36C26120B0007-A0002005.pdf

ICRA & ICCP

VA Northern California Health Care System

Attachment C Policy Statement 138-56 March 1, 2019

Infection Control Risk Assessment (ICRA)

Type: C

Using the following table, identify the Type of Construction Project Activity (Type A-D) and enter is blank above.

TYPE A

Inspection and Non-Invasive Activities.

Includes, but is not limited to:

removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feet 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:

installation of telephone and computer cabling access to chase spaces 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 floorcoverings, ceiling tiles and casework new wall construction minor duct work or electrical work above ceilings major cabling activities 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 new construction.

TYPE E All projects which are external/detached from patient care areas and existing facility buildings.

Project Name: Planned Project Start Date:

Project Number:

PM / COR P.O.C. : P.O.C extension:

Location of Construction: Estimated Duration:

Attachment C Policy Statement 138-56 March 1, 2019

ICRA & ICCP

VA Northern California Health Care System

Step 2: Highest Risk

Using the following table, identify the Patient Risk Groups (Low, Medium, High, Highest) that will be affected and enter in the blank above. If more than one risk group will be affected, select the higher risk group.

Low Risk Medium Risk High Risk Highest Risk

Office areas

All external/deta ched projects that have no physical communicat ion with patient care areas or existing facility buildings

Cardiology Echocardiography Endoscopy Nuclear Medicine Physical Therapy Radiology/MRI Respiratory Therapy Primary Care Inpatient/Outpatient

Behavioral Health

Emergency Room Laboratories (specimen) Medical/Surgical and telemetry units Outpatient Surgery Pharmacy Post Anesthesia Care Unit

Any area caring for immunocompromised patients

Cardiac Cath Lab Central Sterile Supply Intensive Care Units Negative pressure isolation rooms Hematology/Oncology Operating rooms Sterile Processing Services

Step 3: IV

Match the:

Patient Risk Group (Low, Medium, High, Highest) with the planned … Construction Project Type (A, B, C, D, E) on the following matrix, to find the … Class of Precautions (I, II, III, IV) or level of infection control activities required.

Class I-IV or Color-Coded Precautions are delineated on page 7’s Infection Control Construction Permit.

Patient Risk Group TYPE A TYPE B TYPE C TYPE D TYPE E

LOW Risk Group I II II III/IV I

MEDIUM Risk Group I II III IV N/A

HIGH Risk Group I II III/IV IV N/A

HIGHEST Risk Group II III/IV III/IV IV N/A

Step 4: Identify the areas surrounding the project area, assessing potential impact.

Unit Below Unit Above Lateral Lateral Behind Front

Risk Group Risk Group Risk Group Risk Group Risk Group Risk Group

Attachment C Policy Statement 138-56 March 1, 2019

Step 5: Identify any other potential requirements by using the following checklist.

INFECTION CONTROL REQUIREMENTS CHECKLIST YES NO N/A

INFECTION CONTROL EDUCATION: Identified site specific activity and met with Services/Sections surrounding construction site to inform them of impact/precautions to be taken & to instruct them in basic I/C requirements?

INFECTION CONTROL EDUCATION: Met with the Construction Manager, Construction Crews, and Sub- Contractors to inform them of impact/precautions to be taken & to instruct them in Basic I/C requirements? □ □ □ OUTAGE EVENTS: Identified any issues related to ventilation, plumbing and electrical in terms probable outage events? □ □ □ CONTAINMENT MEASURES: What types of barriers, i.e., solids, wall barriers? Will HEPA filtration be required? □ □ □ CONTAINMENT MEASURES: Discussed containment issues with the project team like traffic flow, housekeeping and debris removal (how and when)? □ □ □ CONTAINMENT MEASURES: Informed the Project Coordinator that barriers are not to be removed from work area until completed project is inspected by the Safety and Infection Control Sections and thoroughly cleaned by Environmental Management Service?

WATER DAMAGE RISK: Is there a risk due to compromising structural integrity, i.e., wall, ceiling and/or roof?

