ATTACHMENT C 600-21-116 Infection Control Permit.pdf

Revised 3/14/2019

Infection Control Permit

Location of Construction: Project Start Date:

Project Coordinator: Estimated Duration:

Contractor Performing Work: Telephone:

Supervisor: Email:

Project or Work Order #

Description of project: (Choose only one.) Demolition Construction Renovation Repairs

Yes No

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

a. If so, these departments must be notified.

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

Yes No

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

Yes No

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.

Yes No

Are any of the following environmental hazards present?

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.

Yes No Will any of the following systems be out of service at any time during the project?

• 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.)

• E lec t r i ca l

• Domestic water

• O xy ge n

• S e w a g e

• H V A C

Richard Moss

TBD

28 days

TBD TBD

TBD TBD

600-21-116 x x x x

Conduct work outside normal business hours if necessary

Conduct work outside normal business hours if necessary x x x x x x x x x x x x x x x

B7 2nd floor, B2 1st floor, B126 1st floor

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 work that impacts an EXIT or stairs,

• Any work 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).

Yes No

Will work affect exit routes from occupied areas adjacent to work 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 x x x x x x x x x x x x x x x x x x x x x x x x

STOP! DO NOT FILL BELOW, FOR INFECTION CONTROL USE ONLY.

Note: If you email this form to one of the Infection Control Practitioners, please follow-up with a phone call to IC to ensure it was received (310-268-3715). Do not leave a message.

Risk Levels

Group 1 Lowest Risk Group 2 Medium Risk Group 3 Medium-High Risk Group 4 Highest Risk

Office Areas Ambulatory Care Emergency room Operating Rooms, Clean and Soiled

Non-patient Care Radiology/MRI Utility Areas

Areas Day Surgery Supply, Processing or Distribution

PACU Areas/DSU All Intensive Care Units Cardiovascular Procedure Areas

Nuclear Medicine Cardiac Cath and Angioplasty Areas

Admission Procedure Rooms

PT, Pool/Water Therapy Isolation Rooms

Housekeeping Closets Dialysis

Dietary Storage Cardiology

Food Preparation Areas Anesthesia and Pump Areas

Canteens Pharmacy Admixture Area Laboratories Interstitials in Group 3

Endoscopy Areas Interstitials in Group 4

Respiratory Therapy Patient Units: (Mental Health, Medicine, Rehab)

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; minimal dust GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requiring >1 work shift for completion;

demolition or removal of any fixed bldg components or assemblies

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

"D"

INFECTION CONTROL

RISK GROUP

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 Construction Permit is required for any work done in Class III or IV. Refer to shaded area on Classification of Required Prevention Measures above. In addition, for in-house electricians, plumbers, etc., permits are required for any work that produces dust or penetrates a barrier (including ceiling tile removal) in Group 3 or Group 4 within Risk Levels section above.

x x

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.

2. Water mist work surfaces to control dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Wipe surfaces with disinfectant.

6. Contain construction waste before and during 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 as needed.

9. Remove or isolate HVAC system in areas 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 before construction begins.

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

5. Contain construction waste before and during transport in tightly covered containers.

cleaned.

6. Seal holes, pipes, conduits, etc. appropriately.

7. Place dust mat at entrance and exit of work area. Replace as needed.

8. Do not remove barriers from work area until completed project is inspected by Safetly and Epidemiology Depts. and thoroughly cleaned.

After work is completed:

9. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

10. Remove isolation of HVAC system.

Class IV

7 .

1. Obtain infection control permit before construction begins.

2. Isolate HVAC system in area where work is being done to prevent contamination of 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. Seal holes, pipes, conduits, and punctures appropriately.

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

7. All personnel entering work site are required to wear shoe covers.

8. Contain construction waste before and during transport in tightly covered containers. Cover transport receptacles or carts. Tape covering.

9. Do not remove barriers from work area until completed project is inspected by Safety and Epidemiology Depts. And thoroughly cleaned.

After work is completed:

10. Vacuum work area with HEPA filtered vacuums.

11. Wet mop with disinfectant.

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:

1. 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.

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

3. Clean up dust tracked outside of construction area immediately.

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

5. Removal of debris must be in covered containers.

Additional Requirements or Concerns:

Outside Contractors must abide by VA-WLA contract regarding TB skin testing as well as the requirement to have evidence that each contract worker had education and training in infection control measures.

Inside contractors (employees) may watch the film on the Infection Control SharePoint site at http://vaww.portal.gla.med.va.gov/sites/QMNew/IC/default.aspx.

Permit Request By Infection Practitioner Approval

Date: Date:

http://vaww.portal.gla.med.va.gov/sites/QMNew/IC/default.aspx

VHAWLASILVAFA

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