36C26118B0293-00001004.pdf

Infection Control Risk Assessment Matrix

Please complete this form and attach the Scope of Work document with this form.

Infection Prevention and Control contact is Laura Markman RN (x64168) or Teela Swanson RN (x4849).

Project #: 640A0-16-111

Project Title: Replace Flooring Building 331 MPD

COTR (print): Ralph Lappin Ext: 62243

Part I (Engineering to complete):

Using the following table, identify the type of construction project activity (Types A-D):

Type A Inspection and Non-invasive Activities Includes, but is not limited to:

Removal of ceiling tiles for visual inspection limited to 1 tile per 50 square feet;

Painting but not sanding; and Wall covering, electrical trim work, minor plumbing and other 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:

Installation of telephone and computer cabling;

Access to chase spaces; and Cutting of walls or ceiling where dust migration can be controlled.

Type C Work that generates a moderate-to-high-level of dust or requires demolition or removal of any fixed building components or assemblies Includes, but is not limited to:

Sanding of walls for painting or wall covering;

Removal of floor coverings, ceiling tiles and casework;

New wall construction;

Minor duct work or electrical work above ceilings;

Major cabling activities; and Any activity which cannot be completed within a single work shift.

Type D Major demolition and construction projects Includes, but is not limited to:

Activities which require consecutive work shifts;

Requires heavy demolition or removal of a complete cabling system; and New construction.

Type:

Part II (Engineering to complete):

Please answer the following questions (circle yes or no):

1. Is disruption of essential services (e.g., ventilation, water) to patients/employees anticipated?

No Comments: Work is to building finished, no structural or mechanical system is effected

2. Is relocation of patients to alternate units required or being considered?

Yes Comments: Work cannot be performed with patient or staff present during work activities

3. Will the removal of debris pass through patient care areas?

No Comments: Exits exist that the contractor will use that go directly outside the building

Part III (Infection Prevention/Control to complete):

Using the following table, identify the patient risk groups that will be affected:

Low Risk Medium Risk High Risk Highest Risk

Office areas - Cardiology - CCU - Any area caring for

- Echocardiography - Emergency room immunocompromised patients

- Endoscopy - Labor and delivery - Burn unit

- Nuclear medicine - Laboratories - Cardiac cath lab

- Physical therapy - Newborn nursery - Central sterile supply

- Radiology/MRI - Outpatient surgery - Intensive care units

- Respiratory therapy - Pediatrics - Medical unit

- Pharmacy

- Post anesthesia

- Negative pressure isolation rooms

- Oncology

- ORs

Risk Level (circle one): Low Medium Highest

Part IV (Infection Prevention/Control to complete):

Using the following table, identify the Precaution Class (I, II, Ill, or IV) or level of infection control activities required for the planned construction project. Match the construction type (A,B,C,D) with the risk level (low, medium, high, highest).

Patient Risk Group Type A Type B Type C Type D

LOW risk I II II III/IV MEDIUM risk I II III IV HIGH risk I II III/IV IV HIGHEST risk II III/1V III/IV IV Source: Virginia Kennedy, St. Luke's Episcopal Hospital, Houston/ icanPREVENT.com

Precaution Class (circle one):

Precaution Classes (Levels of Required Infection Control Activities)

All precautions in the determined class must be followed:

Class Precautions/procedures that are required for each class I During work:

1. Execute work using methods to minimize raising dust from construction operations.

2. Immediately replace a ceiling tile displaced for visual inspection.

3. Minimize traffic (decrease exposure of patients to construction).

4. If disruption of water supply is necessary, schedule interruptions during low activity.

After work: General clean up as needed

II During work:

1. All Class I activities listed above

2. Provide active means to prevent airborne dust from dispersing into the atmosphere.

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

4. Seal unused doors with duct tape.

5. Block off and seal air vents.

6. Provide and use walk-off mats at work areas. Replace used mats with new mats in accordance with manufacturer's recommendations and when dirty.

7. Contain construction waste before transport in tightly covered containers. For removal of construction waste, follow pre-determined route.

8. Seal off isolate heating, ventilation and air conditioning (HVAC) system in areas where work is being performed.

After work:

1. Clean and wipe work surfaces with hospital-approved disinfectant.

2. Wet mop and/or vacuum with HEPA-filtered vacuum before leaving the work area.

3. Remove isolation of HVAC system from work area.

III During work:

1. All Class I and ll activities listed above

2. Complete all critical barriers (i.e., sheetrock, plywood, plastic, or implement the control cube method [cart with plastic covering and sealed connection to work site with HEPA vacuum for cleaning prior to exit]) to seal the area before construction begins.

3. Maintain negative air pressure within the work site utilizing HEPA-equipped air filtration units.

4. Cover transport receptacles or carts. Tape covering unless the cart has a solid lid.

After work:

1. Do NOT remove barriers from work area until completed project is inspected by the Safety Office and Infection Control and the area has been thoroughly cleaned by Environmental Management.

2. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.

3. Vacuum work area with HEPA-filtered vacuums.

4. Wet mop area with hospital-approved disinfectant.

5. Remove isolation of HVAC system in area where work is being performed.

Ralph Lappin Print name (Engineering)

Print name (Infection Prevention/Control) Signature

2/15/2018 Date

Class Activity IV During work:

1. All Class I, II, and III activities listed above

2. Relocate patients away from construction areas.

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

4. Seal holes, pipes, conduits, and punctures appropriately.

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

6. All personnel entering work site are required to wear shoe covers, which must be changed each time the worker exits the work area.

7. Provide and use adhesive walk-off mats within the anteroom. Replace used mats with new mats in accordance with manufacturer's recommendations and when dirty.

8. Contain construction waste before transport in tightly covered clean (wiped clean with wet cloth) containers. For removal of construction waste, follow pre-determined route.

9. Construction/work area should be periodically inspected by Safety Office and

Infection Control as appropriate

After work:

1. Do NOT remove barriers from work area until completed project is inspected by the Safety Office and Infection Control and the area has been thoroughly cleaned by Environmental Management.

2. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.

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

4. Vacuum work area with HEPA-filtered vacuums.

5. Wet mop area with hospital-approved disinfectant.

6. Remove isolation of HVAC system in area where work was performed.

Additional Risk Assessment (Completed by IPC only):

Is work being conducted in area where exposure to active TB is possible? Yes C9.

If yes, contractor must provide documentation that construction workers have been screened for active TB within 90 days of work commencing. Anyone screening positive must show proof of being on treatment.

Additional Comments: Work to be completed in phases, one half of a wing at a time. Patients and staff will be relocated to suitable facilities while the half wings is isolated and worked on.

Part V: Persons completing the Infection Control Risk Assessment: