected by Safety and Epidemiology Depts. and thoroughly

5. Seal holes, pipes, conduits, and punctures appropriately. cleaned.

6. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA After work is completed:

vacuum cleaner before leaving work site or they can wear 10. Vacuum work area with HEPA filtered vacuums.

cloth or paper coveralls that are removed each time they 11. Wet mop with disinfectant.

leave the work site. 12. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

13. Remove isolation of HVAC system.� Additional concerns for all classes:

Maintain manpower and equipment including dust mops, wet mops, brooms, buckets, and clean wiping rags for cleaning fine dust from floors and adjacent occupied areas.

Contain work areas outside of construction barriers, including spaces above ceilings, with full height polyethylene sheet barrier, tightly taped.

Clean up dust tracked outside of construction area immediately.

Temporary construction barriers and closures above ceiling must be dust tight.

Removal of debris must be in covered containers.� Additional Requirements or Concerns:� Permit Request By� Safety Approval� Infection Preventionist Approval� Date:� Date:� Date:