(Note: Renovation/construction area will be isolated from occupied areas and negative with respect to surrounding areas)

WORK HOURS: Can or will the work be done during non-patient care hours? □ □ □

ISOLATION/NEGATIVE AIRFLOW: Do plans allow for adequate number of isolation/negative airflow rooms? □ □ □ HAND HYGIENE: Does the plan allow for the required number and type of hand washing sinks? □ □ □ HAND HYGIENE: Does the infection prevention & control staff agree with the minimum number of sinks for this project?

(Note: Verify against FGI Design and Construction Guidelines for types and area)

CLEAN/SOILED UTILITY: Does the infection prevention & control staff agree with the plans relative to clean and soiled utility rooms? □ □ □

TUBERCULOSIS RISK ASSESSMENT: Does this project involve risk of airborne exposure to known or suspected TB case. Is construction near patient care areas?

NO: Baseline TB skin testing is not required for contractors

YES: The Contractor will provide written certification that all contract staff have a pre-placement TB screen within 90 days prior to assignment to the worksite and have been found to have negative TB screening reactions. Contract staff manifesting positive screening reactions to TB must show proof of being on treatment prior to working on VHA property.

LEGIONELLA IMPACT: Will this project involve disturbing or breaking water systems, or result in stagnation of the water systems for greater than 7 days?

1. All hot/cold water systems will be flushed until flow clear and without air in the system.

NOT LESS THAN 10 MINUTES.

2. All faucets and showerheads will be removed and cleaned.

3. Temperatures will be measured to insure hot water is within limits identified above.

4. Water samples will be taken to verify: levels of chlorine/safety of water for human use.

5. Take a representative sample at affected distal fixtures and send for culture testing.

(Note: It is not necessary to wait for sample prior to returning the area to service)

Attachment C Policy Statement 138-56 March 1, 2019

Signature of Project Manager Date

Signature of Project Manager’s Supervisor Date

When the Construction Activity and Risk Level indicate Class III or Class IV, control procedures are necessary and the following signatures are required. The Infection Control Construction Permit on page 7 of this attachment is also required and MUST BE POSTED AT SITE.

Signature of VANCHCS Infection Control Nurse Date

Signature of VANCHCS Safety Designee Date

Please describe, in the brief, the nature of the work to be undertaken and detail all infection control mitigation measures:

Attachment C Policy Statement 138-56 March 1, 2019

Infection Control Construction Permit Permit No:

Location of Construction: Project Start Date:

Project COR: Estimated Duration:

Contractor Performing Work: Permit Expiration Date:

Supervisor: Telephone:

YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP

□ □ TYPE A: Inspection, non-invasive activity □ □ GROUP 1: Low Risk

□ □ TYPE B: Small scale, short duration, moderate to high levels □ □ GROUP 2: Medium Risk

□ □ TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion

□ □ GROUP 3: Medium/High Risk

□ □ TYPE D: Major duration and construction activities Requiring consecutive work shifts

□ □ GROUP 4: Highest Risk

CLASS I

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

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

3. Minor demolition for remodeling.

CLASS II

1. Provides 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 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 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 or implement control cube method before construction begins.

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

5. Do not remove barriers from work area until complete project is thoroughly cleaned.

6. Vacuum work with HEPA filtered vacuums.

7. Wet mop with disinfectant.

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

Contain construction waste before transport in tightly covered containers.

9. Cover transport receptacles or carts. Tape covering.

10. Remove or isolate HVAC system in areas where work is being performed.

Date

Initial

CLASS IV

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. Do not remove barriers from work area until completed project is thoroughly cleaned.

9. Vacuum work area with HEPA filtered vacuums.

10. Wet mop with disinfectant.

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

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

13. Cover transport receptacles or carts. Tape covering.

14. Remove or isolate HVAC system in areas where construction is being done.

Date

Initial

Additional Requirements:

Date Initials __________________ Exceptions/Additions to this permit

Date Initials are noted by attached memoranda.

Permit Requested By: Permit Authorized By:

Date: Date:

1.Obtain infection control permit before constructionbegins.

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.